SENSORY INTERVENTIONS FOR OUTLIERS AT-RISK OF FALLS AND RESTRAINTS ON GERIATRIC PSYCHIATRY INPATIENT UNIT

Abstract

Introduction Non-violent restraints are used in hospitals to address unsafe behavior in confused patients who are unable to follow redirection but are not aggressive toward self or others. On a geriatric psychiatry unit, one of the most common indications is to prevent falls. Approximately 7% of hospitalized patients will fall with up to nearly 30% of falls resulting in injury.(1) Risk factors for falls, such as cognitive impairment, agitation(2) and psychotropic medication, are very common on geriatric psychiatry inpatient units. However, data indicate that restraints may actually be associated with more falls due to deconditioning and other negative outcomes, including worsened agitation, decreased cognitive performance, walking dependence, increased difficulty with activities of daily living, pressure ulcers, and contractures.(3) Internal data from the geriatric unit at Western Psychiatric Hospital (WPH) in 2016 show that a small number of very high risk patients account for the majority of non-violent restraint. Most were patients with behavioral disturbance of dementia, including agitation, wandering and impulsivity. Often these behaviors may be driven by an unmet need, such as pain, boredom or lack of appropriate sensory stimuli.(4) Non-pharmacologic interventions such as sensory stimulation and individualized behavior plans have shown benefit in behavioral symptoms of dementia.(4,5) Aim: Our primary outcome was to reduce restraints without increasing falls with secondary outcome of decreased staff injury. Methods Setting: Integrated Health and Aging Program (IHAP), Western Psychiatric Hospital, a 40 bed geriatric psychiatric inpatient unit.Population: Approximately 35% Major Neurocognitive and 65% primary psychiatric diagnosesData collection: Number of falls and restraints per week and number of staff injuries per month were collected for an 11-month pre-intervention period beginning January 2016 and an 11-month intervention period. Intervention: Three part plan to decrease use of restraints for fall prevention, using behavioral interventions targeting patients “at-risk” for falls and restraintsPart 1: Identify “at risk” patients at admission using an initial RN screening assessment, or at any point during hospitalization by the treatment team or milieu staff.Part 2: Universal “at-risk” interventions checklist implemented by milieu staff for any patient identified as “at-risk”Part 3: Individualized behavior plan created by program director based on information collected by milieu staff in Part 2. Results Our primary outcome, restraints per week, decreased from 11.3 to 4.61 (p = 0.009) after the intervention began. The number of falls was unchanged with a mean of 6 per month before the intervention and 6.5 after (p = 0.45). Staff injuries per month decreased from 4.6 to 2.1 (p = 0.007). Conclusions The intervention successfully decreased use of nonviolent restraint without increasing falls. This benefit was sustained over at least 11 months, making it unlikely that increased observation, or the Hawthorne effect, was solely responsible. Factors that likely contributed include the successful identification of “at-risk” patients and early intervention. The behavioral interventions focused on sensory stimulation, assessment of unmet needs and individualized behavior plans which have been shown to be effective non-pharmacological interventions for behavioral disturbance of dementia. As restraint use decreased so did staff injury, demonstrating that decreased restraints benefits staff as well as patients. This likely contributed to helping create a culture change around the use of restraints ensuring that the benefits of this intervention persist. Developing an intervention targeting a very high risk population allowed us to decrease our overall restraint use. This study helped us successfully advocate for a behavioral health counselor for the unit to focus on further implementation of sensory interventions and behavior plans for patients with major neurocognitive disorder. This research was funded by: UPMC Department of Psychiatry Clinical Values Grant