Reducing Patient Restraints: A Pilot Approach Using Clinical Case Review

Background: Restraint in the psychiatric unit is a common practice but it is very controversial and it has undergone a poor evaluation according to methodological investigations. Using restraint is a common problem and has a significant impact on patients, families and health care staff. Therefore, this systematic review will discuss the important reasons as to why restraint should be reduced. It will also explain several alternative treatments for aggressive patients in mental hospitals.Method: The database searches were used to identify potential articles: Scopus and Proquest were the focus. The search was limited to those published in the range of the last 5 years from 2013 to 2018. The keywords that were used were ‘restraint in the hospital’, ‘restraint reduction’, ‘the elimination of restraint’ and ‘physical restraint’.Result: Only 15 articles met the inclusion criteria. The results suggest that restraint is considered to be a violation of human rights and that it traumatizes the patients. It is inhuman and degrading. Besides this, restraint can result in physical complications in the form of lacerations, asphyxia, thrombosis and death. Restraint is permitted when other methods fail and in emergency conditions.Conclusion: Some of the ways to reduce the use of restraint are by constant monitoring and through the control of individual behavior, including verbal management and attitudes, reducing the environmental risks, and administering drugs. Some of the efforts to avoid restraint are the "Positive and Safe in Calderstones" program, sensory modulation and peer advice and support.

Effect of Physical Restraint Reduction on Older Patients’ Hospital Length of Stay

Background The use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioral health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, contraindicating the therapeutic treatment environment aimed to support the healing journey. Using a strategy of leadership, workplace development, and data, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting. Performance was sustained over the following year. Objectives The goal of this project was to fully eliminate the use of mechanical restraints in an inpatient behavioral health setting. Adopting the Six Core Strategies for Reducing Seclusion and Restraint Use, the hospital sought to provide staff with alternative tools supported by an evidence-based practice. The result would be a reduction of trauma and injury occurring during the restraint process. Methods This quality improvement project identified processes, structures, and patient outcomes related to restraint reduction within the organization. Each opportunity for improvement included a needs assessment for the identified barriers. The action steps necessary to implement change and accomplish the goal of reducing the use of four-point mechanical restraints in hospitalized patients were guided by trauma-informed care and the Six Core Strategies, in turn decreasing physical and psychological injuries, and improving patient care. Results Progress toward zero mechanical restraints was incremental. Both qualitative and quantitative data were used on a daily basis to support staff interventions. Active investment from leadership and allied professions provided support for a culture shift that went from using mechanical restraint almost daily to a culture where mechanical restraint is seen as a failure. This success was sustained through 2022 and is now a standard expectation for care at Belmont. This project enabled the removal of mechanical restraints from an acute inpatient behavioral health hospital servicing children, adolescents, and adults. The factors that supported the success of this project were true endorsement from leadership, robust staff training, and continuous feedback and supervision. Sustainability over at least one year was achieved. Conclusions Belmont is not the first inpatient setting to eliminate restraints for its programming; however, this project provides additional evidence that a restraint-free inpatient setting is possible with sufficient investment in staff and training. Using trauma-free interventions was an additional quality benefit that has enhanced the advantages of the way this program was designed. The implementation of this model and supporting interventions can provide a roadmap for other programs seeking to enhance the inpatient experience for both staff and patients.

We examined physical restraint use among 1856 nursing home residents hospitalized with hip fracture using a data set of hip fracture patients in 20 U. S. hospitals from 1983-1993. Mean age of patients was 85.2 years, 81.7% were women, and 91.3% were white. Rate of physical restraint use was 59.4%. Pre-operative physical restraint use was predicted by younger age, confusion, dementia, and needing assistance or dependency in activities of daily living (ADL). Physical restraint use following surgery was predicted by pre-operative physical restraint use, confusion, dementia, and lower co-morbidity of illness. At hospital discharge, restrained patients were more likely to be dependent in ADL and continence. The reduction of physical restraints among hospitalized nursing home residents will require attention to a multiplicity of factors that contribute to restraint use.

Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’)

Preventing the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards: A cluster-randomized trial

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Our present understanding of mechanical restraint is heterogenous, largely due to the important differences between countries/regions. In Spain, the use of this restrictive practice is not regulated, nor is its use protocolized. Previous studies that have investigated the impact of organizational factors and changes in these protocols are often short and not conducted within a framework designed to establish a long-term plan for reducing the use of mechanical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We demonstrate that the implementation of administrative and protocol changes in our psychiatric unit significantly reduced the use of mechanical restraint, thus laying the foundations for a regulatory framework. Our analysis shows that the profile of patients who require mechanical restraint is highly variable, but that certain clinical and institutional aspects within the framework of a long-term plan for the reduction in mechanical restraint can be targeted with long-lasting positive effects. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizational changes focussed on training staff, promoting family support and requiring the registration and close monitoring of episodes empower the role of the nursing staff in the prevention, monitoring and regulation of mechanical restraint. ABSTRACT: Introduction Mechanical restraint is a controversial restrictive practice to manage agitation or violent behaviour. Numerous studies have evaluated the factors and organizational changes that influence on mechanical restraint, but only for short time periods. None of those studies have assessed the effects of measures applied within the framework of a long-term plan to reduce the use of mechanical restraint. Given the lack of specific legislation in Spain, more data are required for its proper regulation. Aim/Question To evaluate the risk factors associated and the impact of specific measures designed to minimize the application of mechanical restraint in an acute mental health unit over an 8-year period and previous observation of 5years. Methods Cross-sectional study based on a retrospective analysis of mechanical restraint records. We compared admissions requiring ≥one episode of restraint versus admissions not requiring this coercive measure. Results Between 2007 and 2014, 412 admissions (12%) required mechanical restraint. The data show that the measures applied in the previous five years had significantly reduced the total hours of restraint per semester. The factors associated with admissions requiring mechanical restraint were involuntary, unscheduled and longer admissions. The best predictor of restraint was involuntary admission (OR=6.37), followed by the diagnosis of personality disorder (OR=5.01). Discussion Identification of the factors associated with mechanical restraint would allow for early detection strategies. Our results provide additional evidence on the usefulness of organizational changes to reduce coercive measures, even in a country without specific legislation. Implications for Practice Organizational changes, such as staff training and increased family support during admission of episodes of mechanical restraint, can reduce the use of this measure. These measures also give the nursing staff greater responsibility in terms of their role in registering and monitoring the restrictive practice, thus helping to prevent or minimize the use of mechanical restraint.

BackgroundRestraints are likely to negatively affect patients’ health and therefore a reduction in their usage is recommended for all health-care settings. To date, research on restrictive practices has concentrated on mental health and long-term care settings. In the acute-care hospital setting few studies have been published and these studies mainly focus on physical/mechanical restraints in specific subpopulations and/or on intensive care units. However, to ensure restraints are used as little as possible in the acute-care hospital setting, it seems important to investigate more comprehensively the use of restraints, to include all types of restraints irrespective of ward type or subpopulations and to identify factors associated with restraint use. ObjectiveThe aim of this study was to investigate restraint use regardless of ward type in the acute-care hospital setting, including restraint type, reasons for restraint use, process indicators when using restraints and restraint use-associated patient characteristics. MethodsUsing a cross-sectional multi-centre design, data were collected by means of an annual international prevalence measurement in acute-care hospitals in Switzerland and Austria. All hospitalised patients aged 18+ who gave informed consent were included. Data were collected at three measurement points between 2016 and 2018. Descriptive and multivariate logistic regression analyses were performed. ResultsA total of 29,477 patients hospitalised in 140 hospitals were included in this study. The prevalence rate for the use of at least one restraint over a 30-day period was 8.7% (n = 2577), with mechanical restraints representing the highest proportion of restraint type used (55.0%, n = 1417). The main reason for restraint use was fall prevention (43.8%, n = 1129), followed by confusion or delirious behaviour (20.4%, n = 525). In 64.3% of the cases (n = 1657), restraint use was documented in the patient file. Regular evaluation occurred in 42.9% of the cases (n = 1105). Care dependency had the strongest association with restraint use (odds ratio [OR] 25.00, 95% confidence interval [CI] 21.01–29.78 for completely dependant patients in comparison to completely independent patients), followed by mental and behavioural disorders (OR 2.36, 95% CI 2.15–2.59). ConclusionsRestraints are often utilised in hospitals in complex care situations such as with patients at risk of falling or with delirium. When using restraints the consideration of processes like documentation and evaluation shows great potential for improvement. Standardisation of these processes and education of the interprofessional team could be beneficial for raising awareness and for the sustainable reduction of restraint use.Tweetable abstract: In hospitals restraints are often used in complex care situations. However, their use seems to be insufficiently documented and evaluated.

There has been a strong movement in residential treatment programs to reduce the use of restraints. In the article, a restraint reduction initiative is described as implemented at a large children's residential agency. Results were examined and compared between 2004 (prior to implementation) and 2008. Results indicated a significant decrease in the number of restraints, amount of staff time spent in restraints, and the number of child injuries related to restraint per year. Additionally, the average number of staff injury due to client behavior stayed the same despite the belief that decreasing restraints will lead to increased staff injury.

The aim was to examine the impact of post restraint reduction meetings upon the frequency and restrictiveness of restraint use in English children's residential services. Attention has been drawn to the misuse, overuse and safety of some techniques used to physically restrain children in residential services. Successful interventions to reduce restraints have been reported, mostly from the USA. Demonstrate a significant overall reduction in both, frequency and restrictiveness of restraints; the greatest percentage decrease in the most restrictive floor restraints. Whilst five services reduced both frequency and restrictiveness, five services showed some increases in frequency and/or restrictiveness of restraints employed. Restraint reduction is most effectively reduced through employing multiple strategies and that post restraint reduction meetings maybe one useful component. Organisations seeking to promote restraint reduction meetings need to allocate sufficient priority and resources to support these.

The Crisis of Disability Is Violence

We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.

Organisational interventions aimed to implement a least-restraint policy probably reduce the number of residents with at least one PR and probably largely reduce the number of residents with at least one belt. We are uncertain whether simple educational interventions reduce the use of physical restraints, and interventions providing information about residents' fall risk may result in little to no difference in the use of physical restraints. These results apply to long-term care institutions; we found no studies from community settings.

To explore nurses' feelings and thoughts about physically restraining older hospitalized patients. The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan. A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data. Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings. Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints. The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.

Importance of interprofessional collaboration in teaching diabetic foot self-management: Perceptions of health care professionals