Staffing and pattern of mechanical restraint use across a multiple hospital system.

BACKGROUND: In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals. OBJECTIVES: To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing. METHODS: This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999. RESULTS: The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001). CONCLUSIONS: Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.     

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.     

The effect of a translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: A prospective pre–post implementation study in the U.S.

BackgroundFalls are a major public health problem internationally. Many hospitals have implemented fall risk assessment tools, but few have implemented interventions to mitigate patient-specific fall risks. Little research has been done to examine the effect of implementing evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.ObjectivesTo evaluate the impact of implementing, in 3 U.S. hospitals, evidence-based fall prevention interventions targeted to patient-specific fall risk factors (Targeted Risk Factor Fall Prevention Bundle). Fall rates, fall injury rates, types of fall injuries and adoption of the Targeted Risk Factor Fall Prevention Bundle were compared prior to and following implementation.DesignA prospective pre–post implementation cohort design.SettingThirteen adult medical-surgical units from three community hospitals in the Midwest region of the U.S.ParticipantsNurses who were employed at least 20 hours/week, provided direct patient care, and licensed as an RN (n = 157 pre; 140 post); and medical records of patients 21 years of age or older, who received care on the study unit for more than 24 hours during the designated data collection period (n = 390 pre and post).MethodsA multi-faceted Translating Research Into Practice Intervention was used to implement the Targeted Risk Factor Fall Prevention Bundle composed of evidence-based fall prevention interventions designed to mitigate patient-specific fall risks. Dependent variables (fall rates, fall injury rates, fall injury type, use of Targeted Risk Factor Fall Prevention Bundle) were collected at baseline, and following completion of the 15 month implementation phase. Nurse questionnaires included the Stage of Adoption Scale, and the Use of Research Findings in Practice Scale to measure adoption of evidence-based fall prevention practices. A Medical Record Abstract Form was used to abstract data about use of targeted risk-specific fall prevention interventions. Number of falls, and number and types of fall injuries were collected for each study unit for 3 months pre- and post-implementation. Data were analyzed using multivariate analysis.ResultsFall rates declined 22% (p = 0.09). Types of fall injuries changed from major and moderate to minor injuries. Fall injury rates did not decline. Use of fall prevention interventions improved significantly (p < 0.001) for mobility, toileting, cognition, and risk reduction for injury, but did not change for those targeting medications.ConclusionsUsing the Translating Research Into Practice intervention promoted use of many evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.     

Fall incidence and fall prevention practices at acute care hospitals in Singapore: a retrospective audit

OBJECTIVE: To investigate the incidence of falls and explore fall prevention practices at acute care hospitals in Singapore. DESIGN: A retrospective audit to collect baseline data on (1) incidence of falls (patient fall rates and fall injury rates) and (2) fall prevention practices, was conducted in five acute care hospitals in Singapore from December 2004 to March 2005. STUDY PARTICIPANTS: Medical record data (n = 6000) of patients admitted into the medical, surgical and geriatric units in the five hospitals. OUTCOME MEASURES: Fall incidence was obtained from the hospital's fall databases and incident reports for the period of June 2003 to May 2004. In total, 6000 medical records from five hospitals were randomly selected, retrieved and reviewed to determine whether falls, fall assessments and interventions were being initiated and documented. RESULTS: The number of fallers for all hospitals was 825. Analysis showed that patient fall rates ranged from 0.68 to 1.44 per 1000 patient days, and the proportion of falls associated with injury ranged from 27.4% to 71.7%. The use of a fall risk assessment tool by nurses was recorded in 77% of all the nursing records. CONCLUSION: This study has laid the foundation for further research for fall prevention in Singapore by describing current fall rates, fall-associated injury rates and the status of fall prevention practices in acute care settings. The results will be used to inform the development of a tailored multifaceted strategy to facilitate the implementation of Fall Prevention Clinical Practice Guidelines to reduce the burden of falls and fall injuries in hospitals in Singapore.     

A study into the use of restraint in nursing homes in Norway

The aim of this study was to describe the reasons for the use of restraint, the decision-making procedure for their use and the documentation of their use in Norwegian nursing home units. Structured interviews were carried out with the carers of 1362 patients in 160 regular nursing home units and 564 patients in 91 special care units for people with dementia. The reasons given for the use of restraint were to protect the patient or others, and to carry out necessary care or treatment. The main reason for the use of force or pressure in medical treatment was non-compliance of the patient. The nurse in charge (44%, n = 670) or a carer (13%, n = 201) most frequently decided that restraint should be used. In 65% (n = 892) of all the instances of restraint, no documentation was found in the patients' records. It was concluded that routines for quality assurance for decision-making about, and the documentation of, the use of restraint are lacking in Norwegian nursing homes.     

Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: An Australian survey

Seclusion and restraint continue to be used across psychiatric inpatient and emergency settings, despite calls for elimination and demonstrated efficacy of reduction initiatives. This study investigated nurses’ perceptions regarding reducing and eliminating the use of these containment methods with psychiatric consumers. Nurses (n = 512) across Australia completed an online survey examining their views on the possibility of elimination of seclusion, physical restraint, and mechanical restraint as well as perceptions of these practices and factors influencing their use. Nurses reported working in units where physical restraint, seclusion, and, to a lesser extent, mechanical restraint were used. These were viewed as necessary last resort methods to maintain staff and consumer safety, and nurses tended to disagree that containment methods could be eliminated from practice. Seclusion was considered significantly more favourably than mechanical restraint with the elimination of mechanical restraint seen as more of a possibility than seclusion or physical restraint. Respondents accepted that use of these methods was deleterious to relationships with consumers. They also felt that containment use was a function of a lack of resources. Factors perceived to reduce the likelihood of seclusion/restraint included empathy and rapport between staff and consumers and utilizing trauma‐informed care principles. Nurses were faced with threatening situations and felt only moderately safe at work, but believed they were able to use their clinical skills to maintain safety. The study suggests that initiatives at multiple levels are needed to help nurses to maintain safety and move towards realizing directives to reduce and, where possible, eliminate restraint use.     

Inappropriate restraint practices in Australian teaching hospitals.

The use of restraints in contemporary healthcare represents an ethical problem to nurses and nursing. This paper describes a point prevalence study undertaken to examine the patterns of restraint use in an Australian teaching hospital. The objectives were: to clearly define restraint; establish its prevalence; the reasons for its use; and, to describe staffing levels in relation to restraint rates. Of the 256 patients who were observed, 9.4% were restrained. A third of the patients aged 85 years and over were restrained. The results support a previous Australian study that reported restraint rates of between 8.5% and 18.5% in acute hospitals.     

Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study

The literature is replete with articles describing restraint reduction strategies used in long-term care settings, geriatric specialty units, and medical/surgical units in the acute care setting. The feasibility, effectiveness, and appropriateness of such strategies cannot be capriciously applied to the intensive care setting. This article provides an overview of the implementation and outcomes of a pilot study using an algorithmic approach that is clinically appropriate and justifiable for restraint use in the intensive care environment. It provides the critical care nurse with a standardized method for decision analysis when managing patients at risk for treatment interference.     

Long-term restraint reduction: one hospital's experience with restraint alternatives

Over the last several years, regulatory bodies have implemented and maintained strict standards and regulations regarding the use of restraint in the acute care setting. Hospitals have responded by attempting to reduce restraint use and increase alternatives to restraint. Our hospital formed a Restraint Reduction Task Force, setting a goal to decrease restraint use. This article describes the task force's actions, interventions, and findings for the long-term reduction of restraint use in a 236-bed community-based hospital setting. Hospital administrators have been and continue to be supportive of the initiatives set forth by the Restraint Reduction Task Force, which has been a vital component of the ongoing restraint reduction efforts in the hospital.     

P07Reduction of Allogeneic Red Cell Transfusion using Autologous Blood Cell Salvage in Knee Arthroplasty

Recent Hospital Transfusion Committee (HTC) audit at the Royal Bournemouth Hospital (RBH) confirmed an allogeneic red cell transfusion rate of 20% for primary Total Knee Replacement (TKR). Current policy at RBH states that when blood stocks reach 67% of normal (amber alert) then surgery with a >20% likelihood of blood transfusion will be cancelled. At current transfusion rates this would include primary TKR. Recent studies have shown a reduction in allogeneic transfusion rates when autologous transfusion drains are utilized. The purpose of this study was to see whether the current rate of allogeneic transfusion could be reduced with the introduction of the CellTransTM Autologous Knee Drainage Blood Transfusion System (ABT) in TKR at RBH. Over a 3 month period all patients undergoing primary, bilateral or revision knee arthroplasty received an ABT. Demographic data was collected from the orthopaedic pre‐assessment clinic. Following surgery further data was collected relating to volume of blood loss into the drain, volume of autologous blood re‐transfused, units of allogeneic blood required and the transfusion trigger, postoperative haemoglobin levels, infection rates and length of stay in hospital. We then compared this data set with retrospective data. Of 170 patients undergoing knee arthroplasty 141 received the ABT. The data collected was compared retrospectively with 169 patients from the previous 3 month period. We demonstrated a reduction in transfusion rates of 13% for primary TKR, 42% for bilateral TKR and 57% for revision TKR with the use of the ABT. In addition we demonstrated a reduction in total allogeneic blood use (99 units to 26 units) and a reduction in mean length of stay in hospital (8.6 days to 7.5 days) with the ABT. Further analysis of the data collected showed a 46% reduction in the allogeneic transfusion rate and a reduction in total allogeneic blood usage (99 units to 9 units) of anaemic patients presenting for surgery. This study has demonstrated a dramatic reduction in allogeneic blood transfusion rates with the use of the CellTransTM Autologous Blood Transfusion System. We have also shown a reduction in length of stay in hospital. Prior to the study primary total knee replacement would have been cancelled during times of limited blood availability (amber alert). The use of the ABT is good for the patient in reducing the need for allogeneic blood, and in addition has demonstrated a significant cost saving due to the reduced blood usage and potential prevention of cancelled operation lists.     

Factors influencing critical care nurses’ intentions to use physical restraints adopting the theory of planned behaviour: A cross-sectional multicentre study

BackgroundStudies addressing critical care nurses' practices regarding physical restraints have focused on individual nurses' knowledge and attitudes but lack the understanding of other social influences that could affect nurses’ intentions to use them.ObjectiveThe objective of this study was to determine critical care nurses’ attitudes, subjective norms, perceived behavioural control, and intentions to use physical restraints in intubated patients and the relationship between them and sociodemographic, professional, and contextual factors using a survey approach.MethodsA cross-sectional, multicentre study was conducted in a convenience sample of 12 intensive care units from eight hospitals in Spain (n = 354). The Physical Restraint-Theory of Planned Behaviour questionnaire and a researcher-developed survey were used to collect structural and clinical data from each unit. Multilevel model analysis was used.ResultsCritical care nurses showed a moderate level of intention to use physical restraints 12.52 (standard deviation = 3.81) [3–21]. More than a half (52%) agreed restraints were safe. The highest perceived barrier against physical restraint use was patient cooperation. Although nurses did not feel that others expected them to use restraints, they did not perceive high levels of disapproval of such practice. Nurses who had received previous training on restraints and who worked in units with a flexible family visitation policy, an informed consent form for restraint use, analgosedation and restraint protocols, and nurse-driven analgosedation management reported lower levels of intention to use restraints. Working in smaller units (beta −1.81; 95% confidence interval [CI]: −0.18, −3.44) and working in units with a consent form for restraint use (beta −4.82; 95% CI: −2.80, −6.85) were the variables with the highest impact on nurses’ intentions to use restraints.ConclusionsCritical care nurses’ intentions to use physical restraints are moderate and are influenced by intrapersonal, patient, and contextual factors. Nurses who work in units with organisational policies and alternatives to restraints demonstrated lower levels of intention to use them.     

Prevalence of patients subjected to constraint in Norwegian nursing homes

BACKGROUND: A recent questionnaire showed that different kinds of constraint such as physical restraint, electronic surveillance, use of force or pressure in medical treatment and in activities of daily living (ADL) are frequently used in Norwegian nursing homes. The study did not include information at patient level, and except for studies about physical restraints, we have not found any studies reporting the prevalence of various forms of constraint. AIM: To describe the prevalence of various types of constraint in Norwegian nursing homes. MATERIALS and METHOD: A structured interview was carried out with the primary carers of a random sample of 1501 patients from 222 nursing-home wards in 54 municipalities representing all five health regions in Norway. Data were collected from regular units (RUs) and special care units (SCUs) for persons with dementia. Episodes of constraint during 1 week were recorded. Five main groups of constraint were aggregated, mechanical restraint, nonmechanical restraint, electronic surveillance, force or pressure in medical examination or treatment and force or pressure in ADL. RESULTS: Patients (36.7%) in RUs and 45.0% of the patients in SCUs were subjected to any constraint. Most frequent was use of mechanical restraint (23.3% in RUs; 12.8% in SCUs) and use of force or pressure in ADL (20.9% in SCUs; 16.6% in RUs). Use of force or pressure in medical examination or treatment was more frequent used in SCUs (19.1%) compared with RUs (13.5%). Nonmechanical restraint was less frequently used (8.3% in SCUs; 3.0% in RUs) and electronic surveillance was seldom used (7.2% in RUs; 0.9% in SCUs). CONCLUSION: The use of constraint is a problem in Norwegian nursing homes. Studies are needed to learn more about why constraint is used, and if there is patient or ward characteristics that can explain the use of constraint.     

Developing a Restraint-Reduction Program for Child/ Adolescent Inpatient Treatment

TOPIC: Meeting mandated guidelines to reduce, if not eliminate, the use of restraints with children and adolescents hospitalized on inpatient psychiatric units. PURPOSE: To present eight promising options for restraint reduction with inpatient children and adolescents, and the research that supports their efficacy. SOURCES: Review of the literature. CONCLUSION: By combining what is known about child/adolescent restraint use with restraint-reduction research in the adult field, several options for restraint reduction can be derived.     

Nursing working conditions in relation to restraint practices in long-term care units

OBJECTIVES: This study examined the effects of nursing working conditions on the use of physical restraints and antipsychotics as restraints in long-term care units for elderly residents. DESIGN: Cross-sectional data were obtained in Finland in 2002 from long-term care units that used the Resident Assessment Instrument (RAI) system and participated in a survey on working conditions. SETTING: A sample of 91 inpatient units in 31 facilities (23 residential homes and 8 health centers). PARTICIPANTS: Data included 2430 resident assessments and 977 nursing staff survey responses. MEASUREMENTS: We measured unit-level mean scores of physical restraint and antipsychotics use as restraints and resident characteristics (activities of daily living, cognitive impairment, and daily behavioral problems) based on the RAI system as measured by the Minimum Data Set 2.0. Head nurses reported the structural factors (nurse staffing levels and unit size). Nursing working conditions were measured by the Job-Demands and Job-Control Scales in the staff survey questionnaire. RESULTS: Controlling for resident characteristics, nurses' job demands and control had a combined effect on restraint practices. Job demands strongly increased the risk of physical restraint use in units where nurses reported low job control (odds ratio [OR] = 13.31, 95% confidence interval [CI] 1.55-114.30, P = 0.019), but not among high-control units (OR = 0.23, 95% CI 0.04-1.29, P = 0.090). Although the use of antipsychotics was not related to job demands in units with low control (OR = 1.11, 95% CI 0.26-4.99, P = 0.891), the antipsychotics use in particular decreased when high job demands were coupled with high job control (OR = 0.17, 95% CI 0.03-0.91, P = 0.038). CONCLUSION: The results suggest that restraint use can be reduced by enhancing working conditions so that the nursing staff has possibilities for skill usage and decision-making.     

Reducing serious fall‐related injuries in acute hospitals: are low‐low beds a critical success factor?

Aim. This article is a report of a study of associations between occurrence of serious fall‐related injuries and implementation of low‐low beds at The Northern Hospital, Victoria, Australia. Background. A 9‐year evaluation at The Northern Hospital found an important reduction in fall‐related injuries after the 6‐PACK falls prevention program was implemented. Low‐low beds are a key component of the 6‐PACK that aims to decrease fall‐related injuries. Design. A retrospective cohort study. Methods. Retrospective audit of The Northern Hospital inpatients admitted between 1999–2009. Changes in serious fall‐related injuries throughout the period and associations with available low‐low beds were analysed using Poisson regression. Results. During the observation of 356,158 inpatients, there were 3946 falls and 1005 fall‐related injuries of which 60 (5·9%) were serious (55 fractures and five subdural haematomas). Serious fall‐related injuries declined significantly throughout the period. When there was one low‐low bed to nine or more standard beds there was no statistically significant decrease in serious fall‐related injuries. An important reduction only occurred when there was one low‐low bed to three standard beds. Conclusion. The 6‐PACK program has been in place since 2002 at The Northern Hospital. Throughout this time serious fall‐related injuries have decreased. There appears to be an association between serious fall‐related injuries and the number of available low‐low beds. Threshold numbers of these beds may be required to achieve optimal usability and effectiveness. A randomized controlled trial is required to give additional evidence for use of low‐low beds for injury prevention in hospitals.