I'm a new grad working on a cardiac progressive care unit and have identified an issue with the way our recliners are being used. When assisting patients into a reclining position, nurses and aids often put the garbage can under the foot of the recliner to prevent it from falling back into the sitting position because they don't stay in the reclining position for some reason.
Our patients are older and our plan of care includes getting them out of bed and into the chair for breakfast lunch and dinner and walking four times a day among other things. We encourage them to only use the bed at night so reclining in the chair is a great way to make position changes and allow them to rest between meals, assessments, interventions, walks and physical therapy.
The problem is that I've walked into rooms to see confused patients or patients who can't reach their call light trying to get out of the recliner with their foot/feet stuck in the garbage can and/or one or more legs caught in the space between leg-rest and the seat. I'm afraid that someone will end up falling and sustaining an injury. It seems to me that if using all four bed rails can is considered entrapment, then the same would be true if a patient can't get out of a recliner without assistance moving the object from under the let-rest.
Does anyone else think that this situation seems dangerous or know of any facilities that have policies that prohibit the use of objects to hold up the leg-rest in a recliner chair?
Thanks in advance for reading my post and sharing your input.
Meanwhile, on my unit I can't get the recliners to recline or go back upright without practically throwing my back out. I agree safe chairs need to be purchased.
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It's pretty clearly a reduced risk of injury, and there is no modification to the recliners being done. It also covers our requirement by the manufacturers instructions that the patient be prevented from altering the position themselves.
Is there published research that compares the injury rates in patients using recliners with and without garbage can props?
As a legal issue, it's not considered a restraint from a regulatory standpoint. Using four bedrails up is actually not considered a restraint if the primary purpose is not to keep the patient from intentionally getting out of bed. If the rails are up to facilitate treatment such as auto-rotation, or to just keep a turned patient from rolling or sliding out of bed then it is not considered a restraint. If the purpose of the garbage cans is to keep the chair from doing things it should only be doing under the control of staff then that is also not a restraint.
Au contraire. I worked for several years as a hospital surveyor for my state and CMS, and we certainly considered a recliner or geri chair from which the individual couldn't freely get up without assistance to be a restraint, and cited facilities for restraining people without orders all the time. Here is the CMS definition of "physical restraints" (emphasis mine):
Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Under this definition, a recliner that the person cannot easily get out of is clearly a "physical restraint." If you don't have a physician's order (as well as all the other documentation that goes along with physical restraint), you are restraining people without an order.
Is there published research that compares the injury rates in patients using recliners with and without garbage can props?
It is not realistic to expect statistics on the injuries, fatalities and lawsuits related to poorly designed reclining chairs, or any other faulty device until it rises to the level of a class action suit. I have looked and I can assure you that the international corporations such as Stryker, Hillrom, and ArjoHuntleigh do not have recalls, incident reports or instruction manuals available online. These corporations and their customers have minimized their liability and kept that information out of all the public databases. Nor will you find any cases or statistics in any public database of any regulatory agency.
I have worked in both world class facilities and third world overseas hospitals. In both I have had to resort to propping a footrest with a garbage can or a chair in order to maintain safety due to poorly designed reclining chairs. I would much rather prop the footrest than have my patient have head bleed secondary to trauma or a similar catastrophic event.
Au contraire. I worked for several years as a hospital surveyor for my state and CMS, and we certainly considered a recliner or geri chair from which the individual couldn't freely get up without assistance to be a restraint, and cited facilities for restraining people without orders all the time. Here is the CMS definition of "physical restraints" (emphasis mine):
Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Under this definition, a recliner that the person cannot easily get out of is clearly a "physical restraint." If you don't have a physician's order (as well as all the other documentation that goes along with physical restraint), you are restraining people without an order.
Part of my job involves regulatory compliance, and while I've heard a number of odd interpretations from surveyors, I've yet to hear that sitting in a recliner is a restraint. Having a table across the lap that is in some way locked or having the chair in a sort of reverse trendelenberg is typically considered a restraint, but simply being in a recliner or a bed for that matter has never been considered a restraint by any of our surveyors. This is why we've now gone with a non-TJC surveyor that only allows their surveyors to work in pairs.
In the context of the original post, having a chair where the patient cannot independently alter the positions is not something that using some sort of supports changes; by the manufacturers own description they are designed to only be adjusted by staff. If that makes all of those recliners restraints then you're suggesting a massive change to how restraints are currently defined, and would also include all beds as well.
Is there published research that compares the injury rates in patients using recliners with and without garbage can props?
There is no published research that compares injury rates in people jumping out of an airplane with and without a parachute, are you suggesting we should then assume the risk of injury is not decreased by using a parachute?
I don't really think you need an RCT to show that preventing a patient from taking an unexpected backwards somersault out of a recliner is safer than not reducing that risk? I guess I'm not really sure what you're arguing, are you saying there is no reason to believe getting flung out of a chair could harm a patient?
O my goodness, so many issues. First question does your manager know about it. Report this as both a clinical and oh&s risk. Get it visible, get people annoyed about it, dump the damaged recliners.
"damaged recliners"? Nope- they were almost new. They were like that from day 1. A lot of equipment has design trade-offs. These were fairly easy to sanitize, and small enough to accomodate the other necessary equipment in tthe room- they just tended to be a little unstable- easily fixed with a trash can.
I understand what you are saying muno, but I have read many malpractice inurance settlements and that influences how I see the risks associated with using faulty hospital equipment. If the manufacturer does not provide trash cans and written instructions on how to prop the recliner, then you are modifying the manufacturer's intended use of the recliners. In the event of an injury sustained from a propped recliner, the litigation will be against the nurse for malpractice, not against the manufacturer for product liability.
You do not have any written evidence to support propping the recliners and it is possible to find alternatives to the recliners, there are occupational therapists and ergonmists who have specialized training and they can recommend safer seating options for your patients.
Part of my job involves regulatory compliance, and while I've heard a number of odd interpretations from surveyors, I've yet to hear that sitting in a recliner is a restraint. Having a table across the lap that is in some way locked or having the chair in a sort of reverse trendelenberg is typically considered a restraint, but simply being in a recliner or a bed for that matter has never been considered a restraint by any of our surveyors. This is why we've now gone with a non-TJC surveyor that only allows their surveyors to work in pairs.
In the context of the original post, having a chair where the patient cannot independently alter the positions is not something that using some sort of supports changes; by the manufacturers own description they are designed to only be adjusted by staff. If that makes all of those recliners restraints then you're suggesting a massive change to how restraints are currently defined, and would also include all beds as well.
I'm not talking about some "odd interpretation" of my own, I'm telling you what I was told in official CMS surveyor training. Sitting in a recliner is not, by itself, a restraint. However, if the recliner is positioned in such a way that the person cannot freely get up and walk away if s/he wants to, that is a restraint per CMS' definition.
Thank you all for your comments. I appreciate the input and can see the pro's and con's of using a trash can and not using a trash can. I can see that there is a tension between managing day to day patient injury risk and managing litigation/regulatory risk. I have reported the issues that I witnessed to my managers and over the last 10 years on our unit, there has never been an injury related to use of a trash can as a prop for the foot rest. Since starting this post, I've taken a new approach with the recliners. I have found that there are two reclining positions. The first position keeps the upper torso in an upright position where the second position reclined further allowing the patient to lay almost flat as if in bed. I've found that if I move the patient into the second position and then back to the first position, I don't need a prop under the footrest. In situations where this works, I will not need a trash can prop. If the footrest still does not stay up, I will inform the patient that we unfortunately cannot use the reclined position and will offer for them to sit up in bed if their bottom is getting tired or sore from sitting in the chair upright with feet down. Another option that I'm thinking about is giving them some way to elevate their feet without using the foot-rest of the chair. Something like an ottoman or footstool may be safer. Before I escalate reporting this concern within our hospital system, I want to find other options that don't require reporting. Of course, if I witness someone trapped or fallen, I will report but for now, I feel like I've done my job.
One clarification I'd like to make is that the concept I was speaking about in legal terms is False or Wrongful Imprisonment. While four bed rails can be considered a restraint, I was thinking about the concept of wrongful imprisonment but I don't think that applies to our situation unless someone were to put a patient who had limited mobility alone in a room in the recliner with the foot-rest propped and the door closed for hours at a time. We are not a nursing home. I also don't see the chairs as a restraint from a legal or medical perspective with the foot propped up because a healthy person with full mobility and range of motion (ROM) would be able to safely get out of the chair. The problem is that our patients don't have full ROM because they are in a lot of pain after open heart surgery.
Anyway... For those of you who have the recliner that has a second position, try adjusting to the second position before putting it back to the first position and see if that helps.
I also don't see the chairs as a restraint from a legal or medical perspective with the foot propped up because a healthy person with full mobility and range of motion (ROM) would be able to safely get out of the chair. The problem is that our patients don't have full ROM because they are in a lot of pain after open heart surgery.
The issue isn't whether a hypothetical "healthy person with full mobility and range of motion" could get out of the chair at will; the issue is whether that real-life individual who is actually in the chair is able to. If your clients are being put in recliners that they can't get out of on their own when they want to, that is a restraint per CMS' definition.
I disagree because some people have such limited mobility that they cannot get out of a bed, chair or recliner (with our without a prop) at home without assistance. If the CMS definition is taken too literally, a flat bed with no guardrails would be considered a restraint for a quadriplegic. We do need to consider the actual patient, but to me it seems that common devices and equipment that people use at home for ADL's like beds, chairs and recliners should not be considered restraints unless they are modified in a way that would be unusual at home. This is where I agree with you because the prop is a modification. I can also see people doing the same thing at home, where guardrails on a bed are not an option at home and therefore worthy of more scrutiny.
From the CMS definition:
Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.
I think the key here is "attached to or adjacent to". A patient with limited mobility/ROM may not be able to touch their toes sitting in a chair or recliner at home. In this case, we are not restricting, their current state of health is restricting. We have not caused this situation their health is the causative factor. The problem I still see is that we are using the recliner in a way that the manufacturer didn't intend, putting ourselves and the institutions we work for at risk for being at fault if an injury were to occur.
What I'm hearing from people who have posted, there are two real risks when using the recliner; the first is risk for entrapment and the second is risk for ejection. While their isn't any empirical data, I am seeing that the anecdotal evidence suggests that the safest course of action is to not use the recliner in an unsafe position. I'm okay with using deductive reasoning to create an evidence based practice statement. If the evidence is pointing to a particular practice creating a risk for injury, stop the practice.
What if the solution is as simple as this: If a patient can demonstrate being able to move themselves in and out of a reclining position, then they can utilize the recliner and if not, they should remain in the seated position.
The thing that I like about this solution is that it doesn't cost money to implement, it maintains patient safety by removing the risk for ejection injury and entrapment injury. I don't have to rock the boat on my unit and start bothering the managers and safety officers. At this point, there have been no reportable incidents and there is no way that an institution is going to make these chairs a budgetary priority at this time.
I would appreciate if people would comment on the strengths and weaknesses of my proposed solution.
ixchel
4,547 Posts
Meanwhile, on my unit I can't get the recliners to recline or go back upright without practically throwing my back out. I agree safe chairs need to be purchased.
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