Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan

Organizational factors associated with less use of restraints in older adults with dementia in acute care hospitals: A scoping review

OBJECTIVE

Dementia affects more than 55 million people worldwide. Use of restraints for hospitalized older adults with dementia is a social issue that should be addressed systematically and should not depend on the characteristics of nurses. This study reviewed the literature on organizational factors associated with reducing use of restraints in older adults with dementia admitted to acute care hospitals.

METHODS

A scoping review was performed. Three databases were searched for papers that met our eligibility criteria. Factors related to restraint reduction were extracted, and results were deduced. Through inductive analysis, subthemes were categorized according to similarities and differences, which were then integrated into broader themes.

RESULTS

Sixteen studies were eligible for inclusion. The prevalence of restraints ranged from 5.1% to 80.0% depending on how the meaning of restraint was interpreted. The most common indications for restraints were history of falls and fall risk. Interdisciplinary screening for restraints was associated with reduced prevalence of restraints, with a 0.18-fold (confidence interval [CI]: 0.12-0.24) reduction through use of a restraint decision flowchart and a 0.76-fold (CI: 0.63-0.92) reduction through consultation with a psychiatrist. Interdisciplinary members included nurses, physicians, clinical psychologists, pharmacists, respiratory therapists, and therapists.

CONCLUSIONS

Research is needed to introduce and develop an interdisciplinary restraint decision-making system and to test its effectiveness. Important factors in implementing alternatives to restraints are the harmful effects of restraints, expertise in dementia, regular education on alternative methods, an inpatient environment that ensures patient safety, and the development of human resources.

COVID-19 pandemic and emergency department visits for psychosis: Visit volume, restraint use, medication use, psychiatric hospitalization, and length of stay

BACKGROUND

Individuals with a schizophrenia spectrum disorder were at heightened risk for interruptions in psychiatric care during the coronavirus-19 (COVID 19) pandemic. There is limited work exploring the pandemic's impact on emergency department (ED) visit volume, use of restraint and parenteral medications, inpatient psychiatric (IP) hospitalization, and ED length of stay (LOS) among this population.

METHODS

We retrospectively examined 2134 ED visits with a billing code for psychosis between March 1, 2019-February 28, 2021. We used Poisson regression analysis to compare ED visit volume between the pandemic and pre-pandemic periods. Restraint use, parenteral antipsychotic or benzodiazepine use, IP hospitalization, and ED LOS were compared between the two periods using chi-square tests and independent samples t-tests.

RESULTS

Overall volume of psychosis-related ED visits during the pandemic did not differ significantly from the prior year. Rates of restraint use (16.2 % vs 11.6 %, p < .01), parenteral antipsychotic (22.6 % vs 14.9, p < .001), and parenteral benzodiazepine (22.3 % vs 16.3 %, p < .001) use were significantly higher during the pandemic. Fewer patients had an IP hospital disposition during the pandemic than the year prior (57.8 % vs. 61.9 %, p < .05). ED LOS was longer during the pandemic compared to pre-pandemic (28.37 h vs 20.26 h, p < .001).

CONCLUSIONS

Although the volume of psychosis-related ED visits remained constant, restraint and parenteral medication use rates were significantly higher during the pandemic. ED LOS increased but fewer ED visits resulted in IP hospitalization. These findings underscore the importance of planning for increased acuity of psychosis ED presentations during public health emergencies.

The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based study

While COVID-19 impacted all aspects of health care and patient treatment, particularly for patients with mental health/substance use (MH/SU) concerns, research has suggested a concerning increase in the use of restraint and seclusion (R/S) interventions, although results vary depending on facility type and patient population. Thus, the present study sought to explore COVID-related changes in the use of R/S interventions among patients presenting to Ontario emergency departments (EDs) with MH/SU complaints. To determine whether temporal and clinical factors were associated with changes in R/S use during COVID, binary logistic regression models were computed using data from the National Ambulatory Care Reporting System database. We then compared both prevalence rates and probability of an R/S event occurring during an ED visit in Ontario before and after the onset of COVID. The number of ED visits during which an R/S event occurred for patients presenting with MH/SU concerns increased by 9.5%, while their odds of an R/S event occurring during an ED visit increased by 23% in Ontario after COVID onset. Similarly, R/S event probability increased for patients presenting with MH/SU concerns after COVID onset (0.7% - 21.3% increase), particularly during the first wave, with the greatest increases observed for concerns associated with increased restraint risk pre-COVID. R/S intervention use increased substantially for patients presenting to Ontario EDs with MH/SU concerns during the first wave of COVID when the strain on healthcare system and uncertainty about the virus was arguably greatest. Patients with concerns already associated with increased R/S risk also showed the largest increases in R/S probability, suggesting increased behavioural issues during treatment among this population after COVID onset. These results have the potential to inform existing policies to mitigate risks associated with R/S intervention use during future public health emergencies and in general practice.

Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection

COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis

BACKGROUND

The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA.

OBJECTIVE

This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors.

DESIGN

The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019.

PARTICIPANTS

Hospitalized patients aged 18 and older.

MAIN MEASURES

Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges.

KEY RESULTS

In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race.

CONCLUSIONS

In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

COVID-19 delirium and encephalopathy: Pathophysiology assumed in the first 3 years of the ongoing pandemic

Background

The coronavirus disease (COVID-19) continues to spread worldwide. It has a high rate of delirium, even in young patients without comorbidities. Infected patients required isolation because of the high infectivity and virulence of COVID-19. The high prevalence of delirium in COVID-19 primarily results from encephalopathy and neuroinflammation caused by acute respiratory distress syndrome (ARDS)-associated cytokine storm. Acute respiratory distress syndrome has been linked to delirium and psychotic symptoms in the subacute phase (4 to 12 weeks), termed post-acute COVID-19 syndrome (PACS), and to brain fog, cognitive dysfunction, and fatigue, termed "long COVID," which persists beyond 12 weeks. However, no review article that mentions "COVID-19 delirium" have never been reported.

Basic Procedures

This narrative review summarizes data on delirium associated with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and related neurological symptoms of persistent post-infection illness (PACS or long COVID) after persistence of cognitive dysfunction. Thus, we describe the pathophysiological hypothesis of COVID-19 delirium and its continuation as long COVID. This review also describes the treatment of delirium complicated by COVID-19 pneumonia.

Main Findings

SARS-CoV-2 infection is associated with encephalopathy and delirium. An association between COVID-19 infection and Alzheimer's disease has been suggested, and studies are being conducted from multiple facets including genetics, cytology, and postmortem study.

Principal Conclusions

This review suggests that COVID-19 has important short and long-term neuropsychiatric effects. Several hypotheses have been proposed that highlight potential neurobiological mechanisms as causal factors, including neuronal-inflammatory pathways by cytokine storm and cellular senescence, and chronic inflammation.

Exploring the ethics of physical restraints: Students' questioning

BACKGROUND

Physical restraints are routinely employed to ensure patient safety in Japanese acute care. Little is known about nursing students' perspectives and how they begin to question their value and knowledge in the face of restraint experiences in clinical practice.

OBJECTIVE

To investigate nursing students' questions about patient restraints and how they understand the ethics of the use of restraints in nursing.

RESEARCH DESIGN

Qualitative descriptive research using narrative analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Experiential data were generated and thematically analyzed from semi-structured interviews with 16 nursing students who had completed their bachelor's degree program requirements.

ETHICAL CONSIDERATIONS

The study was approved by academic and clinical ethics agencies. Participants provided written informed consent.

RESULTS

Physical restraints were encountered in 16 incidents, 3 with children and 13 with older patients with dementia. Students struggled to comprehend the policies and protocols of restraint use and worried their use was primarily for security rather than therapeutic purposes. Five themes were identified: (1). Questioning the tension between person-centered care, patient autonomy, and restraints, (2). Questioning the nature of restraints in which participants analyzed the policies and protocols around restraint use, (3). Questioning the professional nursing self whereby students reflected on how restraint use challenged their nursing values, and (4). Questioning professional nursing practice, in which students explored how restraints fit within a nursing perspective and positioned themselves as patient advocates. Students encountering physical restraints should ask questions based on values of patient-centeredness, autonomy, and advocacy. There is a need for education that facilitates reflection and questioning so that it informs students' ethical thinking which may enhance nurse advocacy to reduce restraint use.

CONCLUSIONS

Restraints provide contexts in which students must face tensions between nursing values and clinical reality. Further research on nursing education strategies within non-psychiatric settings is needed to reduce physical restraints.

Prevention of physical restraints in the acute care setting (PROTECT): study protocol for a cluster-randomised controlled pilot study

INTRODUCTION

Physical restraints (PR) are regularly used in acute care settings, although evidence for their effectiveness and safety (eg, for prevention of falls) is lacking. Their use is associated with adverse events, such as decreased mobility and injuries for patients. We developed a complex intervention to prevent PR in acute care settings according to the UK Medical Research Council Framework, and investigated the feasibility. The intervention comprised the qualification of key nurses as multipliers and a short interprofessional information session. The intervention has proven to be feasible. It also became apparent that further development of the intervention and the study procedures is necessary. Therefore, this study aims to refine and pilot the complex intervention. Furthermore, the objective of this pilot study is to improve study procedures.

METHODS AND ANALYSIS

In a preparatory phase, we will conduct focus groups and individual interviews with the target groups to explore the possibilities for adaption of the intervention and implementation strategies. Subsequently, a cluster-randomised controlled trial with a 6-month follow-up period will be conducted. It is planned to recruit eight general hospitals in Germany (area of Halle (Saale) and Leipzig) with 28 wards and 924 patients per observation period (2772 overall). Primary outcome is the proportion of patients with at least one PR after 6 months. Data will be collected by direct observation over a period of seven consecutive days and three times a day. Secondary outcomes are falls, interruptions in therapy and prescription of psychotropic medication. A comprehensive process evaluation will accompany the study.

ETHICS AND DISSEMINATION

The Ethics committee of the Medical Faculty of the University of Halle (Saale) approved the study protocol. Results will be published in a peer-reviewed journal and presented at conferences. Study information and additional material will be freely available on an already existing website.

TRIAL REGISTRATION NUMBER

DRKS00027989.

Restraint Practices in Incapable Wandering Patients During COVID-19: Ethics and Best Practice Recommendations

Patients who wander as one of their psychological and behavioural symptoms of dementia are often unable to follow or recall Infection Prevention and Control precautions, putting them at risk of contracting or spreading COVID-19. Physical and chemical restraints have been used to limit the risk of transmission to wandering patients and their care providers, but restraints are not the standard of care for wandering behaviour in non-pandemic scenarios. Although provincial policies on restraint use are available, their guidance may not provide the context-dependent information necessary for individual patient decisions. To address this knowledge gap, we reviewed the medical, ethical, and legal considerations through an interdisciplinary approach including nurses, physicians, ethicists, hospital leadership, risk management, and legal counsel. We present an ethical framework that front-line health-care workers can use to create a balanced patient-centred care plan for incapable wandering patients who are at risk of contracting or spreading COVID-19.

What factors contribute to the need for physical restraint in institutionalized residents in Taiwan?

Background

In Taiwan, physical restraint is commonly used in institutions to protect residents from falling or injury. However, physical restraint should be used cautiously to avoid side effects, such as worse cognition, mobility, depression, and even death.

Objectives

To identify the rate of physical restraint and the associated risk factors in institutionalized residents in Taiwan.

Methods

A community-based epidemiological survey was conducted from July 2019 to February 2020 across 266 residential institutions. Among the estimated 6,549 residents being surveyed, a total of 5,752 finished the study. The questionnaires were completed by residents, his/her family or social workers. The cognition tests were conducted by specialists and a multilevel analysis approach was used to identify cognition/disability/medical history/special nursing care/BPSD risk factors for physical restraints.

Results

Of the 5,752 included institutionalized residents, 30.2% (1,737) had been previously restrained. Older age, lower education level, lower cognitive function, higher dependence, residents with cerebrovascular disease, pulmonary disease, dementia, and intractable epilepsy, all contributed to a higher physical restraint rate, while orthopedic disease and spinal cord injury were associated with a lower physical restraint rate. Furthermore, residents with special nursing care had a higher restraint rate. Residents with most of the behavior and psychological symptoms were also associated with an increased restraint rate.

Conclusions

We studied the rate of physical restraint and associated risk factors in institutionalized residents in Taiwan. The benefits and risks of physical restraint should be evaluated before application, and adjusted according to different clinical situations.

Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis

Background

Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited.

Objectives

To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use.

Design

Retrospective cohort study with a time series analysis.

Participants

Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020.

Main measures

We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR).

Key results

We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83).

Conclusions

The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.

Staff perceptions of the consequences of COVID-19 on quality of dementia care for residents in Ontario long-term care homes

OBJECTIVES

The first wave of the COVID-19 pandemic necessitated extensive infection control measures in long-term care (LTC) and had a significant impact on staffing and services. Anecdotal reports indicate that this negatively affected LTC residents' quality of care and wellbeing, but there is scarce evidence on the effects of COVID-19 on quality of dementia care in LTC.

METHODS

From December 2020 to March 2021, we conducted a cross-sectional online survey among staff who worked in LTC homes in Ontario, Canada. Survey questions examined staffs' perceptions of the impact of COVID-19 on dementia quality of care during the initial wave of the COVID-19 pandemic (beginning 1 March 2020).

RESULTS

There were a total of 227 survey respondents; more than half reported both worsened overall quality of care (51.3%) and worsening of a majority of specific quality of care measures (55.5%). Measures of cognitive functioning, mobility and behavioural symptoms were most frequently described as worsened. Medical and allied/support staff had the highest odds of reporting overall worsened quality of care, while specialized behavioural care staff and those with more experience in LTC were less likely to. LTC home factors including rural location and smaller size, staffing challenges, higher number of outbreaks and less COVID-19 preparedness were associated with increased odds of perceived worsening of quality of dementia care outcomes.

CONCLUSIONS

These findings suggest that COVID-19 pandemic restrictions and related effects such as inadequate staffing may have contributed to poor quality of care and outcomes for those with dementia in LTC.