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.

Methodologic issues in conducting research on hospitalized older people

OBJECTIVE

To describe challenges in conducting research with hospitalized geriatric patients.

DESIGN

Quasi-experimental longitudinal study with inperson interviews at baseline and discharge and a three-month postdischarge telephone interview. Study protocol required baseline interviews within 48 hours of admission for patients or 72 hours for proxies.

SETTING

813-bed urban teaching hospital.

PARTICIPANTS

240 patients, mean age 83.8 years, at moderate to high risk for functional decline during hospitalization, admitted from the emergency room to a general medical unit.

MEASUREMENTS

Delays starting or interruptions continuing interviews; patient and environmental conditions potentially affecting data quality; and information on proxy use.

RESULTS

Timely access to patients or proxies was a major difficulty, resulting in the screening of only 53.1% of 867 potentially eligible patients. Multiple patient contacts and visits were required to complete interviews. Only 61.3% of baseline and 28.1% of follow-up interviews were completed on the initial day of contact. Despite having on-site interviewers 7 days a week, 29% of discharge interviews were conducted by telephone. Interviews were >90% complete in 487 of 503 of encounters (97%). Baseline delays and interruptions were usually due to the presence of medical staff, off-unit tests, patient illness, nurse unavailability for interview, and need for a proxy. Most in-hospital interviews were conducted with others present. Proxies were required for approximately one-third of patients at all three interviews.

CONCLUSION

Conducting clinical research with older adults in the current inpatient setting, where patients are more severely ill yet have shorter lengths of stay now than in the past, proves a challenging yet achievable goal. Effective procedures for negotiating the acute care environment are critical to successful studies.

Sexual contact with clients: assessment of social workers' attitudes and educational preparation

The purpose of this study was to assess social work students' attitudes about sexual contact with clients and their perceptions about their training and education in this area. The sample included 349 social work students in their final semester of an MSW program. There were relatively high levels of approval for sexual contact between social workers and clients in certain circumstances. Approval was not limited to circumstances in which professional relationships were terminated, were brief, or had involved only concrete services. Students with less social work experience and who thought class content on sexual ethics was inadequate were more likely to approve of sexual contact between social worker and client. Students did not feel that they had received adequate education or training on sexual ethics, and many felt unprepared to handle sexual feelings from or toward a client. Implications for education, training, and practice, and suggestions for future research are discussed.

Attitudes toward Physician-Assisted Suicide among Persons with Multiple Sclerosis

This study was conducted to estimate the level of interest in assisted suicide among persons with multiple sclerosis (MS), the hypothetical conditions under which they would consider assisted suicide, and the factors associated with such interest. The sample of 511 members drawn from the Oregon and Michigan chapters of the National Multiple Sclerosis Society (NMSS) completed a mail questionnaire indicating whether they had ever considered assisted suicide, under what conditions they would consider it, and the correlates of considering assisted suicide. Close to one third of persons with MS in this study had thought about assisted suicide as an option for themselves. One quarter to one half would consider assisted suicide in five hypothetical circumstances, including experiencing unbearable pain, being unable to do things that made them happy, causing financial burden to caregivers or family members, or experiencing extreme emotional distress. Religiosity, social support, depressive symptomatology, MS symptoms, NMSS chapter, years since diagnosis, and gender were associated with some or all of the responses to the hypothetical conditions. The clinical and policy implications of these findings are discussed.

The relationship between ethnoracial group and functional level in older persons

The objective of this study was to determine: (1) the differences between blacks, Latinos, and whites in relation to functional level, (2) whether these differences could be entirely explained by differences in socioeconomic status (SES) for both blacks and Latinos, and (3) which SES indicators might account for differences in function. Data from the 1570 respondents in the Growing Older in New York City Study, a representative sample of black, Latino, and non-Latino white persons, age 65 years and over, were used. Latinos were significantly more functionally impaired than the other two ethnoracial groups, but this was accounted for by income, education, and the residential environment. Blacks were the least functionally impaired when income, education and the residential environment were controlled. Possible explanations for these results and implications for service delivery are discussed.

The relationship among income, other socioeconomic indicators, and functional level in older persons

Socioeconomic status (SES) is well established as a cause of morbidity and mortality, but relatively few studies have investigated the relationship between SES and functional level. Functional level is closely related to the use of long-term care services and is a more salient indicator of quality of life than specific diseases. We used data from 1,570 respondents in the Growing Older in New York City Study, a probability sample of people age 65 and older, to examine this relationship. The association between income and function was seen throughout the full gradient of income and remained significant when controlling for age, gender, race/ethnicity, household size, education, occupation, age of immigration, and locus of control. Education and residential environment, but not occupation, were independently associated with functional level. These findings support both the association between SES and functional limitation and the hypothesis that the SES and health association continues into old age.

Homophobia and heterosexism in social workers

Evidence suggests that social workers may be biased when dealing with gay and lesbian populations. The study discussed in this article attempted to measure the extent of homophobia and heterosexist bias and their correlates in a cohort of 187 social workers using the Index of Attitudes toward Homosexuality, the Attitudes toward Lesbians and Gay Men Scales, and a newly created scale to measure heterosexist bias. We found that 10 percent of respondents were homophobic and that a majority were heterosexist. Levels of homophobia and heterosexism were negatively correlated with amount of social contact with homosexual men and women. Religiosity was associated with higher levels of homophobia and heterosexism, and having been in psychotherapy was associated with more positive attitudes toward gay men and lesbians. Amount of education on topics related to homosexuality was not correlated with levels of homophobia and heterosexism.

Predictors of improvement in tardive dyskinesia following discontinuation of neuroleptic medication

Forty-nine chronic psychiatric out-patients (ten were schizophrenic) with tardive dyskinesia (TD) were examined monthly for a mean of 40 weeks (range 1-59 months) after discontinuation of neuroleptic medication. Complete and persistent reversibility of TD was rare (2%), but many patients showed noticeable improvement in movements within the first year of discontinuation, which was sometimes interrupted by psychological relapse. Using three separate outcome measures and appropriate model-fitting techniques for each, we identified several predictors of improvement in TD, including an affective or schizoaffective psychiatric diagnosis, chronic (over 20 years) psychiatric illness, being employed, younger age, and increased neuroleptic dose before discontinuation. Consistent findings emerging from these analyses suggest that the type and history of psychiatric illness affect the course of TD.

Injection site leakage of depot neuroleptics: intramuscular versus subcutaneous injection

In a cross-sectional study of injection site leakage of fluphenazine decanoate in 40 psychiatric outpatients, significantly more leakage occurred after intramuscular than after subcutaneous injection. Results of the study suggest that age, sex, body mass, and injection volume may also affect leakage.

Depressive symptoms in relation to physical health and functioning in the elderly

The associations between depressive symptoms and functional disability and chronic conditions are examined in an elderly cohort of 2,806 noninstitutionalized men and women living in New Haven, Connecticut who were interviewed in 1982 as a part of the Yale Health and Aging Project. The aim is to explore several potential sources of invalidity in using the Center for Epidemiologic Studies-Depression scale (CES-D) to measure depressive symptoms in elderly populations. In particular, the authors are concerned with the possibility that prevalent physical illnesses and disabilities may cause the older person to report many somatic complaints, a major component of most measures of depressive symptomatology, and thereby inflate his or her CES-D score. Mean CES-D scores are 4.86 for those without any disabilities and range to 13.51 for those with major functional disabilities. However, physical disability is significantly associated with virtually every item on the CES-D scale not just those somatically-oriented items. The addition of functional disability to a multivariate model including age subfactor analysis of responses from this elderly sample produces results almost identical to those reported by earlier investigators who studied younger and middle-aged adults. The authors conclude that physical disabilities among the elderly do not appear to be a major threat to the validity of the CES-D scale and that the strong associations between physical and mental health should be rigorously investigated.