Michael J. Brescia, MD, remembers clearly why he called for a restraint-free environment at Calvary Hospital in the Bronx 10 years ago.
Brescia, executive medical director and senior vice president at Calvary, responded to a room after a patient had fallen out of bed. After checking the patient for fractures, he informed the patient that nurses would use a Posey restraint belt to help keep him from falling again. And once the patient was stabilized, the nurses would remove the restraint.
The patient looked at me and said that when he was in a concentration camp he was tethered six inches with a razor-tight barbwire to his neck that was slung on a pole. If he fell it would cut his throat, Brescia says. He said to me, I beg of you not to put the belt on because of my memories of that terrible time.
The patients son, who was in the room when his father fell, started weeping. Caught in what Brescia calls an emotional avalanche, he left the room, walked about 12 feet, stopped, and went back into the room, kissing the patients tattooed number, and promising that day that staff would never restrain another person at Calvary again.
Brescias decision would be the beginning of a difficult and expensive cultural change. The population at Calvary would be particularly challenging because the Bronx hospital, and its Brooklyn site, exclusively provides palliative care for high-risk adult advanced cancer patients.
To not only reduce restraint use but totally eliminate it was forward-thinking at the time, according to Sally Umbro, RN, MS, CNAA, vice president for Patient Care Services at Calvary.
Nursing would take on the challenge, Umbro says, but not without the buy-in of the hospitals administrative decision-makers. It was an enormous financial commitment, she recalls.
Restraint-free Nuts and BoltsSally Umbro, RN
It helped that the hospital was already ahead of its time, Umbro says. Calvarys nursing units are configured in such a way that each one has 25 beds 18 of which have direct visualization from the nursing station.
The layout of the unit lends itself very well to our being able to monitor patients, she says.
But to achieve a 100% restraint-free environment, the nurses would need more. The hospital committed to restructuring the rooms: taking two rooms on each floor, knocking out the walls between them, and replacing the walls with sliding glass partitions. The glass-partitioned rooms are for patients who would otherwise clearly need to be restrained, according to Umbro. But to achieve that goal, it took a lot of moving around of patients on any given day.
By using these rooms as our observation rooms, we can open that sliding glass door and place the staff member in between the two rooms. The staff member, then, is basically within arms reach of both patients and has the ability to provide constant observation, Umbro says.
The nursing staff providing observation is in addition to regularly scheduled staff, she says. That means staffing all eight units with extra personnel.
The hospital also instituted hourly rounds, to check on patients needs and keep close tabs on patients.
Its an incredibly expensive program to maintain and to maintain with full support for more than 10 years. Its an enormous commitment on the nursing staff, because, again, I cant downplay the constant merry-go-round of rooms that takes place, Umbro says.
Its a Culture
Brescia says that the hospital proudly displays images and a sculpture of a patient lying in bed, surrounded by a technician who is holding the patients head, a nurse who is holding the patients arm, and a physician who is at the patients feet.
Theyre all surrounding the patient and are consoling him. The patient has a tranquil look. Its a beautiful bronze figure that is emblematic of the hospital, he says.
The hospital measures itself against benchmark data by the Specialty Performance Measurement System and, for the most part, she says, hovers around two standard deviations below the SPMS national average for falls.
Thats despite the fact that most of our patients are highly at risk for falls based on their diagnoses and their disease progression, Umbro says.
Calvary staff has been able to maintain the more humane approach to patient care without sacrificing safety.