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PubMed2001

[Physical restraint in geriatric psychology].

The use of physical restraint is a fact which we confront in everyday practice. The objective of this article is to establish some basic operating guidelines in order to prevent the use of physical restraint and which procedures to follow when its use is unavoidable. The authors describe some adequate instances when use of physical restraint may be required and they identify different methods and their procedures. Its use may cause a series of complications, specific risks and general risks, which one needs be aware of in order to prevent them. Considering the importance of having protocols for all these aspects in each center, the authors propose the contents on a clinical report sheet to facilitate a good control of the restraint used for each patient. This article was submitted as an oral report at the 8th Congress of the Catalonian-Balearic Geriatrics and Gerontology Association and at the 4th Conference of Current Practices in Psycho-Geriatrics.

Aged↗

PubMed1989

Tying down the elderly. A review of the literature on physical restraint.

The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.

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PubMed1995

Physical restraint of critically ill patients: a human issue.

Physical restraints modify the behavior of an individual through the limitation of movement. Despite awareness of physical, psychological, and ethical problems associated with the use of physical restraints on elderly patients, the practice remains widespread in critical care units and appears to be an accepted standard of care. Legal and ethical issues as well as personal dilemmas complicate and influence the decision to use restraints. This article reviews the current literature about physical restraints and presents suggestions for practice and research regarding their use in critical care.

Clinical Nursing Research↗

PubMed1997

Physical restraint of patients in a psychiatric hospital.

Use of physical restraint occurs within British psychiatric hospitals yet there has been little evaluative research on current practice. The present study aims to describe a group of disturbed in-patients who had required physical restraint at some point during the course of their stay in hospital and to classify the reasons for its use. Cases were identified using Case Register data and information obtained from patients' records. In the 48 episodes of physical restraint identified, patients were predominantly schizophrenic (60%), male (67%) and had been restrained because of physical violence to others (44%) or because they were attempting to abscond (31%). Although the majority of patients were compulsorily detained prior to the use of physical restraint, three remained informal. The findings are discussed in the context of the legal justifications for use of restraint. Further research on current practice is required to enable formulation of clear guidelines.

Adult↗

PubMed2002

Nursing homes with persistent deficiency citations for physical restraint use.

OBJECTIVES: This paper examines the organizational and aggregate resident characteristics of nursing homes associated with persistent poor quality in the use of physical restraints. Deficiency citations for physical restraint use in two and three consecutive certification survey inspections are used as our measures of poor quality. MATERIALS AND METHODS: Nationally representative data from the 1996, 1997, 1998, and 1999 Online Survey, Certification, and Reporting system are used, first, to provide descriptive analyses. Second, multinomial logistic regression analyses are used to examine organizational and aggregate resident characteristics associated with deficiency citations for restraint use on any survey inspection, on two consecutive inspections, and deficiencies for physical restraint use in three consecutive inspections. RESULTS: It is shown that 729 (5.2%) nursing homes had deficiency citations for restraint use on two consecutive inspections and 317 (2.3%) on three consecutive inspections. Persistent poor quality in the use of physical restraints in nursing homes is negatively associated to higher staffing levels of care givers, and positively associated to higher Medicaid census, and higher average activities of daily living (ADL) levels. CONCLUSION: The Nursing Home Reform Act has been extremely influential in reducing the overall prevalence of physical restraint use in nursing homes, but the number of facilities with persistent quality problems in their use of restraints in the face of this legislation is surprising. The organizational and aggregate resident characteristics of these nursing homes, especially RN staffing levels, Medicaid census, and average ADL levels differ from those that did not receive any deficiency citations for use of physical restraints.

Activities of Daily Living↗

PubMedDate not supplied

[The circumstances of using physical restraint in psychiatric services].

Adequate law regulations specify conditions under which mentally disordered persons may be submitted to physical restraint. Medical staff who decide on the application of physical restraint play the role of police. They limit the liberty of mentally disordered persons to protect society against their dangerous behaviour. Protection of patients' health gives the possibility of using physical restraint on the basis of medical circumstances. A literature review shows the different range of physical restraint use in comparable medical units. It suggests that medical staff decisions about the use of physical restraint can be dependent not only on dangerous behaviour but on different specific and non-specific factors. The aim of this article is to analyse factors which can have influence on applying of physical restraint in mentally disordered persons. Description of specific circumstances in which physical restraint is used can help in the optimization of psychiatric treatment and requires further research in both psychiatry and law.

Commitment of Persons with Psychiatric Disorders↗

PubMed1991

The use of physical restraint in patients with cerebral contusion.

Behavioral problems resulting in the use of physical restraint is a clinical problem seen in the acute phase of recovery from cerebral contusion. However, little is known about the frequency of physical restraint, factors that might predispose to its use, the pattern of adjunctive psychotropic drugs used or the outcome for patients needing this form of management. In order to examine these issues, a retrospective study of all patients (N = 34) admitted with cerebral contusion to a neurosurgical service over a one-year period was undertaken. Physical restraint was used in twelve patients (35%) for an average length of 4.3 days. The use of physical restraint was associated with presumptive evidence of alcohol abuse or dependence but not with level of consciousness on admission. Restrained patients were frequently prescribed psychotropic drugs during hospitalization. Patients requiring physical restraint stayed in hospital nearly twice as long as those not needing restraint. Close attention to the identification and treatment of alcohol problems and their complications in this population may reduce the need for physical restraint and shorten length of hospital stay.

Activities of Daily Living↗

PubMed2001

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.

Academic Medical Centers↗

PubMedDate not supplied

The use of physical restraints to psychogeriatric patients in Hong Kong.

The use of physical restraint has been a controversial intervention in the nursing management of hospitalized elderly patients in many countries. This ethnographic study was conducted in one psychogeriatric ward in Hong Kong in order to explore what determines psychiatric nurses' decisions to use restraints on their elderly patients. By comparing the findings of three data sources, comprising semistructured interviews, observations, and clinical records, five main themes were identified with regard to the nurses decision of restraint use. They included the rationale of physical restraint, consideration of alternative measures, consideration of adverse consequences, ethical considerations, and policy and documentation of restraint use. The findings of this study demonstrate that nurses must question the established practice myths about restraint use being the best way to maintain patient safety. Most importantly, nurses need cognitive and ethical preparation to face different situations in which physical restraint may be used.

Adult↗

PubMed2005

Deep venous thrombosis and pulmonary embolism following physical restraint.

OBJECTIVE: We describe a case of deep venous thrombosis (DVT) and pulmonary embolism (PE) following the use of physical restraint in a patient with a diagnosis of acute delusional psychotic disorder. METHOD: A new case report of DVT and PE associated with prolonged physical restraint is presented. The literature on physical restraint, DVT, and PE was reviewed using a search of Medline and Psychinfo from 1966 to the present. RESULTS: Four other reported cases of DVT and PE were found in association with physically restrained patients. CONCLUSION: Risk of DVT and PE in association with immobilization during physical restraint may occur in spite of no pre-existing risk factors. Medical guidelines for the prevention of thrombosis following physical restraint are presented. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of DVT and PE warrants early and vigorous intervention in patients undergoing physical restraint.

Acute Disease↗

PubMed2004

Use of physical restraints with cognitively impaired nursing home residents.

AIM: The aim of the study was to examine the prevalence of physical restraint use in cognitively impaired nursing home residents, the manner in which restraints are used, reasons for using them, and relationships between residents' characteristics and use of physical restraints. METHODS: A point prevalence study was conducted on the use of physical restraints among all residents cared for in two Dutch nursing homes and one nursing home unit (n = 265). Data about the nursing home residents and the use of restraints were collected by means of a questionnaire, which was filled in by the nurses. The response rate was 98%. The mean age of residents was 81 years (sd = 8.6), 74% of whom were female. RESULTS: One or more restraints were used with 49% of the residents. The most frequently used physical restraints were bed rails, a waist belt, and a chair with a table. In almost all situations (90%), residents were continuously restrained and restraints were used for longer than 3 months. The most common reason (90%) for use of restraints was to prevent falls. Logistic regression analysis revealed that use of restraints was highly associated with poor mobility, care dependency and risk of falling in the opinion of nursing staff. CONCLUSIONS: The results of this study are comparable with those of other studies. However, since recent studies have reported that physical restraints are inadequate to prevent falls, recommendations are made to re-evaluate critically the use of restraints and to conduct future research into a responsible and safe way of decreasing the use of physical restraints.

Accidental Falls↗

PubMed1997

The use of physical restraints in elder care in relation to fall risk.

Physical restraints are a frequently used but disputed method to prevent falls. The aim of the present study was to investigate how the use of restraints in institutional elder care relates to previous falls and to the estimated fall risk of the individual patient. A total of 1142 patients, mean age 82 years, were included in the study. A questionnaire, the Multi-Dimensional Dementia Assessment Scale (MDDAS), was used to measure motor function, vision, hearing, ADL performance, behavioral symptoms, psychiatric symptoms, cognitive impairment and use of medication. Questions concerning the use of physical restraints and known previous falls were added to the instrument. Based on data from the questionnaire (MDDAS), a score on the Downton Fall Risk Index was calculated for each patient. All in all, 248 (22%) of the patients had been subject to restraints and for 155 of them (14%) such measures had been taken to prevent falls. Only weak connections were found between the restraining of patients to prevent falls and the prevalence of known previous falls during hospital stay (phi = 0.05), and estimated fall risk (phi = 0.07). The results indicate that the use of physical restraints is poorly connected with the estimated fall risk. Therefore, this study may point to a possible overuse of these measures.

Accidental Falls↗

PubMed1994

Individualized care alternatives used in the process of removing physical restraints in the nursing home.

OBJECTIVE: To describe the individualized care alternatives used during the process of removing physical restraints in a nursing home. DESIGN: Descriptive survey. SETTING: A non-profit geriatric long-term care facility. SUBJECTS: Sixty-three physically restrained residents (mean age = 85.3 years). MEASURES: Information regarding the different care alternatives used to replace physical restraints was obtained from the Gerontological Clinical Nurse Specialist implementing the process of removing restraints. RESULTS: The physical restraints of six of the 63 participants were removed without implementing any care alternative. With the remaining 57 participants, an average of 3.3 different care alternatives were used (range 1-7 care alternatives). Environmental alternatives (such as wheelchair adaptations and alternative seating) were used with 86% of the restrained residents; alterations in nursing care (such as additional supervision and toileting schedules) were used with 77% of the participants. Psychosocial and physiological alternatives, as well as the use of structured activities, were used less frequently. At the end of the study period, five residents remained restrained. CONCLUSIONS: This papers shows the complexity of the process of removing physical restraints in the nursing home. The need of an individualized approach is stressed.

Aged↗

PubMed1997

Breaking loose. Use of physical restraints in nursing homes in Queensland, Australia.

A survey was completed by 123/203 (61%). Directors of Nursing of Queensland's nursing homes, to obtain information about the use of physical restraints. Of a total of about 6500 (4693 females; 1807 males) nursing home residents in Queensland, Australia, 23.6% (1536) were reported to have been physically restrained at the time the survey was completed. Of this group, females comprised 72.9% (1120) and males 27.1% (416). The commonest forms of physical restraint were bedrails (38.2%) and restraining belts (23.7%). The commonest patient-oriented reason for using physical restraints was to "prevent falls" (85.4%) and the commonest nurse-oriented reason was "because no alternative exists" (39.8%). The correlation between the size of nursing homes (bed numbers) and the number of residents was strong and positive, indicating that Queensland nursing homes were functioning at full capacity (r = 0.999, a = 0.05). The correlation between the size of nursing homes (bed numbers) and the number of residents who were physically restrained was weak and negative (r = 0.002, a = 0.05), suggesting that nursing home size did not predict the use of physical restraints. Correlations between the total number of staff, the total number of untrained staff (assistants in nursing) and the number of residents who were physically restrained were also weak (r = 0.0427; 0.0695 respectively; a = 0.05), suggesting that these factors also had little predictive influence on the use of physical restraints. The findings of this research indicate that the extent to which physical restraints are currently being used in nursing homes in Queensland should be of concern, particularly in the context of a general, contemporary professional belief that the use of physical restraints in nursing homes should be minimised, if not entirely avoided.

Accidental Falls↗

PubMedDate not supplied

The use of physical restraints in Western Australian nursing homes.

Sixtyfour directors of nursing of Western Australia's 95 nursing homes that provide care for elderly residents responded to a survey designed to obtain descriptive information about the use of physical restraints. The study found that physical restraints had been applied to 26% (n = 787) of the 3028 nursing home residents. The most common forms of restraint were bedrails, which were used in 38.3% of homes, restraining belts (26.7%) and vests (16.7%). Ninetyfive percent of DONs cited "preventing falls" as a patient-oriented reason for using physical restraints and 19% said "because no alternative exists" was the nursing-oriented reason for restraint. While there may have been therapeutic reasons for using physical restraints, the extent to which they were used is cause for concern. Further efforts to reduce the use of restraints are needed. In particular, all nursing home staff involved in direct care of residents should be educated about the effects of applying physical restraints and about alternative way to manage elderly residents.

Accidental Falls↗

PubMed1995

Psychological responses to physical restraint use in older adults.

A view of physical restraint in older adults as ineffective, harmful, and assaultive to the dignity of the individual rather than routine and efficacious, created a paradigm shift among consumers and professionals. Studies exploring the response to restraint and interventions to help a restrained individual resolve the trauma, the assault on their personal integrity, and the loss of control, are needed. Recognition that physical restraint can be traumatic for individuals warrants an assessment of psychological responses of restrained older adults by health professionals and supports the goal of restraint reduction or elimination

Aged↗

PubMed2005

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 < .001), patients were more sedated (P < .001), and nurse-to-patient ratios were higher (1.05:1 vs 0.65:1, P < .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.

Adult↗

PubMed1996

Physical restraint use in the hospital setting: unresolved issues and directions for research.

Although the use of physical restraint has declined in nursing homes, the practice remains widespread in hospitals. The use of physical restraint in hospitals was reviewed to identify the current clinical, legal, and ethical issues and the implications for policy and further research. Clinicians use physical restraints to prevent patient falls, to forestall disruption of therapy, or to control disruptive behavior, but they vary in how they determine to institute these restraints. The evidence to support the reasons for their determinations is not compelling. Fear of litigation remains a powerful motivator. The ethical dilemma of autonomy versus beneficence has not been resolved satisfactorily for patients in this setting. The lack of large-scale studies in any of these areas makes it difficult for policy makers to determine whether it is necessary to address hospital physical restraint practices through additional regulation.

Behavior Control↗