Restrictive Practices Clinical Intervention or Management Failure May 2013 Chris Gork
Governance and guiding principles Decision Making Tool: Supporting a Restraint Free Environment in Residential Aged Care National Aged Care Accreditation Standard 4 Last resort Least restrictive Temporary Page 2
Influencing and impacting factors Organisational culture, policy and procedure Increasing diversity of role and responsibilities, workloads and expectations from management, staff and family The built environment Lack of clinical governance Knowledge of behaviour management and Increasing resident acuity Page 3
Justification for a restraint Falls Aggressive behaviour Wandering Injury to self and other (Wang, WW., Moyle, W., (2005) Physical Restraint Use on People with Dementia, Australian Journal of Advanced Nursing, Vol 22, Number 4, p. 46 52) Page 4
A different perspective A restraint is not an illness; it is an intervention used to treat a symptom, which is usually demonstrated by the resident through their behaviour. (Assessment and Alternative Help Guide, Centres for Medicare, www.cms.gov/regulations-and-guidance/.../restrainteducationpdf ) Page 5
Restraint Reduction Framework 1. Identification of the symptoms, behaviours and key events that occurred in the resident s journey prior to the application or administration of the restraint 2. Collection of other related data 3. Analysis and generation of assumptions 4. Testing of assumptions Page 6
Identification of symptoms, behaviour and key events Page 7
Relationship of behaviour to time 24 hour chart Page 8
Collection of other relevant data Diagnosis Review of assessment tools and care plan List of current regular and prn medication Interview with the resident (if possible), primary care staff and family Direct observation of the resident, staff and their interactions with each other Environmental audit Page 9
Analysis domains Biological Social and emotional Physical environment Human Falls Education Policy and procedures Page 10
Analysis of information Completed by Reviewer Completed Clinical Staff on Site Behaviour Review Area Potential factors impacting on the resident and behaviour management Recommendations Action taken & date Outcome & date Biological Social & Emotional Physical Environment Human Falls Education and training Process and systems Page 11
Case Study Mr X Male 80+ Alzheimer s Disease, Hypertension, Osteoarthritis, Depression, R) TKR, Ischaemic Heart Disease, Glaucoma, R/o Cataracts Physical aggression, day and night time wandering, restlessness and agitation, constant self talk Non-secure facility Administration of regular and prn Risperdal to manage behaviour Page 12
What were staff doing? AIN s were applying about 4 to 5 basic interventions to manage his behaviour Taken for a walk Settled in front of the TV Holding his hand and speaking to him calmly Putting him to bed Alarm bracelet and 15 minute visual observations RN s primarily used one intervention Administration of an prn antipsychotic No documented administration of prn analgesia There were no strategies in place to improve the situation Page 13
Potential triggers identified Pain associated with pressure risk, osteoarthritis and oral tooth decay Potential side effects of current medications e.g. risperdal and movox Potential for undiagnosed delirium Dehydration, hunger Trajectory of dementia Repetition of life time patterns Boredom Inability to way-find due to environmental issues Page 14
What we did Pressure relieving device Changed focus of prn medication Introduction of spiritual activities to meet lifetime habits Investigated potential clinical issues related to his blood glucose and blood pressure 1:1 supervision and assistance for all meals Increased level of lighting and signage Dental referral Improved staff understanding of behaviours as an expression of need Improved communication techniques Page 15
Benefits for Mr X No recorded administration of prn risperdal since retrospective review and education delivered Waking once/twice at night due to incontinence, but re-settles quickly - no documented episodes of nightime wandering Reduced episodes of physical aggression associated with care activities Staff verbally report resident is calmer throughout the day with a 50% reduction in his daytime wandering and only one episode of his trying to leave the unit Page 16
Restraint Reduction Framework 1. Identification of the symptoms, behaviours and key events that occurred in the resident s journey prior to the application or administration of the restraint 2. Collection of other related data 3. Analysis and generation of assumptions 4. Testing of assumptions Page 17
Benefits for the staff & facility Reduced time spent managing behaviour Staff are more confident they can make improvements to resident care and wellbeing Staff have a framework for review of restraint Review identifies other clinical areas where improvement can be made Review supports continuous improvement in Standard 2 Health and personal care and Standard 4 Physical environment and safe systems Page 18
What stands If freedom falls Rudyard Kippling Page 19