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A league of her own
From day one, Elizabeth Capezuti set her sights on improving care for what would become the largest patient population in the country—the elderly

By Pam Auchmutey

 

Elizabeth Capezuti (right) has approached the task of making bed siderails safer by working with a variety of experts in health care, law, social work, science, and engineering. Here Capezuti consults with Jennifer Coates, an MSN-MPH student in gerontology, and Martha Niblack, a resident at Wesley Woods Center.

 

 

At any given moment in a hospital or nursing home, an elderly patient risks falling from bed and suffering a serious or fatal injury. Elizabeth Capezuti is doing everything in her power to prevent that.

Ironically, the injuries she seeks to avoid are often caused by devices meant to keep patients from harm. An internationally known research scholar in gerontological nursing, Capezuti has questioned the routine usage of bed siderails and other physical restraints in the care of frail older patients. Her research focuses on developing nonrestraint interventions to enhance patient mobility and dignity, and her efforts have led to new guidelines governing hospital bed safety. Last fall, she brought her expertise to Emory to assume the Independence Foundation–Wesley Woods Chair in Clinical Gerontological Nursing Scholarship, supported by a previous endowment to nursing from the Independence Foundation in Philadelphia and by funding from Wesley Woods. Already, she is boosting interdisciplinary research and benefiting students enrolled in the Gerontological Advanced Practice Nurse Program.

“One of the things I want to do at Emory is to be involved at all levels,” says Capezuti, who came from the University of Pennsylvania School of Nursing. “I’m directing the GNP program, but I also want to work with faculty to infuse more geriatric content into the undergraduate and doctoral programs, so we can get students excited about the field. Without more faculty role models, we are not going to get the number of students and nurses that we need to care for our older population. That’s why this new appointment is so important to me.”


Blazing trails in long-term care

Capezuti knows what it’s like to get inspiration from faculty role models. As a nursing undergraduate in the mid-1970s, she was inspired by her own geriatrics instructors and chose to work in a nursing home right after college. At the time, few in health care foresaw the coming tide of changing demographics, with people age 85 and older now comprising the fastest-growing population segment.

“My background is unusual because there wasn’t a lot of strength in geriatric nursing when I entered the field,” she says. “When I attended Herbert Lehman College in the Bronx, there were two women on the faculty who would later become the leading experts in geriatric nursing in the country. They loved working with older people and knew their work was important. They were ahead of their time.”

Capezuti followed in their footsteps. After earning her master’s degree, she joined Penn in 1984 as a geriatric nurse practitioner and instructor. Among her colleagues were Neville Strumph and Mathy Mezey, her former Herbert Lehman instructors who had moved to Penn.

“Liz has been on the cusp of rising interest and specialization in gerontology,” says Strumph, now interim dean of nursing at Penn. “She is among the early stars educated at the master’s and PhD levels in gerontology who is making important contributions to the field.”

Under her mentors’ guidance, Capezuti evolved as a nurse scholar with interests in elder abuse and nonrestraint interventions to prevent falls and injuries among older patients. Initially, she focused on removal of vest and belt restraints, in which some patients became entangled and died of asphyxiation. “These interventions are not very dignified or positive in keeping people mobile or active,” says Capezuti. “They have just the opposite effect. I wanted to come up with new interventions and test the ones we had to see how effective they were in promoting safety, rehabilitation, and quality sleep, while preventing falls and injuries.”

Her program of research grew, and Capezuti zeroed in on restraints used at night, including bed siderails. Studies from the past 20 years clearly show that elderly patients can entrap themselves in the rungs of a siderail or between the mattress and siderail. Confused or in pain, some patients try to get out of bed by climbing over the siderail, which adds 2 feet to the height of a fall. Siderails have also been shown to contribute to emotional stress, urinary incontinence, and infections.


Raising rails, reducing liability

To understand these outcomes, Capezuti went back to the root of problem. Last year, she and Boston College nursing historian Barbara Brush searched through archives around the country to learn how bed siderails came into use. They found that nurses seldom used them before 1950 because rails had
to be manually attached to the bed. This practice changed when manufacturers began making hospital beds with affixed rails that nurses could raise and lower easily. Widespread siderail use coincided with another phenomenon—hospitals’ growing concern over liability.

“Patients and families were able to sue hospitals for malpractice,” Capezuti explains. “Insurance companies began to look at falls from beds and realized that if rails were raised, a jury was likely to decide in favor of a hospital. Hospitals knew that using bed siderails reduced their insurance claims, even though studies showed they weren’t effective in preventing falls. Raising rails protected them from liability.”

It wasn’t until the 1980s that health care and government experts began questioning this common practice and searching for suitable alternatives that would assist patients. “Rails were never designed to do that,” explains Capezuti. “They were meant to impede people. We don’t want to keep people in bed. We want to get people mobile and out of bed.”


Solutions from all angles

Capezuti has searched for solutions from all angles, working with lawyers, social workers, engineers, and scientists, in addition to health care experts. Among her collaborators is Julie Braun, a Chicago lawyer who co-wrote an article with Capezuti on the legal and medical aspects of restraints and bed siderails in nursing homes for the DePaul Journal of Health Care Law. Included are some practical methods for preventing falls and entrapment injuries, developed by Capezuti with input from fellow nurses and physicians. Bed bumpers, full body pillows, and rolled blankets can be placed to remind patients of the edge of the bed. A nonskid mat by the bed can prevent slipping. A low height of 6 inches to 13 inches makes nursing home beds safer for patients who habitually climb around or over bed siderails. Most important, an involved health care team can provide individual care plans that protect patients and reassure their families.

Despite growing evidence that siderails do not prevent falls and can lead to entrapment injuries, administrators, nurses, and physicians remain concerned with the legal implications of changing their usual practice. This fear is reinforced by the perception that failure to use siderails exposes hospitals to legal liability. Capezuti and Braun are using funding from the Food and Drug Administration (FDA) to examine all reported legal cases of bed-related falls among older adults in nursing homes and hospitals. Their project will evaluate the effect of recent Health Care Financing Administration (HCFA) siderail policy on current case law. Ultimately, their project could influence implementation of this policy by demonstrating legal support for changing practice paradigms.

Capezuti is also testing the effect of individualized interventions and new devices in removing siderails and preventing bed-related falls with more than $200,000 in funding from several private foundations. In addition, Capezuti and physicist Steve Lane have a $390,075 small business innovation grant from the National Institute of Nursing Research to design an air bag that inflates when a patient tries to get out of bed. When that happens, the patient encounters a soft cushion of air, instead of an unfriendly siderail. The device has sent its inventors back to the drawing board for some refinement. “We found that once the air bag inflates, patients think ‘hmm’ and turn around and go back to sleep. So the result is partly what we wanted—to deter them from becoming entrapped or falling. But the idea is also to help them get out of bed safely,” says Capezuti.

As the depth of her research expertise has grown, so has her clout in advocating change and raising awareness. For the past year and a half, Capezuti has served on the FDA’s Hospital Bed Safety Workgroup. Charged with regulating use of restraints as medical devices in hospitals and nursing homes, the FDA issues medical bulletins and safety alerts regarding their use. But updating hospital and nursing home staff on bed siderail use is difficult. Health care facilities are deluged with FDA alerts on any number of topics. And because there are no national statistics, experts often disagree on just how many injuries and deaths are caused by bed siderails. Thanks to Capezuti, HCFA’S newly revised guidelines give more weight to the issue.

“I worked with HCFA to change the standard to say you can’t raise a rail without a reason for it,” she explains. “You also have to carefully assess the situation. Is the bed safe? Does the mattress fit correctly? What is the person’s risk of becoming entrapped? The federal government has been quick to respond to this with new regulations—so quick that many clinicians don’t know about them or question why we need them. There’s still not a lot of awareness.”

Capezuti believes that is changing. “We are hearing more from hospitals and nursing homes about bed siderail accidents,” she says of her work with the Hospital Safety Bed Workgroup. “We don’t think there are more cases. We think more people are reporting entrapment or falls as the cause
of death.”


Joseph Ouslander, MD (right), played a key role in bringing Elizabeth Capezuti to Emory as a member of the nursing faculty and associate director of nursing sciences for the new Center for Health in Aging at Wesley Woods.

  The absolute right choice

Her work regarding the care and safety of older patients did not go unnoticed by those at Emory. Her move from Penn was prompted in part by an invitation from Joseph Ouslander, chief medical officer at Wesley Woods Center, to help lead its new Center for Health in Aging. Once fully established, the center will offer research, teaching, and educational programs in aging and geriatrics for students and faculty in medicine, nursing, and public health. Eventually, the center will include other university partners and provide educational programs for community agencies and the public.

“Dr. Capezuti has a major role in strengthening the ties in gerontology between Wesley Woods and the School of Nursing,” says Ouslander, director
of the new center. “She is the associate director for nursing sciences, where she will continue her research and develop new collaborations, and she
is involved with interdisciplinary training for nursing and medical students.”

It wasn’t hard for Capezuti to make up her mind about coming to Emory. The nursing school is led by Dean Marla Salmon, a former colleague from Penn. Last year, faculty members Christi Deaton and Patricia Clark completed postdoctoral fellowships in gerontology at Wesley Woods, supported by a Woodruff Foundation grant that also brings visiting scholars in the field to campus. And there is ample opportunity for Capezuti to continue her research. On Monday mornings, for instance, she does rounds at Atlanta’s VA nursing home with Ted Johnson, assistant professor of medicine, to study the healing of pressure ulcers from the perspective of nurse and physician.

“Emory was the absolute right choice for me,” says Capezuti. “Dean Salmon and Dr. Ouslander are the kind of people you want to work with. They’re always looking at tomorrow. As we collaborate and learn from each other, we will come up with ways to improve the health of the elderly.”

 

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