Restraint across the aged care spectrum

Restraint
across the aged care spectrum
1 July, 2009
Presented by Philippa Wharton
for WA Dementia Training Study Centre
This presentation will cover
•Introduction
•What is restraint?
•History
•Types of restraint
•Current practice – RACF and Acute care setting
•What leads to restraint?
•Exploring therapeutic interventions
•So what next?
What is restraint?
Restraint may be defined as any device, material or
equipment attached to or near a person's body and
which cannot be controlled or easily removed by the
person, and which deliberately prevents or is
intended to prevent a person's free body movement
to a position of choice and/ or a person's normal
access to their body.
(Australian Society of Geriatric Medicine, 2005)
Restraint is always applied to intentially restrict the
free movement of decision making ability of a person
HISTORY
Types of restraint?
Physical / mechanical
Examples, posey vests, wrist ties, lap
belts, trays in chairs, soft padded limb
restraints, bedrails, hand mitts, seat
belt on chair.
Environmental
Limiting a person to a particular environment
(eg – confining a resident to their bedroom or
excluding resident from an area to which they
want to go.
Perimeter restraints (least restrictive) –fenced
areas with locked gates. Key codes & pads.
Chemical
Key factor that differentiates restraint from other forms of
care or medical treatment is that it is always applied
intentially to restrict the movement or behaviour of a
person
The appropriate use of drugs to reduce symptoms in the
treatment of medical conditions such as anxiety,
depression or psychosis DOES NOT constitute restraint.
Public Advocate Position Statement - 2007
Current practice
Between 3.4% and 21% (average 10%) of acute care
patients were subject to some form of physical restraint
during their period of hospitalisation.
Restraint during ranged from 2.7 days to 4.5 days.
In residential care, proportion of residents restrained
ranged from 12 % to a max of 47% (average 27%)
Ranging in duration from 1 to 350 days
Source: JBI 2002
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.
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Irving 2004 Australian Journal of Advanced Nursing Vol.21, No.4 p23-27
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 torestraints
and the management of difficult patients was found to
be inadequate
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Mott, Poole & Kenrick Int. J Nurs. Prac. 2005 Vol. 11, p95-101
What leads to restraint?
In an attempt to…..
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To control an episode of behaviour
To prevent falls
To protect from injury
To maintain treatment regimes
Meet request by families
Effects of restraint
Physical effects
pressure sores
loss of muscle strength
Incontinence
falls, balance and coordination
Cardiac arrest
Infection
asphyxiation and death.
Effects of restraint
Psychological effects
Demoralisation
Humiliation
Depression
Aggression (fear?)
Agitation
impaired functioning
Isolation
Legal / ethical factors
Duty of care
Acute care setting
RPH Guidelines – Nursing Practice Standard (NPS)
Consider the Four A’s of restraint education:
 Attitude An attitude of ‘last resort not first choice’
reduces the use of restraints
 Assessment A comprehensive multi disciplinary patient
assessment of mental state, mobility and behavioural
cues can minimise the use of restraints
 Anticipation Knowledge of treatment interventions and
therapeutic goals can minimise the use of restraints.
 Avoidance Accomplish goals without physical restraint
Individual Assessment
Identify BOC
Comprehensive
Assessment
Team approach
Consultation
Consider Triggers
Develop NEW care
plan without use
Plan of care
Restraint
Minimal restraint
developed
Applied (Short term)
Assess need for use
& reduce risk
Ongoing
monitoring
If restraint is used
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Consent
Authorisation
Close monitoring
Short term strategy
Ongoing assessment
Clear & ongoing communication with staff,
families, GP
Document
Care of the person being restrained
Alternatives to restraint
Environmental
 Improved lighting, that are easy to use.
 Non-slip flooring
 Carpeting in high use areas
 ensure clear pathway
 Easy access to safe outdoor areas
 Activity areas at end of corridors
 Signage – clear
 Comfortable and appropriate seating
Alternatives to restraint
Quiet areas
 Reduce environmental noise
 Familiar objects from residents home
 ‘Snoozelen’ room
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Alternatives to restraint
Activities and programs to meet the needs
of individuals, such as;
 Rehabilitation or exercise
 Regular ambulation
 Appropriate outlets for industrious people
 Facilitate safe wandering behaviour
 falls prevention program
Alternatives to restraint
Care interventions
 Improved observation skills
 Regular evaluations
 Individualised routines
 Strategies such as ‘Best Friends’ (key to
me), Person Centered Care etc… (truly
gettign to know the person to understand
their unmet need)
Alternatives to restraint
Check ‘at risk’ resident regularly
 Appropriate footwear
 Hip protectors
 Improved communication – ‘make the
bubble bigger’
 Concave mattresses
 Mattress on the floor
 Large pillows
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Alternatives to restraint
Physiological strategies
 Comprehensive physical review
 Medication review
 Treat infections
 Pain management ‘Pain Detective’
 Physical alternatives to sedation – warm
drink, comfort/TLC, soothing music
Alternatives to restraint
Psychosocial considerations
 Companionship
 Active listening
 Visitors
 Staff/resident interaction
 Sensory aids
 Massage
 Relaxation programs
Management responsibilities
Policy &
Procedures
Best
practice
Keep on
the agenda
Promote
Safe working
environ
Education
Prevention
Programs
Decision
making
about
restraint
Prevent &
respond
Team
BOC
Approach
Family support
Case Study 1
86 year old lady admitted from a
nursing home, with CALD background with a
diagnosis of dementia admitted for cellulitis.
Patient continually attempting to get out of
bed and mobilise which she was unsafe to
do. Vest restraint placed on patient, she
remained agitated.
What steps would you take?
Case Study - 2
82 year old gentleman admitted with
chest infection. Confused, unco-operative,
combative at times. Patient restrained with
Wrist restraints but was reported as
continuing to be uncooperative.
What next steps would you take?
Resources available
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Robb, B. 1967. Sans everything - a case to answer. London: Nelson.
Alzheimer’s Australia report by Access Economics. April, 2009.
Making Choices - Future dementia care: projections, problems and preferences.
www.alzheimers.org.au
Australian Society for Geriatric Medicine, 2005 (revised) – Position Statement No 2:
Physical restraint Use in Older People
Irish Nurses Organisation Focus Group from the Care of the Older Person Section,
May 2003. Guidelines on the use of restraint in the care of the older person.
JBI – Best Practice, Evidence Based Practice Information Sheets for Health
Professionals. 2002 – Physical restraint Part 1 and 2, use in Acute and Residential
Care facilities.
DOHA, 2004. Decision-making tool: Responding to issues of restraint in Aged Care
Special thank you too
Margaret Brown – Dementia Care CNC, South Eastern Sydney Illawarra NSW Health
Esther Vance – NSW Falls intervention network, Sydney, NSW
RPH – Nursing Practice Standard for minimising the use of and management of
patient restraints, Nov 2007
Carol Douglas – Residential Care Line
If we spent as much time trying to
understand behaviour as we spent trying
to manage or control it, we might discover
that what lies behind it is a genuine
attempt to communicate
Source: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care 4(4)