Restraints as the Mean Age

Restraints

As the mean age of the general population becomes older, and as we stand on the threshold of the senility of the baby boomers, geriatric health care is becoming a more significant issue. Skilled nursing care for the elderly is at a premium and specialists in the field can name their own jobs as the work is both physically and emotionally demanding. The patients in skilled nursing and hospital settings for gerontological and psychiatric problems are perhaps the most challenging, especially when the patient's agitation or wandering behavior makes it necessary to consider the use of restraints for management and safety. What are some of the correct and incorrect reasons for the use of restraints in the medical population? What are the different types of restraints that are available? Do the patients who require restraint sustain physical or perhaps psychological damage from the use of restraints? What is the effect of restraining a patient, or caring for a patient in restraints on the nursing staff?

It is hopeful that the goal in any care setting is that the patients be treated with the utmost in dignity. Patients at every level should be afforded the greatest measure of control possible and afforded every chance to achieve a high level of wellness. The challenge in the provision of chronic medical care in the assisted living setting is moving away from that of illness-based care to a chronic care plan based on wellness and healing. One sees this demonstrated best in the new types of nursing homes, assisted living facilities and adult family homes which are opening every day across the country. Every patient's well-being is considered to be of the utmost importance and patients are encouraged to be as autonomous as long as possible. This may also include allowing the patient to make choices that include a level of risk. Physical restraint devices, used more frequently in the past, are now seen as the absolute antithesis of the principles of autonomy and wellness-based care. For many years the use of restraint was unquestioned, especially in patients who demonstrated confusion, agitation and even aggressive behaviors. Restraints were also used as a "safety measure" to protect the patient from unexpected falls and injuries. But studies have now shown us that not only does the injudicious use of physical restraint take away a patient's sense of dignity and autonomy, they also contribute to a greater degree of cognitive impairment, and a higher rate of nosocomial infections and iatrogenic injuries such as bed and pressure sores and even death.

Different literature estimates the use of restraint in nursing and psychiatric hospitals at anywhere from 4 to 68% (Castle and More, 1998). Predominantly seen as devices intended to protect patients from injury or wandering, physical restraint devices run the gamut from belts which tie the patient into bed, vests which hold the patient in bed or in a chair, specialized chairs which keep the patient seated, and restraint systems which immobilize the patient's arms and legs. Even bedrails up on a patient's bed can be considered a form of restraint, since they are meant to curb the patient's free and purposeful movement from the bed but are generally not subject to the same strict guidelines as the application of other restraint devices. As noted, in the past it was far more common to see a patient being held in bed via restraints and medical staff perhaps even used them reflexively in the belief that restraint was in the patient's best interest. However, the wide variation in the reporting numbers for the use of restraints is likely related to the different definition of restraints used (i.e. are bedrails a restraint device - in this case the restraint numbers could be as much as 100%), sample sizes used in different studies, the type and characteristics of the care settings being studied (i.e. psychiatric facility vs. long-term skilled nursing facility) and the general characteristics of the residents and patients involved, to include psychiatric morbidity and cognitive status. This being said, a retrospective review of medical records in one study has also demonstrated that the underreporting of the use of restraints is far more likely than the over reporting and therefore the sensitivities of the studies used as reference and background for this paper must also be considered. In this case, and for this matter, for the purpose of this paper we will describe a physical restraint as a mechanical device which is applied to a patient in order to impair his or her mobility and includes, but is not solely limited to vests, waist, wrist and ankle restraints, geriatric chairs, wheel chairs with fixed tray tables, or any other type of device meant to contain the patient to a certain locality. The use of side rails as a means of restraint was only considered when two full length side rails were used, and truthfully should be considered more of an intermediate measure than the previously mentioned methods of restraint since in the most part side rails are used to prevent falls during the nighttime and in care settings of all kinds. Interestingly, the use of seclusion in the treatment of elderly patients is usually not a consideration, as it may be in agitated psychiatric patients. Review of literature shows little has been written or studied surrounding the use of seclusion as a restraint method in patients, and should probably be studied for beneficial and detrimental effects.

Another alternative that may be discussed is the use of chemical restraint via psychoactive medications. Unfortunately, the use of medications like benzodiazepines, antipsychotic and other sedative medications have unpredictable effects in the elderly and in some cases may actually contribute to the patient's confusion or agitation. The phenomenon of "sundowning" is frequently seen, where elderly patients become more agitated in the early evening hours especially when sedative medications are used.

One may consider that the use of chemical restraint is preferable to physical restraint, but in the setting of adverse side effects, the benefit/risk ratio must be carefully weighed.

So we have described the types of physical restraint methods that are available to us, and all of these restraint systems, when used correctly, are generally considered to be effective in the management of patients at risk for falls, wandering, aggressive behavior, etc. But it is interesting to note that only in the last twenty years or so have restraints been considered something within the medical realm of treatment and not a nursing intervention, such as daily care or hygiene. While the regulations surrounding the ordering and use of restraints, as well as the monitoring of patients while in restraints may seem like a bureaucratic nightmare for many, it ensures that each patient be carefully considered for the inherent safety of restraint devices in every case. Restraint orders can no longer be used as a PRN order, and patients who require restraints must usually have the orders rewritten every 8-12 hours after evaluation by a licensed health professional. This is because, far from being benign instruments meant only to help hold a patient in place, restraint devices are associated with serious co-morbidity to include increased behavioral problems, decreased physical activity with resultant increased physical disability, pressure sores, incontinence and direct trauma as a result of the patient resisting against the application or continuation of the restraint device.

Ensuring patient safety is one of the main reasons given for use of restraints. Numerous studies report that the use of physical restraints is unlikely to prevent falls (Catchen, 1983; Lund & Sheafor, 1985; Lynn, 1980; Mion, Gregor, Buettner, Chwirchak, Lee & Paras, 1989). Direct deleterious effects of restraints have been reported including death by strangulation, hypoxic encephalopathy secondary to strangulation, skin abrasions, decreased socialization, and psychological distress. Other effects that are indirectly associated with physical restraints are caused primarily by prolonged immobilization and may include decreased functioning, pressure sores, flexion contractures, pneumonia, and biochemical and physiological changes (Gillick, Serrell, & Gillick, 1982; Lofgren et al., 1989; Miller, 1975). Use of physical restraints to prevent the patient's disruption of therapy, for example, intravenous lines and nasogastric tubes, often is seen in the acute-care setting. Approximately half of the patients who die in these settings have been physically restrained; many die with the restraints still in place (Frengley & Mion, 1986; Lofgren, MacPherson, Granieri, Myllenbeck, & Sprafka, 1989; Mion, Frengley et al., 1989; Robbins, et al., 1987).

Nursing interventions surrounding patients in restraints are also of concern. The interventions currently used are based on guidelines which may or may not be optimal.

It has been questioned whether there is an effect on health care professionals' attitude towards patients who are restrained, in that the patient appears less than a fully competent adult and may affect what care is given. This obviously needs more research.

The effect of restraining patients is not limited to patients alone. An interview by DiFabio (1981) of 15 nurses working inpatient psychiatric wards where restraint application was common showed that the nurses experienced anxiety, feelings of inadequacy, hopelessness, frustration, guilt and dissatisfaction surrounding the use of restraints. Another study surrounding the use of restraints in non-psychiatric patients (Strumpf and Evans, 1998) reported that the nurses had difficulty reconciling the administration of restraints with concerns regarding patient dignity and autonomy. So it appears that the use of restraints is difficult on staff and patients alike. Interestingly enough, in a literature review for this paper, the writer could find no significant supporting data to recommend restraint devices as effective in the management of the confused or persistently agitated patient. In this case, it appears that many times patients are being placed into restraints more "because we have always done so with this kind of patient" rather than on the basis of any science that the use of restraint is beneficial to the patient.

Restraints and the Law

Any time a patient is to be considered for the application of restraint devices, it is important that all members of the care team be well versed in the federal regulations and facility policies surrounding restraints and the monitoring of the same. The same can be said for the knowledge of Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards surrounding restraints. These regulations and guidelines have in fact been based on a melding of medical research surrounding the use of restraints and a trend in the healthcare community towards improving the quality of life and healthcare in long-term care facilities. The Federal Nursing Home Reform Act of 1987 defined physical restraints as "any manual method or physical or manual device, material or equipment attached or adjacent to the resident's body which cannot be removed easily and can restrict the freedom of the resident's movement or normal access to one's body." This regulation also goes on to state "resident has the right to be free from any physical or chemical restraint imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms." This ensures that on a very busy day when the nurses are short staffed, Mrs. Johnson is not placed in a Posey vest simply because she has the tendency to wander and there is no one to keep a good eye on her. It is important to note that before the implementation of the Reform Act, it is estimated that approximately 40% of nursing home residents were physically restrained. Data now shows these numbers to be closer to 12%, a decrease that is hopeful but still sad in comparison with similar patient populations in European communities in which the restraint rate is less than 5%.