Incidence of physical restraints on acute general medical wards

Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department

OBJECTIVES

Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint.

RESULTS

Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)].

CONCLUSION

Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.

Prevalence and risk factors for seclusion and restraint in old-age psychiatry inpatient units

BACKGROUND AND OBJECTIVES

Coercion in psychiatry is legally tolerated as a last resort. The reduction of the use of coercion is a shared goal of hospital administrators, medical and nursing staff and representatives of patients and families but requires the identification of risk factors for coercion. These risk factors in geriatric psychiatric inpatient settings are not well known, especially regarding seclusion. Through examining the prevalence of coercion and patients' characteristics, this study aims to identify risk factors for coercion in elderly people.

METHODS

The use of coercion in the geriatric psychiatry division of Geneva University Hospital in 2017 was retrospectively analyzed. The incidence rate ratios were estimated with multivariable Poisson regressions to assess risk factors for coercion.

RESULTS

Eighty-one of 494 patients (16.4%) experienced at least one coercive measure during their stay (mainly seclusion). The risk factors for coercion were younger age, male gender, being divorced or married, cognitive disorders, high item 1 of the Health of the Nation Outcome Scales (HoNOS) score (overactive, aggressive, disruptive or agitated behavior) at admission, previous psychiatric hospitalizations and involuntary referrals from the emergency department. Other disorders and global HoNOS scores were not associated with the use of coercion.

CONCLUSION

Higher risks of coercion were outlined in men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. They differed from those observed in younger adults in terms of age, civil status, disorders, global HoNOS scores and referrals. Therefore, geriatric psychiatric populations should be specifically investigated for the development of interventions aiming coercion reduction.

Incidence Rate and Patterns of Physical Restraint Use Among Adult Patients in Malaysia

Incidence rate and patterns of physical restraint use were examined based on a cross-sectional study in 22 wards of a large teaching hospital in Malaysia. Results indicated that the highest rate of physical restraint (19.7%) was reported from neurology-neurosurgery wards. "Un-cooperative for electroconvulsive therapy" and "trying to pull out catheters" were the most commonly reported reasons to use restraint in psychiatric and non-psychiatric wards, respectively. There were some relationships between patterns of physical restraint in this study. Exploring the incidence rate and patterns of physical restraint is important so that effective strategies can be formulated to minimize using restraint in hospitals.

Prevalence and Correlates of Disruptive Behavior in the Nursing Home

Estimates of the prevalence of disruptive behavior in the nursing home are presented based upon a representative sample of nursing home residents from intermediate care and skilled nursing facilities (ICF and SNF) in Rhode Island. Results indicate that 26.4% of residents had engaged in some form of disruptive behavior within two weeks prior to assessment. Abusiveness (physical and verbal) and noisiness were identified as the most prevalent behavior types (11.6% and 10.2%, respectively). Given the similarity of Rhode Island nursing home residents to nursing home residents nationally, these estimates may be considered as estimates for the national nursing home population. Older residents and those with greater physical and cognitive impairments were more likely to exhibit behavior problems. Although disruptive behavior seems to be associated with the dementing process, cognitively intact residents also demonstrated these behaviors. These findings suggest that an etiology of disruptive behavior should include both physiological as well as social and psychological factors.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial

BACKGROUND

The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting.

OBJECTIVE

The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults.

METHODS

Secondary analysis was performed on data from the "Best Practices for End-of-Life Care for Our Nation's Veterans" (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation.

RESULTS

Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics.

CONCLUSIONS

This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities.

Physical restraint use and older patients' length of hospital stay

In both acute care and residential care settings, physical restraints are frequently used in the management of patients, older people in particular. Recently, the negative outcomes of physical restraint use have often been reported, but very limited research effort has been made to examine whether such nursing practice have any adverse effects on patients' length of stay (LOS) in hospitals. The aim of this study was to examine the association between physical restraint use on older patients during hospitalization and their LOS. Medical records of 910 older patients aged 60 years and above admitted to one of the Hong Kong public hospitals in 2007 were randomly selected and recorded during July to September 2011. The recorded items included patients' general health status, physical and cognitive function, the use of physical restraints, and patients' LOS. Hierarchical regression analysis was conducted to analyze the data. The results indicated that older patients' general health status, physical, and cognitive function were important factors affecting their LOS. Independent of these factors, the physical restraint use was still significantly predictive of longer LOS, and these two blocks of variables together served as an effective model in predicting older patients' LOS in the hospital. Since physical restraint use has been found to be predictive of longer hospital stay, physical restraints should be used with more caution and the use of it should be reduced on older patients in the hospital caring setting. All relevant health care staff should be aware of the negative effects of physical restraint use and should reduce the use of it in hospital caring and nursing home settings.

Early Pharmacological Treatment of Delirium May Reduce Physical Restraint Use

Introduction: Evidence surrounding pharmacological treatment of delirium is limited. The negative impact of physical restraints on patient outcomes in the intensive care unit (ICU), however, is well published. The objective of this study was to evaluate whether initiating pharmacologic delirium treatment within 24 hours of a positive screen reduces the number of days in physical restraints and improves patient outcomes compared with delayed or no treatment. Methods: Patients from a mixed ICU with a documented positive delirium score using the Intensive Care Delirium Screening Checklist were retrospectively grouped based on having received pharmacologic treatment within 24 hours of the first positive screen or not. Primary end points were number of days spent in physical restraints and time to extubation after delirium onset. Secondary end points included hospital and ICU length of stay (LOS) and survival to discharge. Results: Two hundred intubated patients were either pharmacologically treated (n = 98) or not treated (n = 102) within 24 hours of the first positive delirium score. Patients receiving treatment spent a shorter median time in restraints compared with patients who were not treated (3 vs 6 days; P < .001), and had a shorter median time to extubation (3 vs 6.5 days; P < .001). The treatment group also experienced a shorter ICU LOS (9.5 vs 16 days; P < .001) and hospital LOS (14.5 vs 22 days; P < .001) compared with the no-treatment group. Conclusions: Delirious patients who received pharmacological treatment within 24 hours of the first positive screen spent fewer days in physical restraints and less time receiving mechanical ventilation compared with those who did not. Although delirium management is multifactorial, early pharmacological therapy may benefit patients diagnosed with delirium.

Level of agitation of psychiatric patients presenting to an emergency department

OBJECTIVES

The primary purpose of this study was to determine the level of agitation that psychiatric patients exhibit upon arrival to the emergency department. The secondary purpose was to determine whether the level of agitation changed over time depending upon whether the patient was restrained or unrestrained.

METHOD

An observational study enrolling a convenience sample of 100 patients presenting with a psychiatric complaint was planned, in order to obtain 50 chemically and/or physically restrained and 50 unrestrained patients. The study was performed in summer 2004 in a community, inner-city, level 1 emergency department with 45,000 visits per year. The level of patient agitation was measured using the Agitated Behavior Scale (ABS) and the Richmond Agitation-Sedation Scale (RASS) upon arrival and every 30 minutes over a 3-hour period. The inclusion criteria allowed entry of any patient who presented to the emergency department with a psychiatric complaint thought to be unrelated to physical illness. Patients who were restrained for nonbehavioral reasons or were medically unstable were excluded.

RESULTS

101 patients were enrolled in the study. Of that total, 53 patients were not restrained, 47 patients were restrained, and 1 had incomplete data. There were no differences in gender, race, or age between the 2 groups. Upon arrival, 2 of the 47 restrained patients were rated severely agitated on the ABS, and 13 of 47 restrained patients were rated combative on the RASS. There was a statistical difference (p = .01) between the groups on both scales from time 0 to time 90 minutes. Scores on the agitation scales decreased over time in both groups. One patient in the unrestrained group became unarousable during treatment.

CONCLUSION

This study demonstrated that patients who were restrained were more agitated than those who were not, and that agitation levels in both groups decreased over time. Some restrained patients did not meet combativeness or severe agitation criteria, suggesting either that use of other criteria is needed or that restraints were used inappropriately. Further study of the level of agitation and the effects of restraints is needed.

The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review

BACKGROUND

Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling.

OBJECTIVE

The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.

INCLUSION CRITERIA

This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe.

ASSESSMENT OF METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument).

DATA EXTRACTION

Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI.

DATA SYNTHESIS

Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary.

RESULTS

Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls.

CONCLUSION

From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.

TREC-SAVE: a randomised trial comparing mechanical restraints with use of seclusion for aggressive or violent seriously mentally ill people: study protocol for a randomised controlled trial

BACKGROUND

Thousands of people whose aggression is thought due to serious mental illness are secluded or restrained every day. Without fair testing these techniques will continue to be used outside of a rigorous evidence base. With such coercive treatment this leaves all concerned vulnerable to abuse and criticism. This paper presents the protocol for a randomised trial comparing seclusion with restraints for people with serious mental illnesses.

METHODS/DESIGN

Setting-General psychiatric wards of a large psychiatric hospital in Rio de Janeiro, Brazil. Participants-Anyone aggressive or violent suspected or known to have serious mental illness for whom restriction is felt to be indicated by nursing and medical staff, but also for whom they are unsure whether seclusion or restraint would be indicated. Interventions-The standard care of either strong cotton banding to edge of bed with medications as indicated and close observation or the other standard care of use of a minimally furnished seclusion room but with open but barred windows onto the nursing station. Outcomes-time to restrictions lifted, early change of treatment, additional episodes, adverse effects/events, satisfaction with care during episode. Duration-2 weeks. Identifier: ISRCTN 49454276 http://www.controlled-trials.com/ISRCTN49454276.

Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature

Publications providing information on the safe use of physical restraints, guidelines for restraint use, and journal articles on the care of mental health patients are frequently devoid of information regarding patients' perspectives on physical restraint. As physical restraint is a common procedure in many settings, the purpose of this review is to examine and summarize the qualitative literature on patients' perspectives on being physically restrained, from 1966 through to 2009. A formal integrative review of existing qualitative literature on patients' perspectives of physical restraint was conducted. Studies were critiqued, evaluated for their strength, and analysed for key themes and meanings. Twelve studies were ultimately identified and included in the review. Four themes emerged from the review, including negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. While little qualitative research on patients' perceptions of physical restraint exists, findings within the current literature reveal serious implications for patients and nurses alike. Additional research into physical restraint implications for the patient-nurse dyad is needed, and nurses should approach the use of physical restraint with caution and awareness of their potential psychological impact.

Factor structure of the geriatric institutional assessment profile's professional issues scales

The Geriatric Institutional Assessment Profile (GIAP) is a self-administered survey of hospital nurses, designed to assess a hospital's readiness to implement geriatric programs. A sample of 2,211 direct care RNs in 24 hospitals was randomly split in half to analyze the Geriatric Professional Issues scales of the GIAP, using one sample for exploratory factor analysis and one for confirmatory factor analysis. An exploratory factor analysis of the six Geriatric Professional Issue scales (staff disagreement, staff/family/patient disagreement, use of geriatric services, perceived legal vulnerability, perceived upsetting behaviors, and burden of upsetting behaviors) demonstrated very good internal consistency both as a whole (Cronbach's alpha coefficient = 0.90) and as individual factors (0.94, 0.91, 0.92, 0.89, 0.85, and 0.81, respectively). The six factors were validated in a half randomly selected sample, with a root-mean-square error of approximation fit index of 0.07 and the normed and non-normed fit indices both 0.8, all indicating adequate fit of the six-factor model.

Programme d'intervention visant à réduire l'utilisation des contentions physiques dans des unités de soins de longue durée — mise en oeuvre et effets sur le personnel soignant

This study aimed at (a) developing a restraint reduction program, (b) describing its implementation in long-term care units, and (c) examining its effects on care staff's perceptions of and knowledge about the use of restraints. The program was composed of three parts: consciousness-raising meetings, staff education, and clinical follow-up. The study was a randomized, controlled clinical trial with eight intervention care units (five nursing homes) and 11 controls (five additional nursing homes). Care staff was surveyed at two time intervals over a 7-month period (pre- and post-test intervention; intervention care units: N = 171 [T0] and N = 158 [T1]; controls: N = 181 [T0] and N = 166 [T1]). The implementation of the program was successful and results showed significant changes in care staff perceptions of and knowledge about the use of restraints.

Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US

PURPOSE

To describe physical restraint (PR) rates and contexts in U.S. hospitals.

DESIGN

This 2003-2005 descriptive study was done to measure PR prevalence and contexts (census, gender, age, ventilation status, PR type, and rationale) at 40 randomly selected acute care hospitals in six U.S. metropolitan areas. All units except psychiatric, emergency, operative, obstetric, and long-term care were included.

METHODS

On 18 randomly selected days between 0500 and 0700 (5:00 am and 7:00 am), data collectors determined PR use and contexts via observation and nurse report.

FINDINGS

PR prevalence was 50 per 1,000 patient days (based on 155,412 patient days). Preventing disruption of therapy was the chief reason cited. PR rates varied by unit type, with adult ICU rates the highest obtained. Intra- and interinstitutional variation was as high as 10-fold. Ventilator use was strongly associated with PR use. Elderly patients were over-represented among the physically restrained on some units (e.g., medical) but on many unit types (including most ICUs) their PR use was consistent with those of other adults.

CONCLUSIONS

Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts. Anesthetic and sedation practices have contributed to high variation in ICU PR rates. Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type.

Evidence-based treatment of psychiatric patient

There is controversy concerning the proper treatment of psychiatric patients in the emergency department. Emergency physicians commonly use physical or chemical restraints or both in the course of treating psychiatric patients. This review applies the rigors of an evidence-based evaluation of the literature concerning the choices of treatment for these patients.

Use of Physical Restraints in Adult Critical Care: A Bicultural Study

• Background Although controversial, physical restraints are commonly used in adult critical care units in the United States to prevent treatment interference and self-inflicted harm. Use of physical restraints in Norwegian hospitals is very limited. In the United States, an experimental design for research on use of restraints has not seemed feasible. However, international research provides an opportunity to compare and contrast practices.

• Objectives To describe the relationship between patients’ characteristics, environment, and use of physical restraints in the United States and Norway.

• Methods Observations of patients and chart data were collected from 2 intensive care units (n = 50 patients) in Norway and 3 (n = 50 patients) in the United States. Sedation was measured by using the Sedation-Agitation Scale. The Nine Equivalents of Nursing Manpower Use Score was used to indicate patients’ acuity level.

• Results Restraints were in use in 39 of 100 observations in the United States and not at all in Norway (P = .001). Categories of patients were balanced. In the Norwegian sample, the median Nine Equivalents of Nursing Manpower Use Score was higher (37 vs 27 points, P &lt; .001), patients were more sedated (P &lt; .001), and nurse-to-patient ratios were higher (1.05:1 vs 0.65:1, P &lt; .001). Seven incidents of unplanned device removal were reported in the US sample.

• Conclusions Critical care units with similar technology and characteristics of patients vary between nations in restraint practices, levels of sedation, and nurse-to-patient ratios. Restraint-free care was, in this sample, safe in terms of treatment interference.

Factors relating to the use of physical restraints in psychogeriatric care: A paradigm for elder abuse

The purpose of this study was to address one component of the complex topic "elder abuse". A prospective observational study in the psychogeriatric unit of an acute psychiatric hospital demonstrated that 30% (n=37) of all included patients (n=122) were physically restrained. The highest incidence (48%) was found in elderly patients with severe cognitive impairments (diagnosis of dementia and/or delirium) (n=60). The most commonly used devices of physical restraints were bed rails (100%), belts (trunk 93%, limbs 40%) and chair-tables ("gerichair") (41%). Most restraints occurred at the beginning of hospitalization (83%). Physical restraints were continued for many days and on average of many hours a day. Patients with low cognitive status and serious mobility impairments showed a very high risk of being restrained (p=0.015; OR 32.0 [95% CI:2.0-515.1]). Inability to perform ADL activities increased the frequency of restraint use (p=0.035; OR27.7 [95%CI: 1.3-604.1]). As possible co-factors repetitive disruptive behaviors were found. There was no significant difference between the frequency of falls in restrained or unrestrained patients during the observational period, but fall-related fractures (n=2) only occurred in restrained patients. It is possible that restraints increase the use of benzodiazepines and classical neuroleptics. These results confirm that physical restraints remain a common practice in psychogeriatric care. No evidence-based data support the value of restraints in regard to fall prevention and control of behavioral disturbances in elderly people with serious mental illness. In contrast, these devices can have serious adverse effects and mean one of the most severe interventions in fundamental human rights.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

[Physical restraint in old people's homes. Evaluation of skills following specific training]

AIM

The use of physical restraint in elderly patients is sometimes necessary but not without risk. We studied the prevalence and modalities of physical restraint in elderly patients in 6 old people's homes in the urban area of Toulouse, and emphasized the need for better use by the nursing staff of physical restraint in such patients with a specific training course.

METHODS

Other than the prevalence of restraint, we also examined the modalities of its use in elderly patients. We studied the respect of the Anaes (Agence nationale d'accréditation et d'évaluation en santé) guidelines regarding the use of restraint in such patients, before and after an intervention that associated first a collective training course of all the staff in the old people's homes, and then specific individual training by a visiting practitioner. The information concerning the number of patients in whom restraint was used was obtained from the manager of the home or from the head nurse and was then checked by the investigator.

RESULTS

The prevalence of restraint was of 22.2% (n=110 patients) at the start of the study, 15.9% following training sessions (at 6 months) and 15.5% at the end of the study (at 9 months). Skills improved regarding the benefit/risk assessment, the installation of the person restrained and the regular removal of the restraint during the day.

CONCLUSION

Our strategy helped to underline this problem for the staff. The Anaes guidelines are too strict to be applied in old people's homes. One of the key points in improved management would be the presence of a coordinating physician and nurse in all the institutions caring for the elderly.

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES

To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.

DESIGN

Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.

SETTING

Eleven medical and surgical units in one 600-bed teaching hospital.

PARTICIPANTS

One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.

MEASUREMENTS

Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix.

RESULTS

Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001).

CONCLUSION

Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

A prospective study of the complication rate of use of patient restraint in the emergency department

Patients are frequently involuntarily, physically restrained in the emergency department (ED). The purpose of this study was to determine the type and rate of complications experienced by patients physically restrained in the ED. A prospective, observational study was performed on consecutive patients who were restrained in a community, inner-city teaching hospital ED for a 1-year period. The ED nurses or physicians completed a restraint study checklist. The checklist included the reasons for restraints, restraint duration, method and number of restraints, use of chemical restraint, and complications resulting from the use of restraints. The 298 patients were accumulated during a 1-year period. The mean age was 36.5 years (range 14-89). Sixty-eight percent were men; 73% were African-Americans, 16% Hispanic, and 11% Caucasian. One hundred six patients had more than one indication for patient restraint. Patients were restrained for a mean of 4.8 h (range 0.2-25.0 h), with psychosis being the most frequent discharge diagnosis (33%). Patients were most frequently restrained on a cart with two restraints (59%), in the supine position (86%), and 27.5% had chemical restraint added. There were 20 complications (7%); getting out of restraints was the most common (10) and the remainder included vomiting (3), injured others (2), spitting (2), injured self (1), increased agitation (1), and other (1). These complications were not correlated with age, gender, race, number of restraints, use of chemical restraint, diagnosis, or duration of restraint. This study demonstrates a low rate of minor complications. We found that male patients were most often restrained for violent and disruptive behavior. Most commonly, two restraints were used in combination with chemical restraints for a duration of almost 5 h.

Patient injury and physical restraint devices: a systematic review

OBJECTIVE

To investigate physical restraint-related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury.

DEFINITIONS

Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization.

METHOD

A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion.

RESULTS

The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint-related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined.

DISCUSSIONS

Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.

A review of physical restraint minimization in the acute and residential care settings

OBJECTIVES

The objective of this review was to investigate physical restraint minimization in acute and residential care settings. The first aim was to determine the effectiveness of attempts to minimize the use of physical restraint, and the second was to generate a description of the characteristics of restraint minimization programmes.

METHOD

A comprehensive search was undertaken involving all major databases and the reference lists of all relevant papers. To be included in the review studies had to be an evaluation of restraint minimization in an acute or residential care setting. As only a single randomized controlled trial (RCT) was identified, it was not possible statistically to pool the findings of different studies on the effectiveness of restraint minimization. To generate a description of the characteristics of restraint minimization programmes, the reported components of these programmes were identified and categorized.

RESULTS

A total of 16 studies evaluating restraint minimization were identified: three in acute care and 13 in residential care. Of these, only one was an RCT, with the most common approach being the before and after study design. Based on the findings of the single RCT, education supported by expert consultation effectively reduced the use of restraint in residential care. There has been little evaluation of restraint minimization in acute care settings. The common approach to restraint minimization has involved a programme of multiple activities, with restraint education being the characteristic common to most programmes.

DISCUSSION

Evidence suggests that physical restraint can be safely reduced in residential care settings through a combination of education and expert clinical consultation. There is little information on restraint minimization in acute care settings. The major finding of this review is the need for further investigation into all aspects of restraint minimization.

Individualized music--a different approach to the restraint issue

Rehabilitation nurses who work with geriatric patients are concerned about reliance on physical restraints, as are all nurses. Controversy exists as to the benefits and risks, as well as the ethical and legal consequences, of their use. Nurses are ambivalent about using restraints, believing that they affect patients' freedom, self-respect, and self-reliance; they also often believe that there are no appropriate alternatives. This pilot study explored the use of music as a potential alternative to using physical restraints with hospitalized patients. The research question was: Will patients have more positive behaviors, as measured by the Restraint Music Response Instrument (RMRI), while out of restraints and listening to preferred music compared with the patients not listening to music who are out of restraints while being observed? Forty medical-surgical patients participated in the study and were randomized into either the experimental group (music) or the control group (no music). The mean age of the 21 males and 19 females was 76.6 years (range 56-94). A t test for equality of means was used to determine if there were differences in the number of positive and negative behaviors in the preintervention, intervention, and postintervention phases between the two groups. There was a significant difference (p < .01) in behaviors during the intervention phase. Patients who listened to preferred music had more positive behaviors while out of restraints than patients who were out of restraints but not exposed to music.

Cognitive status and behavioral problems in older hospitalized patients

OBJECTIVES: (a) To determine the quantity and quality of behavioral problems in older hospitalized patients on acute care units; (b) to determine the burden of these behaviors on staff; and (c) to identify predictors of behavioral problems. METHODS: Upon admission, patients performed the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale (GDS), and information was obtained on age, ethnicity, level of education, living arrangement, and psychiatric history. Two days post-admission, a clinical staff member caring for each patient, performed the Neuropsychiatric Inventory-Questionnaire (NPI-Q) to assess patients' behavioral problems and staff distress. PARTICIPANTS AND SETTING : Forty-two patients, over 60 years of age, admitted to medical and surgical units of the Veterans Affairs Hospitals in Palo Alto and San Francisco, participated. RESULTS: Twenty-three of 42 (55%) patients exhibited behavioral problems. Anxiety, depression, irritability, and agitation/aggression were the most frequently observed behaviors. The severity of the behavioral problems was significantly correlated with staff distress. Lower performance on the MMSE at admission was significantly associated with higher NPI-Q ratings. Specifically, of those cases with scores less than or equal to 27 on the MMSE, 66% had behavioral problems during hospitalization, compared to only 31% of those with scores greater than 27. CONCLUSION: Behavioral problems in older hospitalized patients appear to occur frequently, are a significant source of distress to staff, and can result in the need for psychiatric consultation. Assessment of the mental status of older adults at admission to hospital may be valuable in identifying individuals at increased risk for behavioral problems during hospitalization.

Reasons for physically restraining patients and residents: a systematic review and content analysis

OBJECTIVE

The purpose of this systematic review was to determine why people are physically restrained in the acute and residential care settings.

METHOD

A comprehensive search was undertaken of electronic databases to identify studies addressing the reasons for using physical restraint. Findings were synthesised using content analysis.

RESULTS

Twenty-three studies were identified. The most common reason for using restraints related to patient-oriented issues such as ensuring the safety of people. However, they are also commonly used to facilitate treatment, maintain the social environment and because of issues such as understaffing.

Outcomes following physical restraint reduction programs in two acute care hospitals

BACKGROUND

Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities.

METHODS

The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists.

RESULTS

Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event.

DISCUSSION

Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns.

SUMMARY

Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Staffing and pattern of mechanical restraint use across a multiple hospital system

BACKGROUND

In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals.

OBJECTIVES

To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing.

METHODS

This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999.

RESULTS

The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001).

CONCLUSIONS

Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Nurses' use of restraints and their attitudes toward restraint use and the elderly in an acute care setting

A descriptive correlation study was conducted in an acute-care hospital to explore the relationship between nurses' use of restraints and their attitudes toward restraint use and the elderly. A total of 201 nurses returned a questionnaire that collected demographic information and included two research instruments: (i) Perceptions of Restraint Use Questionnaire and (ii) Attitudes toward the Aged Semantic Differential. Results showed slightly positive attitudes towards the elderly and toward the use of restraints, although there was no correlation between scores on the two scales. Furthermore, nurses' attitudes did not predict their self-reported use of restraints.

Physical restraint management of hospitalized adults and follow-up study

During the winter of 1998 the management of 118 (N = 118) physically restrained adult patients in a 238-bed urban acute care hospital were assessed by 26 registered nurse (RN) data collectors. In the spring of 1999, following a comprehensive hospital-wide staff development program and revised physical restraint protocol, 10 RN data collectors conducted a follow-up study of 53 (N = 53) restrained adults in the same institution. In both studies, data regarding restraints management were gathered using a Restraint Management Improvement Indicator. Following a program of restraint management education, substantial improvements were found for virtually all of the physical restraint indices studied. The findings suggest that future educational efforts should be undertaken to further improve the documentation in hospital medical records regarding medical orders and ongoing observation, assessment, and interventions for physically restrained patients. Future research should further document and study interventions to reduce or eliminate the use of physical restraints.

Initiation of physical restraint in nursing home residents following restraint reduction efforts

In this pilot study a one group pretest posttest design was employed to identify resident characteristics and environmental factors associated with initiation of physical restraint. Predictors of restraint initiation for older adults were examined using secondary analysis of an existing data set of nursing home residents who were subjected to a federal mandate and significant restraint reduction efforts. Lower cognitive status (OR = 1.5 [for every 7-point decrease in Mini-Mental State Examination], 95% CI = 1.0, 2.1) and a higher ratio of licensed nursing personnel (OR = 3.7, 95% CI = 1.2, 11.9) were predictive of restraint initiation. Key findings suggest that restraint initiation occurs, despite significant restraint reduction efforts, when a nursing home resident is cognitively impaired or when more licensed nursing personnel (predominantly licensed practical nurses) are available for resident care. Achievement of restraint-free care in nursing homes requires specific and individualized approaches for residents who are cognitively impaired, as well as greater attention to staff mix of registered nurses, licensed practical nurses, and nursing aides.

Israeli student nurses' attitudes about physical restraints in acute care settings

A total of 147 nursing students from an academic school of nursing in Israel, affiliated with the Nursing Department at Tel Aviv University, were studied to determine their attitudes toward the use of physical restraints, their knowledge of patient restraint protocol, related reasons, alternatives, follow-up, and reporting. Data were analyzed according to the student's year of learning and experience in restraining. Significant results showed that most students displayed negative attitudes toward restraining. Most were quite knowledgeable of patient restraint protocol, but they acted according to accepted practice in the hospital wards. These findings suggest that nursing educators must play an important role in reinforcing knowledge and improving the practicum of nursing students in the clinical area concerning restraints. This goal will be achieved by various educational strategies.

Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts

OBJECTIVES

To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction.

DESIGN

Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design.

SETTING

Three nonprofit, religion-affiliated nursing homes in a metropolitan area.

PARTICIPANTS

The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years.

MEASUREMENTS

Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined.

RESULTS

Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use.

CONCLUSION

Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.

Use of physical restraints on elderly patients: an exploratory study of the perceptions of nurses in Hong Kong

A qualitative study was designed to explore nurses' perceptions of the use of physical restraints on elderly patients in Hong Kong. Content analysis of semi-structured interviews with 20 registered nurses working in medical and geriatric settings of two regional hospitals revealed that although nurses generally had mixed feelings about the use of physical restraints on elderly patients, they did not question this 'routine' practice and their knowledge about the consequences and alternatives to the use of restraint was limited. It was found that nurses had an overriding concern in ensuring elderly patients' physical safety and using restraints therefore provided them with a sense of security. The deleterious impact of restraint on the care received by elderly patients was largely unrecognized. Implications for practice and future studies are discussed in the light of these findings.

Prevalence and patterns of physical restraint use in the acute care setting

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

Geropsychiatric restraint use

OBJECTIVES

To investigate predictors and reasons for restraint use with geropsychiatric patients.

DESIGN

A prospective, correlational study.

SETTING

The geriatric unit of an acute-care psychiatric hospital.

PARTICIPANTS

Twenty-one staff nurses and 131 patients admitted consecutively over a period of 6 months.

MEASUREMENTS

Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini-Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses.

RESULTS

Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%.

CONCLUSIONS

The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation.

Research-based practice: reducing restraints in an acute care setting--phase I

The purpose of this research utilization project was to select and implement a research-based Restraint Education Program for reducing the use of restraints in an acute care setting by changing the perception of the restraint coordinators about restraints in the direction of decreased importance. The Iowa Model, Research Based Practice to Promote Quality Care (Titler et al., 1994) was selected to guide the change process. A multidisciplinary team reviewed the restraint policy and procedure, new restraint products and alternative restraint methods. After a review of the literature on restraint education programs, the committee concluded that education was the key component in decreasing the use of physical restraints. The research-based Restraint Education Program developed by Drs. Strumpf and Evans was selected as the educational program. Education sessions were developed and a pilot study was conducted with the restraint coordinators. The Perceptions of Restraint Use Questionnaire (PRUQ) (Strumpf & Evans, 1988) was administered before and after the education sessions. The results of the t-test showed a decrease in the post-test mean scores on 7 of the 17 items indicating a less important perception by the staff about the use of restraints. Four items had an increase in mean scores on the post-test indicating the restraint coordinators increased their perception of the importance of physical restraints with these items. The restraint education program was presented to the nursing staff throughout the institution. Risk management and quality assurance will monitor patients restrained and evaluate the nursing staff with the PRUQ in 3 months.

Music intervention with physically restrained patients

Lack of appropriate alternatives to the use of restraints in hospitals and rehabilitation settings is a major concern of nurses. The purpose of this pilot study was to determine the behavioral effects of music intervention with physically restrained patients. The results demonstrated that the number of positive behaviors increased significantly during the music-listening period, during which patients were not restrained, as compared to their typical restrained status. No differences were found that related to the number of negative behaviors displayed before, during, or after the music intervention. Listening to music of their own choosing may help produce positive behaviors in previously restrained patients; however, further studies are needed to confirm this.

Restraint-free care for acutely ill patients in the hospital

A growing body of empirical evidence documenting the negative effects and the limited effectiveness of physical restraints continues to shape policy and professional standards. In addition to occurrences of serious harm from restraint devices, ethical concerns about care with dignity have supported reevaluation of restraints in all settings for all patients. Lessons from considerable research conducted in nursing homes and clinical experience with restraint reduction in long-term care facilities are applicable to acute care settings, where restraint-free care can and should be embraced.