Alarm Devices Instead of Restraints?

To the Editor:—Up to 50 percent of long-term-facility residents aged 65 and older experience one or more falls annually.1 Most occur during resident transfers in and out of beds and chairs. To guard against the risk of falls and physical injury, nursing facilities in the past have resorted to mechanical devices such as side rails, vests, or waist restraints to restrict unsafe movement out of beds and chairs. However, due to federal initiatives, such as the Omnibus Budget Reconciliation Act of 1987 (OBRA) which discourages the employment of physical restraints, health providers are developing alternatives to restraints as fall preventive measures. Alarm devices (ADs) have been advocated by several as one such alternative.2–4 ADs are designed to detect residents at fall risk who are attempting an unsafe bed or chair transfer.5 These devices, which attach to the resident's bed, chair or wheelchair, function by allowing residents to maintain a free movement zone or area of normal activity. But if residents leave their chair or bed and exceed the free movement zone, a warning sounds and alerts the nursing staff. While ADs appear to be an innovative approach to the prevention of falls and elimination of restraints, and are being commercially marketed to the nursing home industry for these purposes, to our knowledge there are no studies that have documented the benefits and/or problems associated with ADs. Preparatory to an efficacy study of ADs, we conducted a survey at the Jewish Home and Hospital for Aged in New York City to examine: (1) the characteristics of residents placed on ADs and (2) the perceived benefits and problems of ADs according to physicians, nurses, aids, administrative staff, and family members of residents using ADs. A total of 26 residents (mean age 86) were identified as either current (n = 15) or former (n = 11) AD users. The leading characteristics of residents on ADs included cognitive impairment (mean MMSE = 9) and an inability to ambulate independently (62 percent). ADs were used for the purposes of eliminating restraints in residents with prior falls (54 percent), and preventing falls in those residents at risk due to intrinsic and/or extrinsic factors (33 percent). In 13 percent of cases the reasons for use of ADs were not documented. A total of 55 staff and 11 family members were interviewed. Seventy percent of staff members believed that ADs were effective in preventing falls and/or reducing the need for restraints. Family members (81 percent) believed ADs to be effective alternatives to physical restraints. Forty-eight percent of the respondents identified problems with ADs: mechanical problems (35 percent), such as false alarms and malfunction; staff problems (7 percent) which included increased work (attending to the residents' needs), delayed time to respond, excessive cost, and lack of established criteria for their use; and resident problems (5 percent), consisting of residents frightened by the presence or sound of the AD and residents rendering the AD inoperable. In the 11 residents in whom ADs were discontinued, the resident's condition improved or the resident became more functionally dependent (ie bedfast) and no longer warranted a device (54 percent), the AD was removed because of mechanical or resident problems (36 percent) or the AD had no benefit. While these results are encouraging, more research needs to be done before ADS can be fully considered as an approach to the prevention of falls and the elimination of restraints. Specifically, controlled studies on the efficacy of ADs are crucial. Further, research comparing the various AD designs available in terms of safety and adverse effects needs to be completed. Until then, we advise caution in their use. An over-reliance on ADs, in light of their unproven consequences, may result in falls and the risk of legal liability if residents sustain physical injury.