Rate Of Restraint Use Research Articles

Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care

BackgroundPhysical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use. ObjectivesThe primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers. MethodsThis was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test. ResultsRestraints were used in 1228 (0.9%) visits. Younger age, male gender, “unknown” ethnicity, self-pay or “other” nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79–1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95–2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively). ConclusionAt this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis.

The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. Hospitalized patients aged 18 and older. Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

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.

Early identification of persons living with dementia at point‐of‐care hospitalization using the electronic medical record

AbstractBackgroundHospitalization for Alzheimer's disease and related dementias (ADRD) is the single largest expense in the U.S., accounting for two thirds of Medicare costs for ADRD estimated at $155 billion in 2020. Persons living with dementia (PLWD) are twice as likely to be hospitalized, have longer average lengths of stay, higher readmission and mortality rates and are at increased risk for institutionalization. A major challenge is the low rates of identification of PLWD upon admission to the hospital, preventing early institution of person‐centered collaborative care interventions that can improve patient outcomes.MethodTwo trained dementia nurse practitioners performed a prospective daily review of all patients age &gt;70 years admitted to a large academic medical center for a period of 8‐weeks (1/26/2021 – 3/23/2021). The NPs performed a systematic keyword search of the EMR for ADRD diagnoses, which were confirmed through review of past medical history, outpatient primary care and consult notes, problem and medication lists. Hospitalized PLWD were analyzed for quality of care indicators.ResultOf the 249 hospitalized patients (mean age 86.5 years;61% female) with ADRD diagnosis, 47 (18%) had dementia included in the admission diagnosis while 151 (61%) had dementia included in the admission history and/or assessment/plan. 71 patients (29%) had restraints ordered, 120 (48%) were prescribed psychoactive medications and 95 (38%) were put on restraints. Advance directives were completed for 122 (49%) of PLWD and 157 (63%) had a full code status. 149 (60%) had a previous inpatient admission and 57 (23%) had an ED visit in the last 12 months. Ninety‐five (38%) of hospitalized PLWD were discharged to institutional facilities.ConclusionThere are low rates of inclusion of dementia in admission diagnoses and notes of hospitalized PLWD. In contrast, there are high rates of restraint use, psychoactive medication order and discharge to institutional facilities. Most PLWD admitted to the hospital has had a previous hospitalization in the past year. To our knowledge, this is the first study that utilized EMR‐based identification of ADRD diagnosis and tracking of hospital outcomes of PLWD. These findings represent opportunities for improvement in quality and outcomes of hospital care for PLWD.

Recovery Model Implementation for a Medical/Geriatric Psychiatric Unit to Decrease Restraint and Seclusion Episodes: A Quality Improvement Project.

In inpatient behavioral health units, a long-standing behavioral management controversy has been whether to physically restrain or seclude patients. The rate of restraint use at the institution underperformed compared with the national average, which led to the project implementation. This quality improvement project's objective was to decrease restraint and seclusion use, improve quality of care, and decrease cost through implementation of recovery model principles. Implementation started in October 2019 on a 14-bed inpatient medical/geriatric psychiatric unit with 38 psychiatric RNs at a large academic medical center. The project was a pre-post implementation design with interventions consisting of staff education, RN language observation, and orientation toolkit development. Changes in staff knowledge were measured by Recovery Knowledge Inventory surveys at baseline, 1 week posteducation, and 4 months posteducation. Restraint and seclusion use data were analyzed 3 months preimplementation and 3 months postimplementation. Staff knowledge of the recovery model increased from baseline to 1 week postimplementation in all four survey domains (range = 6% to 9% improvement). While improvements were maintained in two survey domains, two domains of staff knowledge showed slight declines (1% to 2% decline in scores) 4 months postintervention. Restraint use decreased 73.1% and seclusion use decreased 16.3% from pre to postintervention. Implementation of recovery model principles can decrease restraint and seclusion episodes, which increases quality and decreases cost to the organization.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit.

To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns. We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day. The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001). Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department

IntroductionEmergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management,...

A bivariate probit analysis of child passenger’s sitting behaviour and restraint use in motor vehicle

Motor vehicle injuries are a leading cause of death among children worldwide, though many of these deaths are preventable. Buckling young children in age- and size-appropriate car seats, booster seats, or seat belts and also seating them in appropriate position can lead to a significant reduction of serious and fatal injuries. This study investigated sitting behaviour and restraint use among child passengers through cross-sectional observational surveys conducted in Kumasi, Ghana. A bivariate probit model was developed for simultaneous determination of the contributing factors influencing child passenger’s sitting behaviour and restraint use. The results showed that 26% of the child passengers observed were occupying the front seat and the prevalence rate of restraint use was 4.5%. The developed bivariate probit model clearly highlights the existence of interrelationship between child passenger’s sitting position and restraint use. The key factors simultaneously influencing child passenger’s sitting position and restraint use include vehicle type, driver’s gender, driver’s belt use, child’s age, and the presence of other child or adult passenger. Furthermore, time of day and day of week also influence child passenger sitting behaviour but not their restraint use. These findings provide insight for better understanding of child transporting practices and the contributing factors influencing their sitting behaviour and restraint use. The findings also highlight the need for policy makers to design effective countermeasures to promote rear sitting and restraint use among child passengers.

A Delirium Risk Modification Program Is Associated With Hospital Outcomes

BackgroundDelirium has been associated with negative health consequences, which can potentially be improved by delirium risk modification. This study sought to determine if a quality improvement project to identify and modify delirium risk and discharge to rehabilitation is associated with improved outcomes for patients and health care systems. MethodsIn older veterans admitted to a tertiary VA hospital, delirium risk was assessed using cognitive impairment, vision impairment, and dehydration. Delirium risk was communicated to providers via electronic medical record. To modify delirium risk, interventions were provided in cognitive stimulation, sensory improvement, and sleep promotion. Primary outcomes included length of stay, restraint use, discharge to rehabilitation, and hospital variable direct costs. Outcomes were compared using a propensity-matched cohort of patients without intervention. Number of intervention categories was compared with primary outcomes. ResultsPatients (n = 1527) were older (78.2 ± 8.3 years) and male (98%). Propensity-matched patients (n = 566) were well matched for age, gender, cognitive deficits, vision impairment, and dehydration. Patients with interventions were discharged to rehabilitation similarly (mean difference [MD] 2.2%, 95% CI −2.5−6.9) and had lower lengths of stay (MD −0.7 day, 95% CI −1.3 to −0.1), lower restraint use (MD −4.0%, 95% CI −6.7 to −1.2) and trended toward lower variable direct costs (MD −$1390, 95% CI −3586−807). Increasing number of interventions was associated with shorter length of stay, lower rate of restraint use, and lower variable direct costs. ConclusionsThis delirium risk modification project was associated with patient outcomes and reduced costs. Serious consideration should be given to delirium risk identification and modification programs.

A Controlled Quality Improvement Trial to Reduce the Use of Physical Restraints in Older Hospitalized Adults

To implement and evaluate an evidence-informed multicomponent strategy to reduce physical restraint use in older adults admitted to acute care medical units. Stepped-wedge trial. Four acute care medical units in Calgary, Alberta, over a 4-month time period. Data were collected from individuals aged 65 and older present on the study units during monthly restraint audits. Development of opinion leaders among the nursing leadership, education and training of physicians and unit nurses, and implementation of least restraint rounds. The primary outcome was rate of restraint use as determined from walk-around audits. Secondary outcomes included number of physician orders for physical restraints on the electronic medical record and fall reports. Thirteen percent to 27% of individuals were being restrained on the medical units before the intervention, with the vast majority of restraints being bed rails. This decreased to 7% to 14% after the intervention. The intervention resulted in a statistically significant reduction in restraint use measured in the early mornings (P = .01), and this trend continued after adjusting for unit and month (P = .06). Similarly, the rate of restraint use trended down at all other measured time periods but was not statistically significant. A limited number of individuals had an order for physical restraint within their electronic medical record (3% before, 2% after the intervention). The median number of monthly fall reports did not change (three before, three after; P = .60). A multicomponent team-focused quality improvement intervention has the potential to decrease the use of physical restraints in older hospitalized adults.

Reduction of Restraint and Seclusion Through Collaborative Problem Solving: A Five-Year Prospective Inpatient Study

This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41+/-8 to 18+/-20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16+/-10 to .3+/-.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27+/-5 to 21+/-5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15+/-6 to 7+/-6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.

Seat belt use among 13–15 year olds in primary and secondary enforcement law states

Context Coverage and enforcement provisions of safety belt use laws vary by state. Most laws cover drivers and passengers age 16 and above. “Primary” enforcement laws allow police to stop and ticket a motorist for a safety belt law violation. With “secondary” enforcement laws, ticketing can only occur in the presence of another traffic infraction. Given the lower rates of restraint use among teen drivers and their passengers, the effect of primary enforcement laws on the restraint use of young teen passengers is of particular interest. Objective To compare restraint use by 13–15 year olds passengers in motor vehicle crashes in states with primary versus secondary enforcement safety belt laws. Methods Cross-sectional study of 3953 crashes involving 5372 children, representing 54,226 children aged 13–15 years in 41,198 crashes of insured vehicles in 16 states and Washington, DC between December 1, 1998 and December 31, 2004, with data collected via insurance claims records and a telephone survey. Results Non-use of restraints by 13–15 year olds was 7.2% (95% CI 4.3–10.1%) greater in secondary enforcement states (10.8%) as compared to states with primary enforcement laws (3.6%). After controlling for driver's age and restraint status and the seating row of the occupant, a 13–15 year olds was over twice as likely to be unrestrained in a secondary enforcement state as compared to a primary enforcement state (adjusted RR = 2.2, 95% CI 1.5–3.1). Conclusions States considering primary enforcement provisions to their restraint laws should consider the potential benefits these laws may have to all occupants in the vehicle, particularly young adolescents who are nearing driving age.

Use of Physical Restraints in Nursing Homes: Current Practice in Singapore

Introduction: One of the indicators of quality care in nursing homes is the proper use of physical restraints. Restraints have been associated with multiple complications, such as pressure ulcers, incontinence and immobility. The aim of our study was to assess the indication, use and complications related to physical restraints in Singapore nursing homes. Materials and Methods: All residents aged &gt;65 years old from 3 nursing homes were included in the study. A geriatrician reviewed the medical records of all elderly residents on restraints. Nursing staff interviews were also done to assess their knowledge regarding restraint use. A brief medical record review was also done for the elderly residents without restraints. Results: Out of 390 elderly residents, 91 were on physical restraints. The mean age of these residents were 80.1 years; 67% were female, 90.1% were Chinese and 82.4% belonged to functional category IV. Both urinary and faecal incontinence were observed in 97.8% of residents. Forty-six (50.5%) residents had no documented indication for restraints. It was noted that 20 (22%) residents were restrained to prevent dislodgement of the feeding tube, 17 (18.7%) were restrained to prevent falls and 8 (8.8%) were restrained for agitation. There were documented trials of removal of restraints for only 21 (23.1%) residents. Alternative approaches, such as diversion technique, were used for 31 (34.1%) residents to avoid restraint use. Conclusion: Our study revealed a high rate of restraint use in the nursing homes. A restraint protocol should be available in every nursing home, requiring physician approval for the long-term application of physical restraints and intermittent reviews by physicians to assess the continued need for restraints.

Avoiding Physical Restraints in Long-Term Care Facilities

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.

Avoiding physical restraints in long-term care facilities.

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.

Risk Factors for Physical Restraint Use in Nursing Homes

This study examined the impact of the Nursing Home Reform Act of 1987 on resident-and-facility-level risk factors for physical restraint use in nursing homes. Data on the 1990 and 1993 cohorts were obtained from 268 facilities in 10 states, and data on a 1996 cohort were obtained from the Medical Expenditure Panel Survey, which sampled more than 800 nursing homes nationwide. Multivariate logistic regression models were generated for each cohort to identify the impact of resident- and facility-level risk factors for restraint use. The results indicate that the use of physical restraints continues to decline. Thirty-six percent of the 1990 cohort, 26 percent of the 1993 cohort, and 17 percent of the 1996 cohort were physically restrained. Although there was a reduced rate of restraint use from 1990 to 1996, similar resident-level factors but different facility-level factors were associated with restraint use at different points in time.

Change in the rate of restraint use and falls on a psychogeriatric inpatient unit: impact of the health care financing administration's new restraint and seclusion standards for hospitals.

This chart review of 767 patients treated on a psychogeriatric inpatient unit over a 2-year period examined the impact of the Health Care Financing Administration's (HCFA) new restraint standards for hospitals on the rate of restraint use and falls. There was a marked decrease in the number of restraint episodes in the year after the introduction of the new standards compared with the year before (44 vs 212 restraint episodes per 1,000 patient-days). However, no notable differences were found in the number of total falls (18 vs 21 falls per 1,000 patient-days) or serious falls (2 vs 1 serious fall per 1,000 patient-days). If replicated, these findings of decreased restraint use without a concomitant increase in the number of falls demonstrate a change in practice patterns as a result of HCFA's action.

Achieving restraint-free care of acutely confused older adults.

Restraint-free care has emerged as an indicator of quality care for older adults in all settings. The most difficult challenges to achieving this goal are care of hospitalized older adults who are functionally dependent and cognitively impaired. The purpose of this article is to report findings from a descriptive study of restrained hip fracture patients, and discuss approaches to achieving restraint-free care. Rate of restraint use was 33.2% among hospitalized hip fracture patients during an 11-year period in 20 metropolitan teaching hospitals. Restrained patients were older men who resided in nursing homes prior to hospitalization. Clinically, restrained patients had a diagnosis of dementia, were noted to be confused or disoriented by nursing staff, and were dependent in activities of daily living. An individualized approach to care is the best method to avoid use of physical restraints for patients with acute confusion and cognitive impairment.

Restraint use in acute care settings: can it be reduced?

The trend in healthcare is to use less restraint and to include patient freedom and respect as part of the quality care provided. Reducing restraint use in an acute care setting is a laudable goal, but the rising age of inpatients and their increasing acuity has made it difficult to meet this expectation. The following discussion addresses the problems of creating a less restrictive environment and the solutions that have been tried. It also contains a list of recommendations based on what is known and what needs to be accomplished. The discussion includes a review of the history and prevalence rate of restraint use, the attitudes of patients, staff, and families toward restraint use, nurses' knowledge about restraint use, the physical and psychological outcomes of being restrained, the ethical and legal implications of using restraints, the strategies used to reduce the use of restraints, and recommendations on how to create a less restrictive acute care environment.

Can Physically Restrained Nursing‐Home Residents Be Untied Safely? Intervention and Evaluation Design

To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing-home residents safely and cost effectively. A multicenter prospective pre-post study. Sixteen high-restraint-use nursing homes, four each from California, Michigan, New York, and North Carolina. The 16 facilities have 2075 beds. A 2-year educational demonstration study, including a 2-day workshop, specially prepared written and video materials, and telephone and on-site clinical consultations. Each nursing home designated a nurse to be the clinical coordinator and to lead a multidisciplinary team in conducting a restraint assessment and devising interventions for removal. We compared pre- and post-study aggregate and individual facility rates of restraint use, incidents and accidents, family attitudes, financial impact, serious injuries, and staff attitudes and work patterns. Preliminary data suggest that this intervention was well received and appears to be effective in achieving restraint-free care.