Prevalence Of Restraint Use Research Articles

The agitated pediatric patient located in the emergency department: The APPLIED observational study.

ObjectivesFocused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients.MethodsWe reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3‐year‐period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute).ResultsOf 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non‐Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2–2.7), but not restrained (aOR, 0.8; 95% CI, 0.3–1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5–3.3), autism (aOR, 2.9; 95% CI, 1.9–4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2–2.5), psychosis (aOR, 14.3; 95% CI, 2.5–271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2–3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0–3.5). Depression (aOR, 0.4; 95% CI, 0.3–0.5) and suicidality (aOR, 0.2; 95% CI, 0.1–0.3) were protective against agitation and restraint use.ConclusionPrevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.

No Decision About Me Without Me: International Views on Providing Care Against Someone’s Will

People with cognitive impairment may experience the care provided by their caregiver(s) as unnecessary or undesirable, which is expressed by behaviors such as resisting the efforts of a caregiver or preventing the caregiver to perform or assist with ADL such as bathing, dressing and toileting. This can lead to stress, agitation and aggression for both the care recipient and the caregiver, and places the caregiver in a complex dilemma. Should the caregiver force hygiene or respect the person’s autonomy to refuse care? It is difficult for caregivers to find a balance between quality of care and safety, while accepting the person’s autonomy. Caregivers in long-term care often feel the necessity to provide care against the will of people with a cognitive impairment, including physical restraints, psychotropic medication, and non-consensual care. This symposium provides an international perspective with presenters from Belgium, Switzerland, Germany, and the Netherlands. The first presenter explores the use and factors associated with physical restraint, psychotropic medication, and non-consensual care in people with dementia receiving home care in the Netherlands and Belgium. Second, a presenter from Switzerland focuses on the prevalence of restraint use in nursing homes. The third presenter introduces an Advance Care Planning intervention from Germany that aims to ensure that personal wishes in home care are followed. The last presenter assesses the feasibility of an approach to prevent and reduce care against a person’s will in the Netherlands. To conclude, our discussant will integrate these insights and draw conclusion for policy, practice and further research. Systems Research in Long-Term Care Interest Group Sponsored Symposium

Restraint use in residents with dementia living in residential aged care facilities: A scoping review.

To provide an overview of restraint use in residents with dementia in the context of residential aged care facilities. Restraints are commonly used in people with dementia living in residential aged care facilities to manage behaviours and reduce injuries, but the concept of restraint use in people with dementia remains ambiguous, and current practices to reduce restraint use in long-term care residents with dementia remain unclear. A scoping review using the methodological frameworks of Arskey and O'Malley and colleagues. Nine databases (CINAHL, MEDLINE, EMBASE, PubMed, Scopus, Web of Science, OVID, Cochrane Central Register of Controlled Trials and ProQuest) were searched from 2005 to 20 May 2019. Articles were included if they were written in English, peer-reviewed and used any research method that described restraint use in residents with dementia living in residential care settings. The PRISMA-ScR checklist was used. From 1,585 articles, 23 met the inclusion criteria. There is a lack of a clear definition of restraint use, and the prevalence of restraint use varied from 30.7% to 64.8% depending on the different operational concepts. People with dementia were at a higher risk for restraint use, and the decision-making process for restraint use was largely ignored in the literature. The effect of staff educational interventions to reduce restraint use was inconsistent due to varying delivery duration and content. The prevalence of restraint use in people with dementia living in residential care settings remains high alongside the absence of a clear definition of restraint use. More research about the decision-making process involved in using restraint and development of effective interventions are needed. Better education about the decision-making regarding staff, conditions of residents and organisations for restraint use is needed to improve the care for people with dementia living in care settings.

Restraint of adults with intellectual disabilities: A critical review of the prevalence and characteristics associated with its use.

As part of their care, adults with intellectual disabilities are often subject to restrictive interventions including restraint. A review examining the prevalence of restraint use with people with intellectual disabilities and the characteristics associated with its use. The seven papers identified used quantitative methodologies and had cross-sectional designs. Prevalence rates of restraint ranged from 11% to 78%, multiple forms of restraint were common. Most studies focused on characteristics within the person with an intellectual disability, three considered external factors. Challenging behaviour was the most consistent characteristic associated with the use of restraint, but how this was defined varied. The review highlights a need for more consistent means of defining and measuring restraint and its associated characteristics. Future research into this area may also want to focus on the context of restraint such as whether it is the least restrictive option used.

Clinical Pearls

The significant morbidity and disability that family members of patients in the intensive care unit (ICU) can experience has been recognized in the past decade. The Society of Critical Care Medicine calls this condition post–intensive care syndrome (PICS). However, as more and more adult ICU patients require long-term acute care hospitalization (LTACH), little is known about PICS in the families of these patients.Petrinec studied LTACH family decision makers during the hospitalization and up to 2 months after discharge. She found the following:The author recommends early recognition of PICS in order to provide opportunities for focused family interventions.See Article, pp 416–422Infants with single-ventricle physiology undergo surgical palliation soon after birth but continue to have imbalance between pulmonary and systemic blood flow. Endotracheal tube suctioning (ETS) is a routine procedure to maintain tube patency but has been associated with various adverse events such as hypoxemia, bradycardia, and cardiac arrest. To date, no published research has been focused on the effects of this procedure in these children.Tume and colleagues examined the processes and adverse events associated with ETS conducted by bedside nurses in the first 48 hours after surgical palliation. They found the following:Because significant hemodynamic instability can occur, the authors recommend that ETS be planned early and with a consistent approach to reduce risks and variability in technique.See Article, pp 388–394Physical restraints are often used to prevent patients in intensive care units (ICUs) from pulling on or dislodging therapeutic devices such as endotracheal tubes and dialysis catheters. Researchers have examined the prevalence of restraint use in the ICU, but little is known about nursing determinants of restraint initiation and discontinuation.Dolan and Looby interviewed surgical ICU nurses about their experiences. They identified 3 general categories of factors considered:Nurses’ contributions are vital for determining best patient practices for educational initiatives and hospital policies related to use of restraints.See Article, pp 373–379The focus of palliative care is to improve the quality of life for patients with serious and complex illnesses and includes symptom management, emotional support, and family communication. Despite the success of nursing education programs such as the national End-of-Life Nursing Education Consortium (ELNEC) project, nurses continue to perceive barriers to integration of palliative care in the intensive care unit (ICU).Anderson and colleagues developed and implemented a system-wide training program called Integrating Multidisciplinary Palliative Care into the ICU (IMPACT-ICU) in 5 medical centers. The purpose was to train advanced practice nurses and nurse educators to provide palliative care education and support to bedside nurses. Findings from the program included the following:The authors note that engagement of stakeholders at multiple levels and disciplines facilitated the successful implementation of IMPACT-ICU.See Article, pp 361–371

Factors Associated With the Trend of Physical and Chemical Restraint Use Among Long-Term Care Facility Residents in Hong Kong: Data From an 11-Year Observational Study

BackgroundNegative effects of restraint use have been well-documented. However, the prevalence of restraints use has been high in long-term care facilities in Hong Kong compared with other countries and this goes against the basic principles of ethical and compassionate care for older people. The present study aimed to review the change in the prevalence of physical and chemical restraint use in long-term care facilities (LTCFs) over a period of 11 years in Hong Kong and to identify the major factors associated with their use. MethodsThis is an observational study with data obtained from the Hong Kong Longitudinal Study on LTCF Residents between 2005 and 2015. Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument to collect the data from 10 residential LTCFs. Physical restraint was defined as the use of any of the following: full bedside rails on all open sides of bed, other types of bedside rails used, trunk restraint, limb restraint, or the use of chair to prevent rising during the past 7 days. Chemical restraint was defined as the use of any of the following medications: antipsychotic, antianxiety, or hypnotic agents during past 7 days, excluding elder residents with a diagnosis of psychiatric illness. OutcomesAnnual prevalence of restraint use over 11 years and factors that were associated with the use of physical and chemical restraints. ResultsWe analyzed the data for 2896 older people (978 male individuals, mean age = 83.3 years). Between 2005 and 2015, the prevalence of restraint use was as follows: physical restraint use increased from 52.7% to 70.2%; chemical restraint use increased from 15.9% to 21.78%; and either physical or chemical restraint use increased from 57.9% to 75.7%. Physical restraint use was independently associated with older age, impaired activities of daily living or cognitive function, bowel and bladder incontinence, dementia, and negative mood. Chemical restraint use was independently associated with older age, falls, bladder incontinence, use of feeding tube, dementia, poor cognitive function, delirium, behavioral problems, and negative mood. The increasing time-trend of physical but not chemical restraint use remained significant after adjusting for other factors as mentioned above (coefficient = 0.092, P < .001). ConclusionsUse of physical and chemical restraint was highly prevalent among LTCF residents in Hong Kong, with an increasing trend over a period of 11 years, especially targeting the most physically and cognitively frail older people. Appropriate healthcare staff education and policy change are urgently needed to ensure personal care that is characterized by respect, dignity, empathy, and compassion for the older generation.

Use of physical restraint in hospital patients: A descriptive study in a tertiary hospital in South Africa

Background: The use of physical restraint in patient management is a common and emotive issue, and has legal and ethical dimensions. Objective: To document the prevalence of physical restraint use, patient characteristics associated with physical restraint use, and nurses’ and doctors’ knowledge and perceptions towards the practice. Methods: A cross-sectional study of 572 patients, of whom 132 were physically restrained, was conducted in acute wards of a tertiary hospital. Data were collected on the 132 physically restrained patients. Fifty-nine doctors and 159 nurses completed a specially constructed questionnaire. Descriptive statistics were derived and expressed as numbers and percentages. Results: Prevalence of restraint use was 23% (132/572). The distribution in acute wards was: medical 54.5%; surgical 44.7%; maternity 0.8%; psychiatry none. Mean age (SD) of the restrained patients was 49 years (20.5); 53.8% were male. The commonest types of restraints used were bed rails 93% and wrist belts 12%. Restraints were used largely to protect medical devices and as protection from harm. Less than 15% of the nurses reported having received training and 36% of the doctors reported having received some guidance on the use of restraints. Only a minority of nurses and doctors knew of a hospital policy on restraint use. Documentation on the prescription and indication for the use of restraint was poor. Conclusion: Prevalence of restraint use is high and poorly coordinated. A policy on the use of restraint and comprehensive guidelines should be developed to guide health care practitioners in the management of patients where restraint cannot be avoided.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life in the Acute Care Setting: An Analysis of Data from the BEACON Trial (TH318-C)

Objectives Gain an understanding of the prevalence of restraint use in dying patients. Understand what patient characteristics and care processes place a patient at greater risk for being restrained at time of death. Original Research Background: The use of physical restraints in dying patients should be limited to situations where patient death is unanticipated. Little is known about the prevalence or risk factors for restraint use at end of life. Research Objectives: To determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults. Design: conducted between 2005 and 2011. Setting/Participants: Data on the last seven days of life were abstracted from the medical records of 5,476 decedents from six Veterans Administration Medical Centers (VAMCs) in the southeast United States and from VA administrative databases. Methods: Based on literature and expert clinical opinion, we prospectively identified potential risk factors for restraint use at the time of death from among all variables collected during the trial. Factors included location of death, medications given, nasogastric tube, intravenous (IV) fluids infusing, family presence at time of death, and receipt of a palliative care consultation.

The use of seatbelts and child restraints in three Mexican cities

Seatbelts and child restraints can reduce deaths resulting from road traffic crashes, and are one of the risk factors being targeted by the Road Safety in 10 Countries project in Mexico. This study quantifies the prevalence of restraint use in two of the intervention sites (Guadalajara-Zapopan and León) and one comparison site (Cuernavaca). Three rounds of roadside observations were conducted between November 2010 and January 2012. The overall prevalence of seatbelt use was 45.0% (95% CI = 44.3–45.7) amongst all occupants ≥10 years of age in the three cities. Child restraint use in children <5 years of age ranged from 7.9 to 17.4%. Two rounds of surveys were administered to all road traffic injury (RTI) victims presenting at a tertiary hospital in each city; RTI victims had lower seatbelt use than the general population (31% vs 42%, p = 0.037). This study demonstrates the need for further targeted intervention to increase use of these highly efficacious safety devices in Mexico.

The factors that influence nurses' use of physical restraint: A thematic literature review

Lane C, Harrington A. International Journal of Nursing Practice 2011; 17: 195–204 The factors that influence nurses' use of physical restraint: A thematic literature review Difficult clinical situations in both hospitals and aged care facilities might lead to the use of physical restraint on older people. This literature reviewed aimed to identify the factors that influence nurses' use of physical restraint on people aged over 60 years. The prevalence of restraint use in aged care facilities was shown to be between 12% and 47%, with 7% to 17% for hospitalized patients. Database searches retrieved studies published after 1992 that highlighted nurses' use of physical restraint on older people in both acute and aged care settings. The analysis revealed two reasons for decisions to use physical restraint that were categorized as ‘patient safety’ and ‘nurses' workload’. It is important for nurses to understand the nursing culture that perpetuates restraint use, and to consider patient‐centred nursing as an instigator for change.

Report of the Council on Scientific Affairs: Use of Restraints for Patients in Nursing Homes

To examine issues related to the use of restraints on nursing home patients, including regulations and guidelines, risks and benefits of restraint use, system problems, and measures to reduce restraint use, to determine when the use of restraints results in clinically desirable outcomes. Sources of information included a review of published articles and reports, a survey of federal and state regulations and guidelines relating to restraint use in nursing homes, review of current legislative initiatives, and consultation with experts in the field. The data reveal that restraint use imposes more risk of falls and other undesirable outcomes than it prevents. In response to legislative initiatives and regulatory activities and by implementing alternatives, the prevalence of restraint use has decreased by 20% in recent years. In many states, facilities have created restraint-free environments or restraint-free policies and goals. The Council on Scientific Affairs finds that current federal and state regulations on the use of restraints have benefited the vast majority of nursing home patients. While guidelines are in place for the use of restraints when clinically necessary, the Council on Scientific Affairs recommends increased research to determine when the use of restraints results in desirable outcomes. Extraregulatory initiatives, such as widespread educational programs, are needed for professionals and consumers to improve awareness of the risks and benefits of restraints, as well as the rights of residents with respect to restraint use.

Restraint reduction: a new philosophy for a new millennium.

With the use of restraints to manage difficult patients becoming routine, one hospital initiated strategies to reduce restraint use. The authors describe the development and implementation of a restraint reduction program, educational strategies, and the evaluation program. The program is successfully reducing the prevalence of restraint use.

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.

Attitudes of wives toward having their elderly husbands restrained: Professional caregivers should be mindful of the feelings of spouses, who may view the use of restraints on their loved one as the end of hope and dreams

To get insight into restraint use in older adults receiving home care and, more specifically, into the definition, prevalence and types of restraint, as well as the reasons for restraint use and the people involved in the decision-making process.Systematic review.Four databases (i.e. Pubmed, CINAHL, Embase, Cochrane Library) were systematically searched from inception to end of April 2017.The study encompassed qualitative and quantitative research on restraint use in older adults receiving home care that reported definitions of restraint, prevalence of use, types of restraint, reasons for use or the people involved. We considered publications written in English, French, Dutch and German. One reviewer performed the search and made the initial selection based on titles and abstracts. The final selection was made by two reviewers working independently; they also assessed study quality. We used an integrated design to synthesise the findings.Eight studies were reviewed (one qualitative, seven quantitative) ranging in quality from moderate to high. The review indicated there was no single, clear definition of restraint. The prevalence of restraint use ranged from 5% to 24.7%, with various types of restraint being used. Families played an important role in the decision-making process and application of restraints; general practitioners were less involved. Specific reasons, other than safety for using restraints in home care were noted (e.g. delay to nursing home admission; to provide respite for an informal caregiver).Contrary to the current socio demographical evolutions resulting in an increasing demand of restraint use in home care, research on this subject is still scarce and recent. The limited evidence however points to the challenging complexity and specificity of home care regarding restraint use. Given these serious challenges for clinical practice, more research about restraint use in home care is urgently needed.

Community-Acquired Fungal Diseases

Negative effects of restraint use have been well-documented. However, the prevalence of restraints use has been high in long-term care facilities in Hong Kong compared with other countries and this goes against the basic principles of ethical and compassionate care for older people. The present study aimed to review the change in the prevalence of physical and chemical restraint use in long-term care facilities (LTCFs) over a period of 11 years in Hong Kong and to identify the major factors associated with their use.This is an observational study with data obtained from the Hong Kong Longitudinal Study on LTCF Residents between 2005 and 2015. Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument to collect the data from 10 residential LTCFs. Physical restraint was defined as the use of any of the following: full bedside rails on all open sides of bed, other types of bedside rails used, trunk restraint, limb restraint, or the use of chair to prevent rising during the past 7 days. Chemical restraint was defined as the use of any of the following medications: antipsychotic, antianxiety, or hypnotic agents during past 7 days, excluding elder residents with a diagnosis of psychiatric illness.Annual prevalence of restraint use over 11 years and factors that were associated with the use of physical and chemical restraints.We analyzed the data for 2896 older people (978 male individuals, mean age = 83.3 years). Between 2005 and 2015, the prevalence of restraint use was as follows: physical restraint use increased from 52.7% to 70.2%; chemical restraint use increased from 15.9% to 21.78%; and either physical or chemical restraint use increased from 57.9% to 75.7%. Physical restraint use was independently associated with older age, impaired activities of daily living or cognitive function, bowel and bladder incontinence, dementia, and negative mood. Chemical restraint use was independently associated with older age, falls, bladder incontinence, use of feeding tube, dementia, poor cognitive function, delirium, behavioral problems, and negative mood. The increasing time-trend of physical but not chemical restraint use remained significant after adjusting for other factors as mentioned above (coefficient = 0.092, P < .001).Use of physical and chemical restraint was highly prevalent among LTCF residents in Hong Kong, with an increasing trend over a period of 11 years, especially targeting the most physically and cognitively frail older people. Appropriate healthcare staff education and policy change are urgently needed to ensure personal care that is characterized by respect, dignity, empathy, and compassion for the older generation.