When Florence Bolella, director of nursing at Kimberly Hall South nursing home in Windsor, told her staff to remove all the alarms from patients, fear and panic set in. Not among the residents, who were relieved to be free of the annoying beeps and squawks that sounded every time someone with mobility problems moved, but among the nurses’ aides.
“The CNAs were so afraid they were going to get in trouble if a patient fell,” Bolella recalled. “It took us almost a year to remove 33 alarms. I eventually had to lock up the alarms, so the staff would stop using them.”
In the two years that the nursing home has stopped using both alarms and restraints, it has seen a decline in the number of falls. Bolella isn’t surprised: “I never felt the alarms were effective.”
Kimberly Hall South is among a handful of nursing homes in Connecticut that have gone “alarm-free,” meaning residents at risk of injury, usually from falls, are no longer outfitted with detectors on their mattresses, chair pads and clothing that emit a warning signal when they try to get up and move around.
Alarms became a mainstay of the nursing home industry after the federal government cracked down on the use of physical restraints in the early 1990s. While most nursing homes still use alarms, in part to protect against state and federal penalties for inadequate fall-prevention measures, the move towards alarm-free facilities is growing in Connecticut, long-term care experts say.
“I think we have to ask, ‘What is the evidence base for the use of alarms to prevent falls and injuries?’ There really is none,” said Ann Spenard, a geriatrics specialist and vice president of operations for Qualidigm, the state’s Medicare quality-improvement agency, which convened a meeting on the topic this month. “They tell us a person’s probably already on the floor, or moving . . . While we’ve gone (away) from restraints, we’ve moved to the crutch of the alarm.”
The use of physical restraints in nursing homes has dropped dramatically in the past decade, with 121 of Connecticut’s 233 homes now restraint-free, Spenard said. Qualidigm is surveying homes to try to gauge how many have eliminated alarms, but Spenard said she believes it’s only a handful, to date.
That could change, as anecdotal evidence begins to show improvements in the rate of falls after eliminating alarms, Spenard said. According to one case study, at the Jewish Rehabilitation Center for the North Shore, in Massachusetts, the number of falls dropped 32 percent below the average quarterly fall rate after alarms were removed from a 45-bed unit.
Similarly, at Cheshire House Nursing and Rehabilitation Center in Waterbury, administrator Joanne Gorenstein reported a 15-percent decrease in falls after the home eliminated alarms more than a year ago. She said her decision to go alarm-free was prompted, in part, by an incident in which multiple alarms were sounding simultaneously, and “we were all running around, colliding with each other.”
Administrators of homes where alarms have been removed said that while the move requires new ways of monitoring at-risk patients, it also lowers anxiety for residents, especially those with cognitive problems, and for staff.
At Glendale Center in Naugatuck, long-term unit manager Doreen Lloret reported that patients in a 30-bed dementia unit who were agitated and restless are “much calmer” since the alarms were removed.
At Bethel Health Care Center, administrators asked residents how they felt about alarms before deciding to remove them.
“They find them intrusive. They say there’s a loss of dignity, “said Diane Judson, director of nursing at Bethel.
Spenard said that while it’s difficult for staff to deal with the cacophony of alarms, “Can you imagine if you can’t process all this information and distill it, how agitating it can be?” She noted that alarms in nursing home settings are counterintuitive.
“Alarms in real life tell us to take action. In the nursing home, they tell the resident not to move,” she said.
A study last year in the Annals of Internal Medicine that was based at a Tennessee hospital found that alarms did not statistically reduce fall rates. Spenard said there is also some evidence indicating that alarms may contribute to falls, because they disrupt residents’ sleep, making them tired and unsteady the next day.
But other experts say alarms are an important fall-prevention measure, especially for residents with dementia or poor safety awareness who may try to get out of bed at night unsupervised. The alarms remind the residents that they should not move, while also summoning staff to assist.
According to data from the U.S. Centers for Disease Control and Prevention, about 1,800 elderly nursing home residents die each year from injuries sustained in falls. Thousands more suffer serious injuries, such as broken hips. In Connecticut, nursing homes overall report that 3.1 percent of long-stay residents experience one or more falls with major injury, slightly lower than the national average.
Spenard and home administrators stressed the need for other interventions to prevent falls, if alarms are eliminated. They include frequent rounding, or checks, on residents who are at risk of falls; detailed assessments of residents’ needs, to identify when and why they get up and try to walk, including their toileting needs; and consistent assignments of nursing staff to particular patients.
“The whole thing is being proactive, not being reactive,” said Lloret. She said consistent assignments allow caregivers to get to know a resident’s schedule and “anticipate their needs.”
Some of the alarm-free homes have CNAs stationed in hallways or checking on high-risk patients at least once an hour. Spenard said understanding the underlying reasons why a resident might become agitated and restless – boredom or pain, for example — is critical, so that a care plan can be developed that might include music, activities or exercise.
Administrators of alarm-free homes said they educated families about the change and encountered little resistance. The buy-in from staff members was harder because of fears that falls would be blamed on them. Because the state Department of Public Health cites homes for lapses in care that lead to falls, removing alarms carries the risk of penalties.
Despite those risks, “It really is a sense of relief for your staff,” said Gorenstein. While nursing staff must be more diligent in monitoring patients, they no longer have to spend time adjusting and checking alarms. She said state inspectors have been supportive of an alarm-free environment, as long as other fall-prevention strategies are in place.
Lloret said the changes in residents’ moods are worth the risk. With alarms, residents were constantly being told to stop moving – not only by workers, but by fellow patients.
“How many times have you heard your staff say, ‘Charlie, sit down!’” she recounted at the recent meeting to discuss the use of restraints and alarms.
“Now, I want them to say, ‘Charlie, why are you standing? What do you need?’”