Physical restraints in the acute care setting: issues and future direction

The pattern and prevalence of physical restraint in hospital settings have changed over the past decade. The challenge to health professionals who wish to reduce or eliminate the use of restraints includes clinical, ethical, and legal concerns. Factors that influence health care providers' decisions regarding whether to use physical restraints include organizational characteristics and systems of care, environmental characteristics, and specific clinical guidelines or protocols, as well as individual patient characteristics. To reduce the incidence of physical restraint, hospital professionals need to develop and test feasible alternative practices using an interdisciplinary approach that addresses organizational, environmental, and patient-specific factors.     

Should physical restraints be used in an acute geriatric ward?

A prospective study was carried out in an acute geriatric ward to determine the incidence of the use of physical restraints, the reasons for using them and the consequences. Over a period of 8 months an independent observer documented all cases in which a restraint was used and followed them until it was removed. A questionnaire was submitted to the nurses as to why they applied the restraints. 16% of patients had some form of restraint applied, in 2/3 of them for up to half of their stay in the ward. In over 90% of those restrained, functional (Barthel) and cognitive (mini-mental) scores were between 0-5. In unrestrained patients, the functional score was 0-5 in 79% and the cognitive score 0-5 in 72%. The main reason for applying restraints, usually sheets or body binders, was to prevent the patient from falling out of, or slipping from chairs, rather than to stop them from rising out of them. Other important reasons, which overlapped, were to prevent the patient from interfering with nasogastric tubes, catheters, and i.v. cannulas, each in 1/3 of the group. Restraints were discarded when deterioration did not allow the patient to sit out of bed, to decrease agitation, to allow enteral or parenteral treatment, and in 12%, when there was supervision by the family. Of 33 families interviewed, none opposed application of restraints, and most left the decision to the responsible ward staff. We conclude that restraints cannot be avoided in some acutely ill, old patients with severe physical and mental dysfunction. However, ways should be sought to minimize their use, as recommended in the literature, by demanding from the staff a specific reason, signed agreement of a physician, close follow-up, and favorable environmental conditions such as suitable chairs, occupational activity, and staff cooperation in removing the restraints.     

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE: Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints. DESIGN: A point prevalence study of patients cared for in various types of geriatric settings. SETTING: Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden. PARTICIPANTS: A total of 1325 patients, mean age 82 years, 64% of whom were women. MEASUREMENTS: The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument. RESULTS: Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances. CONCLUSIONS: This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.     

The practice of health education in acute care settings in Hong Kong: an exploratory study of the contribution of registered nurses

A multiple case study design was used to explore the practice of health education in acute care settings in Hong Kong. Two case studies, a medical ward and a surgical ward, were selected to reflect the real setting in which nurses carry out health education in acute care. Data collection methods involved the use of non-participant observation and semi-structured interviews. Seven nurses and eight patients were interviewed to explore their understanding of health education concepts, the use made in the wards of health education and the factors influencing such practice in the acute settings. Individual and cross-case analysis showed that respondents' understanding of the concept of health education was limited to patient information-giving. Although the importance of health education in acute patient care was acknowledged, the degree to which health education featured in nurses' practice was minimal. Many available opportunities for health education were missed and factors such as nurses' busy-ness and the associated lack of time and staff were identified as influencing health education practice in these acute care settings. Implications for practice and future studies were discussed in the light of these findings.     

Perceptions of acute care physical therapy practice: issues for physical therapist preparation

BACKGROUND AND PURPOSE: Acute care physical therapists have experienced the effects of dramatic changes in health care reimbursement systems and population demographics. Acute care hospitals now serve a patient population of much older, chronically ill patients who are hospitalized for shorter periods of time in a practice environment in which physical therapy staffing resources are often inadequate. The purposes of this study were to document common experiences in the practice of acute care physical therapy and to identify differences in the perceptions of physical therapists with varying levels of experience and in various sizes of acute care facilities. SUBJECTS AND METHODS: A survey questionnaire was mailed to 500 randomly selected physical therapists employed in acute care facilities. The therapists answered questions regarding the frequency of various physical therapy evaluation and treatment practices, problems encountered in delivering physical therapy services, coordination of the discharge planning process, and perceptions of staffing trends in the acute care setting. The responses of 188 physical therapists who completed the survey were compared by their experience levels and the size of the institutions in which they practiced. RESULTS: Subjects reported that patient factors, such as medical complications and cooperation; organizational factors, such as staffing shortages and large caseloads; and health care system constraints, such as difficulty changing orders and limited time in which to work with the patient interfered with patients reaching physical therapy goals. CONCLUSION AND DISCUSSION: Inadequate skills for successful acute care practice and maladaptive therapist beliefs about acute care career possibilities may adversely affect physical therapist career longevity in the acute care setting.     

Advancing nursing practice: acute care nurse practitioners meet challenges at and beyond the health care horizon

Preparation of advanced practice nurses (APNs) with acute care skills relevant to today's health care environment is a challenge faced by nurse educators, care providers, professional organizations, and regulatory agencies. The acute care nurse practitioner (ACNP) is prepared to provide multidimensional, risk-appropriate management of medically vulnerable patients with serious illness in a variety of settings. ACNPs conduct comprehensive health assessments, order and interpret diagnostic tests, diagnose and manage health problems and disease-related symptoms, prescribe and evaluate drugs and treatments, and coordinate care during setting transitions. Working independently and collaboratively the ACNP enhances access to care and quality of care for patients and families through cost-effective, outcome-oriented practice. This article describes health care market factors fostering ACNP practice, ACNP practice domain, the University of Washington ACNP program, and collaborative contributions from educators, care providers, professional organizations, and regulatory groups needed to implement the role.     

Safety belt restraints and compartment intrusions in frontal and lateral motor vehicle crashes: mechanisms of injuries, complications, and acute care costs

A 3-year prospective study examined 76 frontal (F) and 45 lateral (L) motor vehicle crash (MVC) patients with regard to seatbelt restraint use and occupant compartment contact and intrusion injuries. These 121 MVC victims with multiple injuries (39 belted [B] and 82 non-belted [NB]), admitted to a level I trauma center, were studied by accident reconstruction and medical data analysis. They had a MVC mean impact velocity (delta V) of 30 +/- 11 mph and an injury Severity Score of 29 +/- 12. Proper restraint use reduced brain injury in F MVCs (30% FB vs. 47% FNB) but had no effect in L MVCs (63% LB vs. 30% FB [p < 0.06]). Belt use did not protect against lung, liver, spleen, pelvis, or lower extremity (LE) injury. These appeared to be more a function of crash direction, with LE injuries higher in F crashes (p < 0.04) and pelvis injuries (p < 0.001) higher in L crashes. In FB crashes, however, properly used safety restraints were the primary cause of bowel or colon injuries (p < 0.006). Belts did not prevent thoracic or abdominal solid organ injuries in L crashes. Contact-intrusions (CI) of the car occupant compartment in F crashes were the main cause of brain (A-pillar), lung and liver (steering wheel and instrument panel), and LE (toepan) injuries; but in L crashes, side-door CI caused lung, aorta, liver, and pelvic injuries. In contrast, contact-only (CO) injuries of the steering assembly were mainly responsible for injuries to the lung, heart, and liver in F crashes, and side-door CO for lung, liver, and spleen injuries in L crashes. Deaths and complications after injury were higher among F MVC occupants, or when delta V was > or = 30 mph. Hospital and professional costs reflect the complex care needed for victims of multiple injuries: FB, $99,000; FNB, $95,000; LB, $75,000; LNB, $79,000; total, $10.7 million. Present vehicle safety standards are not adequate, and structural design changes are needed to improve restraints and protect occupants from intrusion-related injuries.     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Establishing an integrated care practice in a community health center.

In a progressively complex and fragmented health care system and in response to the need to provide whole-person, quality care to greater numbers of patients than ever before, primary care practices throughout the United States have turned their attention and efforts to integrating behavioral health into their standard service-delivery models. With few resources and little guidance, systems struggle to gather the support required to establish effective integrated programs. Based on first-hand experience, we describe a working integrated primary care model, currently utilized in a large community health center system in Colorado, that encompasses universal screening, consultation, psychotherapy, and psychological testing. With appreciation for the way an organization's unique circumstances inform the best approach for that particular organization, we highlight the clinical-level and system-level variables that we consider necessary for successful practice development and address how our behavioral health program operates despite funding limitations. We conclude that organizations that aim for integrated primary care must mobilize leadership to implement systemic changes while making difficult decisions about program development, financing, staffing, and interagency relationships. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Human papillomavirus as an etiological factor in cervical cancer: significance for health care practice

The migration of substances from rubber packaging materials into drug products can be significant with certain packaging materials in contact with organic solvent systems. Recommendations for testing drug products for leachables are continually evolving to address new developments. Testing packaging materials using simulated solvents is not always an acceptable protocol for the pharmaceutical industry. We describe a rational strategy for evaluation of the drug product for packaging extractables. A profile of the extractables from rubber packaging materials was made with a range of organic solvents and stress conditions to provide information on substances to target in the drug product. The drug product was evaluated to determine if the matrix would cause interferences that might inhibit detection of the found extractables. Analytical methods were selected based on these findings. The procedures were validated according to FDA guidelines. A stability program using time and storage conditions as variables provided information for acceptance criteria. This same strategy can be used on other types of pharmaceuticals and packaging materials.     

Making geriatric assessment an asset to your primary care practice

Geriatric assessment provides the physician with an individualized care plan for at-risk older patients with complex health problems. Its four basic components are physical, mental, functional, and social/economic health. Although the ideal assessment is performed by a team from a variety of disciplines, primary care physicians may perform a limited version in the office and then make appropriate referrals for further evaluation. Various screening instruments are helpful, but they have their limitations. Results provide you with a blueprint that aims to restore function, lower costs, and improve the patient's quality of life.     

I doubt therefore I coach: Critical moments in coaching practice.

How can coaches learn from moments and incidents in their own practice, particularly from moments that somehow feel critical? How can they improve working with the tension and anxiety that such moments will generate, and how might they even make use of such tensions? This is the first report of a research project into critical moments in coaching practice, which looks at critical moments of relatively inexperienced coaches. The second report, which looks at critical moments of much more experienced coaches, can be found as a companion article in this same issue. The sample size of the inexperienced coaches was 65 and 49 coaches communicating a total of 56 critical moments. Analysis of the moments revealed that they were all somehow related to a doubt that the coach had, so doubt seemed to be the overriding form of tension for the inexperienced coach. The type and nature of doubts are analyzed and the possible impact of (in-)experience is studied. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The development of an acute care case manager orientation

The authors describe the development of an inpatient acute care case manager orientation in a community hospital. Benner's application of the Dreyfus model of skill acquisition provides the basis for the orientation program. The candidates for the case manager position were expert clinicians. Because of the role change it was projected that they would function as advanced beginners. It was also predicted that, as the case managers progressed within the role, the educational process would need to be adapted to facilitate progression of skills to the proficient level. Feedback from participants reinforced that the model supported the case manager in the role transition. In addition, the model provided a predictive framework for ongoing educational activities.