Implementing a Restraint Free Policy Esther Vance NSW Falls Injury Prevention Network Prince of Wales Medical Research Institute March 2008
Restraint Definition anything that limits an individual s voluntary response or movement NSW Health
Restraint Free Policy Ideal to aspire towards Restraint free care involves restraints not being used for any reason and not kept by the health care facility Leads to better management of patients particularly those with dementia
Physical/Mechanical Restraints Examples include posey vests, belts, wrist ties, soft padded limb restraints
Mechanical Restraints Include bedrails, concave mattresses and deep seated chairs
Chemical restraints Use of medications such as psychotropic drugs to control or modify an individual s behaviour.
Negative impacts of restraints Physical effects such as pressure sores, loss of muscle strength, incontinence, falls, balance and co- ordination problems asphyxiation and death.
Negative Impacts of restraints Psychological effects included demoralisation, humiliation, depression, aggression, agitation and impaired functioning. Legal/ ethical factors such as duty of care to patients and possible litigation.
Restraint Use in Acute Care Restraints were used in 9.4% of patients over 62 years and 33% in over 85 years. Main reason for use was cognitive impairment or delirium superimposed on dementia. Other reasons were preventing falls, controlling agitation, prevent wandering and prevent injury to staff or other patients. Main restraint used was bedrails (62%) followed by chemical restraints and vests. 85% of Nursing staff did not consider bedrails a form of restraint. Irving 2004 Aust. J. Adv. Nursing Vol.21, No.4 p23-27 27
Restraint Use in Acute Care Agitation reported in > 60% of hospitalised patients over 65 years old Multiple restraint useage Restrained patients tended to have longer hospital stay, more complications and increased likelihood of discharge to residential care. Nursing staff were not well equipped to deal with patients with challenging behaviours. Staff education on restraints and alternatives to restraints and the management of difficult patients was found to be inadequate Mott, Poole & Kenrick Int. J Nurs. Prac. 2005 Vol. 11, p95-101
Guidelines NSW Health Guidelines for working with people with challenging behaviours in residential aged care facilities. NSW Health Management Policy to Reduce Fall Injury Among Older People Department of Health & Ageing, Decision Making Tool: Responding to Issues of restraint in Aged care, 2004 Australian Safety and Quality Council, Preventing falls and harm from falls in older people: best practice guidelines for Australian Hospitals and residential Aged care Facilities, section 4.10 Hospital policies on restraint use
NSW Health Guidelines Restraints can be used only after: Comprehensive Patient assessment and need for restraint documented. Consultation with family/guardian on need and type of restraint. Consent of patient or family/guardian. Other less restrictive alternatives have been tried. Restraint useage recorded in patient file and reviewed regularly.
Australian Commission on Safety and Quality in Health Care Preventing falls and harm from falls in older people-best practice guidelines Section 4:10 Alternatives to restraint should be considered and trialled for people with cognitive impairment. Restraint should be the last option for people who are at risk of falling.
Restraint Policies A number of hospitals and some Area Health Services and Nursing Boards have developed Restraint Policies or Clinical Guidelines These policies/guidelines promote restraint minimisation Give direction when a patient may be mechanically or chemically restrained Provide detail for staff to ensure patients are managed in the most clinically appropriate manner
Restraint Policies Staff committed to restraint minimisation Awareness of legislation such as the Guardianship Act, The law generally protects an individuals right not to be restrained Essential to document compliance to legal responsibilities.
Staff Education Raise awareness of policy Inform staff of their legal responsibilities Implications on practice including assessment, care planning, restraint use and monitoring
Barriers to implementing restraint free care policies NARI study published in 2005 found a number of barriers, these included: Fear of patient/resident injury and subsequent litigation Staffing and resource issues Lack of education on alternatives to restraints Environmental constraints
Barriers to implementing restraint free care policies Policy and management issues Family/patient/staff beliefs or expectations Poor review practices Communication barriers
Alternatives to Restraints Physiological Alternatives Safety Safety in bed Toileting and continence Seating Seating and position support Activities and programs Physical Restraint Part 2 : Minimisation in acute and Residential Care facilities, Joanna Briggs Best Practise Vol 6 Issue 4 2002
Alternatives to Restraints Psychosocial alternatives AlarmsAlarms Alterations to Nursing Care Environmental changes Physical Restraint Part 2 : Minimisation in acute and Residential Care facilities, Joanna Briggs Best Practise Vol 6 Issue 4 2002
Management of Specific populations Cognitively impaired persons Person at risk of falling Person who wanders Person who tampers with medical devices Agitated or violent person Person with impaired mobility Physical Restraint Part 2 : Minimisation in acute and Residential l Care facilities, Joanna Briggs Best Practise Vol 6 Issue 4 2002
Case History 1 82 year old gentleman admitted with a chest infection. Confused, unco-operative operative and combative at times Patient restrained with wrist restraints but was reported as continuing to be uncooperative. Assessment of patient and review of patients previous admission notes revealed the patient had long standing back pain. Recommended and given analgesia for back pain. The patient settled and was co-operative operative
Case History 2 86 year old lady with CALD background with a diagnosis for dementia admitted for cellulitis. Patient continually attempted to get out of bed and mobilise when she was unsafe to do so. Vest restraint placed on patient. Contact with residential Aged care facility she resided at revealed the patient settled with doll therapy. Patient was settled with doll and remained settle for the remainder of her admission (10 days).
Conclusion Restraints are a last resort measure when all other options have been considered and found to be unsuccessful. Follow the policy/guidelines developed by the health care facility. Staff education in restraint reduction, including alternatives and strategies for managing difficult patients is vital. Always consult family/carers and inform them of the available choices. Consider duty of care to patient.
Acknowledgements Thanks to Margaret Brown CNC Dementia Care for South Eastern Sydney Illawarra Health Service for the 2 Case Studies and Information on the preparation of a Restraint Policy NSW Area Health Service Falls Prevention Co-ordinators ordinators for input and advice in this area
2008 Falls Prevention Network Meeting
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