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?’”
how do you feel about wandering devices on patients. i have a relative in an ohio ecf that is forced to wear one. it looks nearly identicle to a house arrest bracelet around the ankle. When we take her out in public, the staff is refusing to remove it! I say it is humiliating to her. She already struggles with depression and she is pretty sharp for her age. While this is not an issue for most because clothing covers the device, this patient wears only dresses and skirts and it is visible for all to see. The nursing home says it is “our policy that we not remove it” , i say, “your policy needs looked at”-what is your opinion?
My wife has fallen out of bed 5 times in the last two years, two requiring a trip to the hospital. It bothers me to think she is lying on the floor for a long period of time in pain.
I installed a bed pad and placed the monitor outside her door with the volume turned down so no one else could hear the ping knowing that the aid would find her sooner. They made me remove it.
If it does not bother anyone then why remove it.
George Sichanis, Sycamore villas, Fort Wayne, In.
That bracelet is a Wander guard which sets off a motion sensor if the wearer crosses a threshold that trips an electronic eye causing it to sound and alert whomever is nearby that someone is about to exit a door. In my 40 yrs as a therapist, I have known only one family who refused to have their loved one wear it. He was hit by a car in less than 24 hours, despite being placed on 15-minute written checks which had been done. He wandered out the front door, walked 2 blocks down the street, and was in a crosswalk when the first driver in line decided the 93 year old man wasn’t walking fast enough and laid on his horn. The blaring noise startled the poor old guy and he sustained a broken hip that necessitated surgery. There are worse things than buying one pair of nice slacks to go on community outings, because there will never be a shortage of idiots (like the honking driver) in this world, sadly. I was Dir of Rehab in the facility in question.
If a patient gets up from his bed or wheelchair and sets off the alarm
he then must sit back down or lie back down (if he didn’t already fall)
so he can wait for assistance.
i NEED HELP TO CREATE A POLICY ON BED/CHAIR ALARM ASSESSMENT AND ASSESSMENT FORM BEFORE ISSUE A DEVICES, PLEASE HELP ME
PLEASE HELP ME WITH A POLICY ON ALARM
I am a nurse of 30 years and you can write all the policies you want saying the high risks patients will be checked every 15 minutes but just bc they signed the paper doesn’t mean they actually checked anything. The cna isn’t going to sit in the hallway to check on these pts bc they are too busy gossiping with the other staff or on their phones. The rns don’t see it as their responsibility these days to assist a pt. My mother, a nurse of 50 yrs, is in a nursing home in nw illinois and when she needed to go to the bathroom the nurse said the cnas were feeding pts in the dining room and would be along shortly. 15 minutes later my father goes to look for someone and the nurse is sitting at the desk eating. The quality of nurses out there these days are an embarrassment to the profession. They don’t know how to think critically and need a computer to tell them what to do. They go to a crappy 2 year program then get their bsn and msn etc online which doesn’t make a better nurse, like at all. But that’s who gets out in the manager positions getting paid too dollar to work Tuesday through Thursday doing their online classes. I hope to just retire soon bc I can’t stand what I see and I’m done fighting the fight. Every time you try to make a change, you turn to rally the troops and find you are alone. Too many are content to just complain and or the higher ups don’t want things to change. I mean, the money and 3 day work week is pretty sweet.
I am an activity aide in a 23-resident dementia unit. The small room is L shaped. We have been informed chair alarms have been removed, and ” staff has to keep their eyes on the residents constantly “. Keep in mind, I said L-shaped room. And I agree with you about many of the CNAs being preoccupied with their phone or gossip. I have not figured out how to be focusing on a resident at one end of the room, and paying attention to the other 22 people. Contemplating quitting, as I am considered a trouble-maker,when I voice my opinion.