Tilt-in-Space vs. Restraints

Q: Are Broda's tilt-in-space wheelchairs considered restraints?

A: No, they are not restraints. Rather, they are Supportive Positioning Devices.
When Broda’s Tilt-in-Space Seating Systems are used properly following the obtainment of a physician’s order and in accordance with the patient care plan they are not considered a restraint.

Let us explain, by definition “A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely” (CFR 482.13(e)(1)).¹ However, 482.13(e)(1)(i)(C) clarifies that “a restraint does not include devices, such as orthopedically prescribed devices…” (typically used for medical-surgical care). As such, this definition does not apply to wheelchairs, seating systems, and secondary supports when used to provide postural support, stability, pressure distribution and pressure relief, as opposed to intentionally immobilizing or reducing movement. The movement may be limited by this seating technology; however, the intent is postural support, stability, pressure distribution and pressure relief for improved function, not a limitation of movement.

According to RESNA², “The purpose of tilt and recline technologies is not that of restraint, but rather re-orienting or repositioning the body for any of the following reasons: pressure redistribution, pressure relief, postural control, pain and fatigue management, post-seizure management, catheterization, dressing, transfers, feeding, and passive range of motion (Dicianno, 2009).

There have been cases when these technologies, particularly tilt, have been perceived as a restraint due to the fact that it is more difficult for an individual to get out of the wheelchair if it is tilted rearward. It is true that attempting to exit a wheelchair when it is tilted is very difficult and may result in a fall. However, when tilt or recline is used for any of the purposes stated above it should not be considered a “restraint” despite its limiting effect on the person’s ability to exit from the wheelchair. In this case, the clinical benefits may still outweigh independent exit.

Q: How do we keep from getting cited for using Broda's Tilt-in-Space seating systems during CAHPS survey?

A:
By using a DETAILED PHYSICIANS ORDER, CLEAR CLINICAL DOCUMENTATION AND A COMPLETE PATIENT CARE PLAN.

The patient care plan and the contents thereof holds the possibility of multiple deficiencies if the documentation is not accurate, clear, complete, detailed, reviewed and timely. The patient care plan has been one of the top 2 deficiencies cited during survey since 2014. Understanding what is required in the patient care plan is vital to the successful completion of your survey. It is vitally important that the Clinical Assessment and Documentation clearly detail and support the use of Broda’s Tilt-in-Space seating as well as any additional supportive devices that are medically necessary. Being prepared with clean, clear and accurate clinical documentation can mean the difference between a deficiency-free survey and one that will require an extensive plan of correction.

Any time Broda chairs are needed for patient use, you must ensure that the following is completed to maintain compliance:
  1. Complete a Comprehensive Clinical Assessment detailing the need for the equipment.
  2. Obtain an order from the patients Attending Physician detailing the type of equipment, reason for use and length of time equipment will be used.
  3. Update the Patient Care Plan to include the use of the Durable Medical Equipment including; Assessment, Indication for use, Interventions, Goals and Expected Outcome.
  4. Review and document continued the need for ALL equipment including, Reassessment of the patient, Indications for extended use, Interventions, Goals and Expected Outcome.
  5. Obtain Attending Physicians signature on all care plans and other documents as applicable.
  6. Review and ensure the Attending Physicians order for the equipment is current, up to date and included in the patient’s clinical record.
  7. Complete and Document ALL staff education and training related to the equipment being used and have available upon request.
  8. If the equipment or secondary supports are or may be considered a restraint, ensure that safety checks are completed and documented per facility protocol, State, and Federal Regulations and are included in the patient’s clinical record.
  9. Ensure all equipment is used following facility protocol, State / Province, and Federal Regulations.
Sources:
  1. ELECTRONIC CODE OF FEDERAL REGULATIONS SUBPART B 482.13 
  2. The Application of Wheelchairs, Seating Systems, and Secondary Supports for Positioning vs. Restraint

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