Self-medication on a rehabilitation unit

A self-medication program (SMP) has been designed and implemented as part of a multidisciplinary approach to rehabilitation. The four stages of the program, coordinated by a pharmacist, are: (1) patient assessment and introduction, (2) self-medication (SM) at the bedside, (3) SM at the nursing station, and (4) discharge assessment. Twenty-four patients, representing 52% of the patients introduced into the program, have successfully completed all stages. Severe physical impairment was not usually a deterrent to the completion of the program. All patients benefitted from the program by acquiring some skills in SM and by receiving additional motivation for improvement. The rehabilitation team received assurance that some patients could comply with their medication regimen after discharge.     

Reducing physical restraints: developing an educational program.

1. Philosophical premises for an educational program aimed at restraint reduction include beliefs about quality of care, commitment to understanding the meaning of behavior, and desire to shift practice from control of behavior to individualized approaches to care. 2. If change is to occur, an educational program aimed at restraint reduction must recognize the potential contributions of all staff members, use an interactive teaching style, and promote discussion and problem solving. 3. Results of testing a Restraint Education Program suggested that altering staff beliefs and increasing knowledge produced a change in restraint practices, at least in the short term.     

The use of restraints

This article describes a flow chart created to help nurses identify interventions other than physical restraint. The decision flow chart comprises five charts, each addressing a common area of patient behavior often cited by nurses as justification for physical restraint in the long-term care setting: poor sitting posture, rigidity, wandering, agitation, and falls. The charts list possible reasons and causes for the behavior and give specific suggestions for interventions based on the identified cause.     

Families' perspectives on the use of physical restraints

There have been many studies on the use of restraints from health care professionals point of view. However, studies that examine the perspective of the patient or the patients family are limited. Using a survey approach, the project team investigated the perspectives of families on the use of restraints on their relatives who had been admitted to a rehabilitation facility. Twenty-five families were recruited into this study through convenience sampling. It was found that the majority of them were not aware of alternatives to physical restraints, had no opinions on restraint use, and found restraints useful. The findings highlighted the need for family education and participation in clinical decision making concerning the use of restraints.     

Discriminating high fall risk on an inpatient rehabilitation unit.

The objective of this study was to identify on admission the most discriminating fall predictors for patients to an inpatient rehabilitation unit. Medical information from 34 patients who fell over a consecutive 7-month period and 102 controls (1:3 ratio) matched for diagnosis, age, and gender was analyzed to identify a set of best predictors. Admission mobility and problem solving FIM scores accounted for 17% of variance in whether a fall occurred during the admission. After statistically deriving optimal cutoff thresholds for decision making, high fall risk was retroactively assigned to patients. Logistic regression revealed increased odds of having fallen by 5.1 times for poorer mobility and 2.4 times for poorer problem solving. The practical benefits of the evidence-based risk assessment were discussed.     

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study.

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.     

Time of care required by patients discharged from a rehabilitation unit.

OBJECTIVE: To determine the amount of care (measured in time) required by patients discharged from an inpatient rehabilitation unit. DESIGN: A total of 103 consecutive patients discharged from an inpatient rehabilitation unit to home were contacted 1 mo after discharge and asked to report the amount of help that they required at home. Correlations were made between the time of help that the subjects reported needing and their age, sex, living situation, marital status, diagnosis, and the score on the FIM at the time of discharge from the rehabilitation unit. RESULTS: The score on the FIM correlated with the time of help reported by the patients. Linear regression analysis showed that each 5-point decrement in FIM score correlates with the need for about 1 hr per day of help with mobility, basic activities of daily living, and instrumental activities of daily living. CONCLUSIONS: The FIM can be used to provide an estimate of the amount of time it will take families to provide help for patients discharged from a rehabilitation unit.     

Pediatric rehabilitation. 4. Disorders of the motor unit

This self-directed learning module addresses diagnostic and rehabilitation issues in children with the most common disorders of the motor unit. It is a section of the chapter on pediatric rehabilitation for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. Conditions occurring only in infancy or childhood and differences in diagnostic and rehabilitation approaches as compared with those used in adults are highlighted.     

The evolution of an acute care hospital unit to a DRG-exempt rehabilitation unit. A preliminary communication

The Health Care Financing Administration's decision to adopt a prospective based payment system has caused many institutions to implement new policies and practices. A recent area of interest for many hospitals has been the creation of diagnosis-related group (DRG) exempt units to maximize reimbursement practices. We analyzed changes which occurred when an eight bed acute care stroke unit (SU) was converted to a DRG exempt eight bed rehabilitation unit (RU). The time period involved was 1 1/2 months before and 1 1/2 months after the transition occurred. Analysis of data from the pre- and posttransition periods revealed that: (1) length of stay increased significantly from 11.7 to 15.3 days (P less than 0.001); (2) functional independence measure (FIM) score improvement was significantly greater (P less than 0.05) for RU patients (0.84/day) than for SU patients (0.39/day); (3) disposition to home v other facilities increased significantly from 50 to 81% (P less than 0.05); (4) the overall occupancy increased from 94 to 100% and all beds were filled with rehabilitation patients; (5) the proportion of patients with Medicare as their primary insurer was comparable before (64%) and after (67%) unit conversion; (6) gross income from rehabilitation patients increased by 43%. Indirect savings via reduction of acute hospital length of stay for Medicare patients increased total income from operation of this unit. We conclude that patients on the RU stayed longer, had greater daily improvements in functional status, and were more likely to be discharged to home. This appears to be due to a more efficient use of rehabilitation beds and a concomitant overall improvement in reimbursement to the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Modifying the environment to decrease use of restraints

Because the majority of residents lack the skills and capacities to adapt to the nursing home environment, it is the staff's responsibility to modify the environment to reflect the residents' needs. In persons with dementia, anxious behavior occurs when the individual's environment provides too many stressors or no opportunities to relax or avoid stimuli, the stress threshold is exceeded, and dysfunctional or problem behaviors are manifested. Nurses must decrease their reliance on physical restraints, think creatively to solve problems, and look to theories to provide ideas and guidance. Administrators must encourage innovation and be willing to take calculated risks.