Physical restraint use in critical care: legal issues

Landmark federal legislation and several other social and clinical forces have induced nursing homes to reduce their use of physical or mechanical restraints on their residents during the past decade. Attention is being paid to the overuse of restraining devices and methods in acute care hospitals, including critical care units, and the need to develop strategies for their reduction or elimination. One of the most serious barriers to accomplishing this objective is anxiety on the part of health professionals and administrators about potential legal liability for patient injury. This article discusses the potential legal implications of physical restraint reduction in hospitals, with special emphasis on the critical care context. It places risks in realistic perspective, ultimately arguing that developing suitable alternatives to restraint use in most cases best serves the legal--as well as the clinical, ethical, and financial--interests of all concerned parties.     

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.     

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.     

Restraints and the elderly with mental illness: ethical issues and moral reasoning

The use of restraints to enable the care provided to the elderly has long been a source of contention and fodder for argument among health care professionals. The question of whether to use mechanical restraints to prevent falls in the elderly is an ongoing debate. An ethical framework is presented to assist the decision-making process.     

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.     

Tube feeding preferences among nursing home residents

OBJECTIVE: To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. PATIENTS/PARTICIPANTS: Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents. MAIN RESULTS: Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender. African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process. CONCLUSIONS: Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.     

Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes

OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). METHODS: A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre- and 6 months' post-intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subjects as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis. RESULTS: While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA-approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home. CONCLUSIONS: Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.     

Mental health providers confronting organizational change: process, problems, and strategies

Under the influence of managed care and diminished funding, the mental health field is undergoing a major transformation. Existing mental health programs, departments, and agencies are downsizing and restructuring to develop new types of service delivery systems. Organizations must change to survive; yet necessary and adaptive change may be resisted in numerous ways by providers whose reactions and behaviors may reduce the viability of their own programs and agencies. This paper explores various characteristics and reactions of mental health care professionals as they face great stress, professional devaluation, and necessary organizational change and restructuring. Adaptive and maladaptive patterns in response to potential organizational change are explored. The role of the leader in guiding and implementing programmatic changes and in dealing with denial and resistance is highlighted. Strategies to enhance the prospects for adaptive organizational change are offered.     

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.     

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.     

The relationship between physical restraint removal and falls and injuries among nursing home residents

BACKGROUND: A major reason cited for continued restraint use in American nursing homes is the widely held belief that restraint reduction will lead to fall-related incidents and injuries. METHODS: This study represents an analysis of data collected in a clinical trial of interventions aimed at reducing the use of restraints in nursing homes. Two different designs were employed to test the relationship between restraint reduction and falls/injuries. First, multiple logistic regression was used to compare fall/injury rates in subjects who had restraints removed (n = 38) to those who continued to be restrained (n = 88); second, survival analysis was employed to test the relationship between physical restraint removal and falls/injuries at the institutional level by comparing fall/injury rates among three nursing homes (n = 633) with varying rates of restraint reduction. RESULTS: Based on the multiple logistic regression analysis, there was no indication of increased risk of falls or injuries with restraint removal. Moreover, restraint removal significantly decreased the chance of minor injuries due to falls (adjusted odds ratio: 0.3, 95% CI: 0.1, 0.9; p < .05). The survival analysis demonstrated that the nursing home that had the least restraint reduction (11%) had a 50% higher rate of falls (p < .01) and more than twice the rate of fall-related minor injuries (p < .001) when compared to the homes with 23% and 56% restraint reduction, respectively. CONCLUSIONS: Physical restraint removal does not lead to increases in falls or subsequent fall-related injury in older nursing home residents.     

Determination of selenium in the human brain by graphite furnace atomic absorption spectrometry

Financial issues are encroaching upon health care decisions at a rapid pace in today's managed care arena. An examination of the parallel historical perspectives of bioethics, health care reimbursement, and quality improvement reveals that, by integrating an ethical framework with the quality improvement process, health care professionals can preserve patient-centered care. The article demonstrates the strength of this combined approach using restraints as an example.     

Hospital nurses' views about physical restraint use with older patients

1. A survey of knowledge, practice and attitudes about physical restraints was completed by nursing staff (RN, LPN, CNA) from four hospitals. 2. Nurses from both geriatric and geropsychiatric units reported significantly more educational activities about restraint use than did nurses on medical units. 3. RNs had the highest knowledge scores (56%), but lacked specific information about the dangers associated with restraint use. 4. While education about restraints is important, staff need role models who can help them problem solve and examine alternatives to restraints.     

The impact of organizational downsizing on the job satisfaction of nurses

Professional nurses across Canada are being affected by health reform initiatives designed to deinstitutionalize the health care system. This panel study examined the impact this restructuring has had on nurses' overall job satisfaction as well as their satisfaction with various aspects of their job and work environment. The participants consisted of 345 nurses employed in 3 community hospitals in southwestern Ontario. Hospital downsizing had relatively little effect on overall job satisfaction, satisfaction with kind of work, amount of work, and physical work conditions. However, compared to before the downsizing, nurses reported a significant deterioration in satisfaction with their career future, hospital identification, supervision, and co-workers following the implementation of restructuring initiatives. We discuss the organizational and management implications of these findings and suggest ways that hospital administrators can minimize the negative effects of downsizing on nursing professionals.     

Secondary prevention of excessive alcohol use: assessing the prospects of implementation

BACKGROUND: Alcohol risk and harm reduction is a public health approach that goes beyond specialized treatments for alcoholism. The greatest potential for reducing alcohol risk and harm in a population depends on the extent to which health care practitioners use secondary prevention programmes. OBJECTIVE: We aim to assess the factors that affect the prospects of disseminating comprehensive, secondary prevention programmes into mainstream practice. METHOD: A decision balance was used to assess the prospects of practitioners implementing comprehensive programmes systematically. The stages-of-change model provides perspectives about behaviour change with regard to patients, practitioners and practice settings. RESULTS AND CONCLUSIONS: Programme implementation is extremely unlikely given the current organization of health care settings. To maintain the use of such programmes, we need to change the "unit of leverage" in the system: from the clinical encounter--that is, practitioners working with individual patients in a case-finding manner--to an organizational level--that is, the appropriate use of managerial and information systems supporting health care settings to identify at-risk patients systematically as they enter primary care and hospital settings. With appropriate infrastructure support, practitioners will be able to fulfil the potential for as well as maintain the use of comprehensive, secondary prevention programmes to reduce alcohol risk and harm in the population.     

Restraint-free care: how does a nurse decide?

Decisions by nurses to avoid physical restraint use in older adults is a complex process that requires individualized, comprehensive assessment and creative problem-solving. Institutional and social policy increasingly support a standard of restraint elimination influencing care decisions with frail older adults. It has become clear that the decision to avoid or use physical restraint is influenced as well by nurses' attitude or beliefs about the efficacy of restraint. To further understand how decisions are made to avoid physical restraint, it is important to also explore the degree to which nurses possess knowledge, autonomy, and accountability in this decision-making process. Understanding how decisions are influenced will advance the development of restraint-free care interventions for older adults.     

The diagnosis, treatment and prevention of early stages of cerebral blood flow insufficiency

1. Although decreasing the use of seclusion and restraints in the management of aggressive children is a critical issue facing pediatric psychiatric inpatient programs, finding effective alternatives has been a difficult challenge. 2. Therapeutic holding appears to be as effective as seclusion and restraint with respect to managing aggressive behaviors in the psychiatrically disordered child. 3. Therapeutic holding has the potential to reduce the episodes of mechanical restraints and to be perceived by children as less punitive.     

Lipid composition of hepatic and adipose tissues from normal cats and from cats with idiopathic hepatic lipidosis

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.