Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings

BACKGROUND

Physical restraints, such as bedrails, belts in chairs or beds, and fixed tables, are commonly used for older people in general hospital settings. Reasons given for using physical restraints are to prevent falls and fall-related injuries, to control challenging behavior (such as agitation or wandering), and to ensure the delivery of medical treatments. Clear evidence of their effectiveness is lacking, and potential harms are recognised, including injuries associated with the use of physical restraints and a negative impact on people's well-being. There are widespread recommendations that their use should be reduced or eliminated.

OBJECTIVES

To assess the best evidence for the effects and safety of interventions aimed at preventing and reducing the use of physical restraint of older people in general hospital settings. To describe the content, components and processes of these interventions.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 20 April 2022.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials that investigated the effects of interventions that aimed to prevent or reduce the use of physical restraints in general hospital settings. Eligible settings were acute care and rehabilitation wards. We excluded emergency departments, intensive care and psychiatric units, as well as the use of restrictive measures for penal reasons (e.g. prisoners in general medical wards). We included studies with a mean age of study participants of at least 65 years. Control groups received usual care or active control interventions that were ineligible for inclusion as experimental interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles for inclusion, extracted data, and assessed the risk of bias of all included studies. Data were unsuitable for meta-analysis, and we reported results narratively. We used GRADE methods to describe our certainty in the results.

MAIN RESULTS

We included four studies: two randomised controlled trials (one individually-randomised, parallel-group trial and one clustered, stepped-wedge trial) and two controlled clinical trials (both with a clustered design). One study was conducted in general medical wards in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. A total of 1709 participants were included in three studies; in the fourth study the number of participants was not reported. The mean age ranged from 67 years to 84 years. The duration of follow-up covered the period of patients' hospitalisation in one study (21 days average length of stay) and ranged from 4 to 11 months in the other studies. The definition of physical restraints differed slightly, and one study did not include bedrails. Three studies investigated organisational interventions aimed at implementing a least-restraint policy to reduce physical restraints. The theoretical approach of the interventions and the content of the educational components was comparable across studies. The fourth study investigated the use of pressure sensors for participants with an increased falls risk, which gave an alarm if the participant left the bed or chair. Control groups in all studies received usual care. Three studies were at high risk of selection bias and risk of detection bias was unclear in all studies. Because of very low-certainty evidence, we are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on our primary efficacy outcome: the use of physical restraints in general hospital settings. One study found an increase in the number of participants with at least one physical restraint in the intervention and control groups, one study found a small reduction in both groups, and in the third study (the stepped-wedge study), the number of participants with at least one physical restraint decreased in all clusters after implementation of the intervention but no detailed information was reported. For the use of bed or chair pressure sensor alarms for people with an increased fall risk, we found moderate-certainty evidence of little to no effect of the intervention on the number of participants with at least one physical restraint compared with usual care. None of the studies systematically assessed adverse events related to use of physical restraint use, e.g. direct injuries, or reported such events. We are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on the number of participants with at least one fall (very low-certainty evidence), and there was no evidence that organisational interventions or the use of bed or chair pressure sensor alarms for people with an increased fall risk reduce the number of falls (low-certainty evidence from one study each). None of the studies reported fall-related injuries. We found low-certainty evidence that organisational interventions may result in little to no difference in functioning (including mobility), and moderate-certainty evidence that the use of bed or chair pressure sensor alarms has little to no effect on mobility. We are uncertain about the effect of organisational interventions on the use of psychotropic medication; one study found no difference in the prescription of psychotropic medication. We are uncertain about the effect of organisational interventions on nurses' attitudes and knowledge about the use of physical restraints (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.

Implementation of nonpharmacologic physical restraint minimization interventions in the adult intensive care unit: A scoping review

OBJECTIVE

To identify the elements informing the successful implementation of nonpharmacologic physical restraint minimization interventions in adult intensive care unit patients. To map those elements to innovation, context, recipients and facilitation domains of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and to describe the outcomes of those interventions.

METHODOLOGY

A scoping review of studies published in English reporting on restraint minimization interventions in adult intensive care units. We searched seven databases (MEDLINE, CIHAHL, Embase, Web of Science, Cochrane Library, PROSPERO and Joanna Briggs) from inception to 2021. Two authors independently screened articles for inclusion, extracted study characteristics and mapped intervention data to the i-PARIHS domains.

RESULTS

Seven studies met inclusion criteria. Innovations comprised multicomponent interventions including education, decision aids/protocols and restraint alternatives. No studies utilised an implementation science framework to diagnose the baseline practice context. A commonly reported barrier to restraint minimization was a risk averse culture. Change was mostly driven by the external context (i.e. national regulations). Overall, nurses were the primary facilitators and recipients of practice change. Outcomes were changes in restraint incidence and prevalence abstracted from the medical record. However, no study validated the accuracy of restraint documentation. All studies documented an initial decrease in physical restraint use, but no long-term results were reported.

CONCLUSION

Restraint minimization intervention studies report nurse-facilitated multicomponent interventions and short-term practice change. Future restraint minimization research incorporating implementation science frameworks, interprofessional teams and patient/family perspectives is warranted.

The principles of physical restraint use for hospitalized elderly people: an integrated literature review

BACKGROUND

Physical restraint (PR) is a routine care measure in many hospital wards to ensure patient safety. However, it is associated with many different professional, legal, and ethical challenges. Some guidelines and principles have been developed in some countries for appropriate PR use. The present study aimed to explore the principles of PR use for hospitalized elderly people.

METHODS

This was an integrative review. For data collection, a literature search was conducted in Persian and English databases, namely Magiran, Scientific Information Database (SID), Scopus, Google Scholar, Web of Science, and PubMed as well as the websites of healthcare organizations and associations. Eligibility criteria were publication in English or Persian between January 1, 2010, and January 1, 2021, and description of the principles of PR use for hospitalized elderly people. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for document screening and selection, while the critical appraisal tools of the Joanna Briggs Institute (JBI) and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument were used for quality appraisal. The data were analyzed through constant comparison.

RESULTS

Primarily, 772 records were retrieved, while only twenty were eligible for the study. The principles of PR use for hospitalized elderly people were categorized into six main categories, namely principles of education for PR use, principles of decision making for PR use, principles of implementing the PR procedure, principles of monitoring patients with PR, principles of PR use documentation, and principles of PR management.

CONCLUSION

PR should be used only by trained healthcare providers, with the consent of patient or his/her family members, with standard devices and safe techniques, based on clear guidelines, and under close managerial supervision. Moreover, elderly people with PR should continuously be monitored for any PR-related complications. The findings of the present study can be used for developing clear PR-related guidelines.

Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

BACKGROUND

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects).

METHODS

A secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016-2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed.

RESULTS

The study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%.

CONCLUSIONS

The use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible.

Physical and Pharmacological Restraints in Hospital Care: Protocol for a Systematic Review

BACKGROUND

Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting.

METHODS

A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied.

DISCUSSION

This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42019116186.