Choosing Staff Members Reduces Time in Mechanical Restraint Due to Self‐Injurious Behaviour and Requesting Restraint

Background Using mechanical restraints to protect a person who engaged in dangerous self‐injury was decreased by manipulation of an establishing operation involving the client choosing the staff person who would work with her. Materials and Methods The client was a 28‐year‐old woman diagnosed with autism, bipolar disorder, static cerebral encephalopathy, moderate intellectual disabilities, hypotonia and musculoskeletal deformities. She had a history of biting herself and further bites could produce irreversible nerve damage. Mechanical restraints were applied when she bit, tried to bite herself or asked for them. Results When she was allowed to choose staff members, the use of mechanical restraint decreased. Conclusion Reducing the time spent in mechanical restraint by giving the client a choice of staff members who would work with her demonstrates that such a choice may be an establishing operation. The usefulness of cumulative records and scatterplots to evaluate changes in the occurrence of self‐injurious behaviour (SIB) and associated mechanical restraint is shown as are the advantages of using alternating treatment designs to assess the effectiveness of treatment conditions for someone who exhibits long‐term cyclic behaviour.     

Developing Emergency Medicine Leaders: The AACEM/SAEM Chair Development Program at 5 Years

The Association of Academic Chairs of Emergency Medicine Chair Development Program (CDP) was started in 2014 to provide emergency medicine (EM) chairs and leaders who aspired to become academic chairs with EM‐specific leadership training. Each class participated in a 1‐year program, with five sessions taught primarily by EM leaders. Data from the first 5 years of the CDP are provided. A total of 81 participants completed the program (16% women). Twenty participants who were not chairs at entry have become EM chairs. Ratings of the CDP based on a survey of participants with a 94% response rate were very favorable. The CDP has been a popular and successful vehicle to increase leadership skills and prepare EM leaders for academic chair positions.     

Evaluation of the Ventilatory Effects of a Restraint Chair on Human Subjects

Background: Combative individuals often require physical restraint in the prehospital and law enforcement setting. Specialized restraint chairs have been utilized for this purpose in the latter case, but concern has arisen that restrained individuals are at risk for ventilatory compromise and asphyxiation. Objective: We sought to determine if placement in a restraint chair results in alterations of respiratory or ventilatory function. Methods: We conducted a randomized, cross-over, controlled experimental trial in 10 healthy human volunteers performed at a university exercise physiology laboratory. After exercise on a cycle ergometer to 85% of the age-predicted maximal heart rate, subjects were randomized to either a sitting position or restraint chair with arms, legs, and chest secured using standard law enforcement protocol. Subjects remained in each position for 30 min, during which pulmonary function testing of maximal voluntary ventilation (MVV) was performed at 11 and 30 min. Arterial oxygen saturation (O₂sat) and end-tidal PCO₂ levels (PETCO₂) were monitored continuously. Subjects repeated the experimental trial in the alternate position after a 45-min rest period. Measures between restraint and sitting positions were compared using a paired t-test at each time measurement. Results: There was no evidence of hypoxemia. Mean PETCO₂ levels were not statistically different between the two groups at any time (p > 0.05), and there was no evidence of hypercapnia. Conclusion: In healthy subjects, placement in a restraint chair resulted in a small decrease in MVV, but did not result in any changes in O₂sat or PETCO₂.     

Physically restraining elder residents of long‐term care facilities from a nurses' perspective

Ben Natan M, Akrish O, Zaltkina B, Noy RH. International Journal of Nursing Practice 2010; 16 : 499–507
Physically restraining elder residents of long‐term care facilities from a nurses' perspective The purpose of the current study was to identify and analyse major variables affecting intended decisions of nursing staff to physically restrain elder residents of long‐term care facilities. The study explored whether a research model constructed of staff characteristics and resident characteristics would prove useful for predicting behavioural intentions. A total of 120 reliable and validated questionnaires, based on the research model, were administered to nurses working in a large long‐term care facility for older adults in central Israel; 104 questionnaires were returned for a response rate of 86%. The research findings indicate that most of the nurses who responded (67.2%) reported that they had physically restrained elder residents more than 10 times over the past year; however, the nurses had a low intention of restraining residents during the coming year. The research results indicate that the intended decision of nursing staff to restrain elderly residents is a derivative of their behavioural beliefs and attitudes, normative beliefs and subjective norms, as well as of residents' dementia, physical state and stress.     

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.     

Nurses’ attitudes towards physical activity care among older people

Aims and objectives. To understand nurses’ attitudes towards physical activity care for older people in long‐term care facilities. Background. In long‐term care facilities, a common approach to daily physical activity is based on the identifiable portions of daily life during which the activity occurs. However, older people are at risk of falling when they perform daily physical activities. Nurses are the first‐line caregivers. What nurses’ think and do regarding older people’s participation in daily physical activities in long‐term care facilities is very important in terms of the clinical decision‐making regarding older people’s physical activity care. Design. An exploratory qualitative design. Methods. Twenty nurses with more than three years of clinical experience from 13 long‐term care facilities located in northern Taiwan were sampled purposively. Data were collected though semi‐structured interviews. The constant comparative data analysis method was used throughout the research. Results. Five themes emerged from the data analysis: ‘recognising the importance of participation in daily physical activity’, ‘encouraging participation in physical activity’, ‘respecting the autonomy of the residents regarding participation in physical activity’, ‘preventing falls’ and ‘facing a dilemma’. Conclusions. This study identifies that there is a conflict between the nurses’ perceptions of the residents’ daily physical activities, the risk of falls and encouraging greater independence. The majority of staff employed in long‐term care facilities is nursing personnel, and it is these nurses who have the most contact with the residents. It is therefore believed that nurses can make the greatest difference to the residents’ lives and support the quality of care if they can resolve this conflict. Relevance to clinical practice. The results suggest the need to increase the nurses’ knowledge base regarding the benefits of physical activity and also highlight the potentially adverse effect of restraint usage by nurses.     

A Survey of Academic Emergency Medicine Department Chairs on Hiring New Attending Physicians

Background

For graduating emergency medicine (EM) residents, little information exists as to what attributes department chairs are seeking in hiring new attendings. Study Objectives: To determine which qualities academic EM department chairs are looking for when hiring a new physician directly out of residency or fellowship.

Methods

An anonymous 15-item Web-based survey was sent to the department chairs of all accredited civilian EM residency programs in March of 2011. The questions assessed the desirability of different candidate attributes and the difficulty in recruiting EM-trained physicians. Respondents were also asked to give the current number of available job openings.

Results

Fifty-five percent of eligible department chairs responded. On a 5-point scale, the most important parts of a candidate's application were the interview (4.8 ± 0.4), another employee's recommendation (4.7 ± 0.5), and the program director's recommendation (4.5 ± 0.7). The single most important attribute possessed by a candidate was identified as “Ability to work in a team,” with 58% of respondents listing it as their top choice. Advanced training in ultrasound was listed as the most sought-after fellowship by 55% of the chairs. Overall, department chairs did not have a difficult time in recruiting EM-trained physicians, with 56% of respondents stating that they had no current job openings.

Conclusion

How a physician relates to others was consistently rated as the most important part of the candidate's application. However, finding a job in academic EM is difficult, with graduates having limited job prospects.     

Endowed chairs and professorships in schools of nursing: a 2004 update.

This article presents data on the 262 endowed professorships and chairs in Schools of Nursing, for the period 1928 through 2004. Since the first survey was published in 1985, the number of professorships/chairs has increased from 20 to the present count. The number of endowments has increased significantly since the 1990s, with the addition of 188 new professorships/chairs since 1990.     

Endowed chairs in nursing

Two distinguished scholars discuss aspects of endowed chairs: Joyce Fitzpatrick provides a brief history of the practice and explains how endowed chairs preserve academic freedom and nursing's place in scientific inquiry. M. Elizabeth Carnegie recounts a brief history of endowed chairs in the U.S. and relates her own experiences gained from filling endowed chairs in nursing.     

Use of pressure reducing seats and cushions in a community setting

It is generally accepted that sitting for long periods of time without frequent repositioning or provision of appropriate cushions or chairs can lead to pressure ulcer development in people who are elderly, frail, immobile or neurologically impaired. When sitting, in comparison to lying, only a small surface area of the body is providing support, predominantly the buttocks and thighs, and the feet. Therefore, interface pressures are much greater in sitting than lying. Sitting for long periods of time can result in the person adopting poor posture, which in turn can lead to the development of pressure ulcers, particularly on the buttocks, sacrum, greater trochanter and heels. Assessment and provision of appropriate seating equipment for people at risk is often difficult for clinicians working in the community. This article aims to describe the problems experienced by people who sit for long periods of time, to discuss where people should go in order to obtain help with seating needs, and outline some of the potential solutions to poor seating which are available to community staff.     

Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke

OBJECTIVE: To examine the reliability and validity of a new wheelchair collision test (WCT) for screening behavioral unilateral neglect in people with stroke. DESIGN: A total of 19 patients with left hemiplegia resulting from first-ever stroke (mean +/- SD, 61.9 +/- 25.8 days after onset) were examined with the WCT, whereby the patient was asked to propel a wheelchair to pass four round chairs arranged in two rows. Separate tests were done using two different distances between the chairs: 120 and 140 cm. The number of collisions with the chairs was recorded. The Catherine Bergego Scale was used to evaluate behavioral unilateral neglect. Because unilateral neglect has an unfavorable impact on rehabilitation, the FIMtrade mark instrument was used to determine the function of daily activities. RESULTS: Test-retest reliability ranged from 0.68 to 0.97 in different situations in the WCT. The rate of agreement tested by Kappa statistics between the WCT and Catherine Bergego Scale was higher when the distance between chairs was 120 cm than when the distance was 140 cm (0.68 vs. 0.58). Spearman's rank-correlation coefficient between the WCT and Catherine Bergego Scale was 0.72 (P < 0.001) if the distance between the chairs was 120 cm and 0.75 (P < 0.001) if the distance was 140 cm. The WCT and Catherine Bergego Scale correlated well with the FIM instrument. Spearman's rank-correlation coefficient between the Catherine Bergego Scale and FIM total score was -0.70 (P < 0.001). CONCLUSION: The WCT is a simple screening test with high test-retest reliability and validity to evaluate behavioral unilateral neglect.     

Endowed faculty positions in academic emergency medicine: where we are and where we need to go

To survey academic departments of Emergency Medicine (ADEMs) in the United States concerning the number of endowed faculty positions, a survey was sent to the chairs of all 62 ADEMs in the United States belonging to the Association of Academic Chairs of Emergency Medicine (AACEM) as of March 1, 2004. The survey requested information on: the number of endowed chair and professorship positions; the amount required to fully fund an endowed faculty position; the date established; the source of funding; and if plans were in place to establish an endowed position. Sixty-two chairs (100%) responded. There are currently five endowed chair positions in four ADEMs. Twenty-eight chairs (45%) replied they are in the process of establishing an endowed chair; of these, six chairs (10%) have partially funded the position. There are four endowed professorship positions in three ADEMs. Twenty-one chairs (34%) are in the process of establishing an endowed professorship; of these, two ADEMs (3%) have partially funded the positions. The most common funding sources cited for these endowed positions were "former residents" and "friends." Nearly all chairs replied they were allowed to spend only 5% of the value of the endowment each year. In conclusion, there are currently only nine endowed faculty positions in six ADEMs in the United States. Another eight positions (six chairs and two professorships) are partially funded. Greater effort must be made in establishing more such positions in Emergency Medicine.     

轮椅碰撞试验：一种评估行为偏侧忽略的新方法

目的采用一种新的方法——轮椅碰撞试验(WCT)评估脑卒中患者是否存在行为偏侧忽略并探讨其有效性。方法对19例首发脑卒中患者进行WCT检查,患者自行驱动轮椅通过2排错位排列的圆凳,圆凳间距离为120或140cm,由检查者记录患者驱动轮椅时轮椅碰撞圆凳的次数。同时采用凯瑟林波哥量表(CBS)进行行为偏侧忽略的评定,采用独立功能评定(FIM)评估患者的日常生活能力,并与WCT结果进行相关性分析。结果不同情况下,WCT的重测信度为0.68～0.97。经Kappa检验分析,圆凳间距120cm时WCT(以有碰撞和无碰撞来表示)与CBS(以有忽略和无忽略来表示)的一致率为68.4%,高于圆凳间距140cm时WCT与CBS的一致率(57.9%)。圆凳间距离为120cm和140cm时,WCT与CBS的Spearman相关系数分别为0.72(P<0.001)和0.75(P<0.001);WCT和CBS与FIM评分也有明显的相关性。结论WCT是检测患者是否存在行为偏侧忽略的一种简单、客观的方法,其结果与CBS和FIM均有明显的相关性,可以在临床推广应用。     

Development of the Video Assessment of Propensity to Use Emergency Restraints Scale (VAPERS): Results of the VAPERS Study Group

Background: Emergency physicians (EPs) may disagree on when or whether patients need restraints. There is no good objective measure of the likelihood of EPs to restrain patients. Objectives: To 1) develop a scale to determine the likelihood that an EP would restrain a patient, 2) develop subscale scoring, and 3) determine a shortened version that correlates highly with the full scale. Methods: This was a prospective cross sectional study. The Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS), consisting of 17 scenarios utilizing actors, was videotaped to produce a research video assessment tool. The VAPERS was designed by development experts to reflect the spectrum of patients who are considered for restraint in an emergency department. The VAPERS was piloted among a 22‐member pilot panel of EPs (faculty and residents). The pilot panel was asked to determine the degree to which each video patient possessed the following patient characteristics: medical instability, trauma, belligerence, agitation, and altered mental status. Each “degree of characteristic” was measured on a separate 100‐mm visual analog scale. Participants were then asked whether or not they would restrain each patient and whether the patient exhibited the potential to harm him‐ or herself or others. VAPERS subscales were developed for the likelihood to restrain patients with each of the patient characteristics. Spearman correlations were used for all comparisons. Linear regression was used to determine which patient characteristics were most related to likelihood to restrain and to develop a reduced scale to predict the overall likelihood to restrain. Results: The overall VAPERS score ranged from 0 to 100, with a median of 50 (interquartile range [IQR], 24–88). The visual analog scale results of how likely each video patient possessed specific characteristics were as follows: medical instability ranged from 0 to 100 (median, 32; IQR, 12–64), trauma ranged from 0 to 69 (median, 0; IQR, 0–31), belligerence ranged from 20 to 93 (median, 28; IQR, 14–63), agitation ranged from 3 to 84 (median, 52; IQR, 23–72), and altered mental status ranged from 1 to 93 (median, 29; IQR, 16–69). Linear regression indicated that two characteristic variables (danger to self and degree of agitation) in the video scenarios were highly correlated (0.87) with overall likelihood to restrain. Based on the results, the authors developed a shortened video assessment tool consisting of five of the original videos that were highly correlated (R= 0.94) with the full VAPERS scale on overall likelihood to restrain. Conclusions: The VAPERS scale covers a wide range of important variables in emergency situations. It successfully measured likelihood to restrain in this pilot study for overall situations, and for subgroups, based on patient characteristics. A shortened five‐video VAPERS also successfully measured the overall likelihood to restrain.     

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2‐year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self‐harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.     

Structured team approach to the agitated patient in the emergency department

Objective: Behavioural disturbance and aggression in the ED is an increasing problem. The present study describes the characteristics of patients with acute behavioural disturbance and their emergent treatment in an ED with a structured team approach. Methods: This was a retrospective review of acute behavioural emergencies that required response from the Code Black (CB) Team (duress response team) in the ED during 2006. The hospital security log and hospital incident‐reporting system identified all documented CB, and the patients' medical records were reviewed. Information extracted included patient demographics and presenting complaint, details of the CB, the use of pharmacological sedation, physical restraint and patient disposition. Injuries to hospital staff were also extracted. Results: There were 122 patients, median age 32 years (interquartile range: 24–43 years, range: 14–81 with 71 male patients (58%) who accounted for 143 CB activations. The primary problems were deliberate self‐poisoning or self‐harm (38%), alcohol and illicit drug intoxication (33%) and psychiatric, organic illness and drug withdrawal (29%). One hundred and eight (89%) patients had a past history of alcohol/illicit drug abuse or psychiatric illness. Indications for CB activation were threatening harm to others or behaving violently in 67% of cases. Combined pharmacological sedation and physical restraint were required on 66 (46%) occasions, pharmacological sedation alone on 20 (14%), physical restraint alone on 14 (10%) and neither on 43 (30%) occasions. Benzodiazepines were most commonly used for initial sedation, including i.m. (29%), i.v. midazolam (20%), diazepam (42%) and antipsychotics (9%), most commonly droperidol. More diazepam and droperidol were used for subsequent pharmacological sedation. A staff member was injured on only one occasion (0.7%). Conclusions: Acute behavioural disturbance was common in the present study, and underlying causes were predominantly organic in nature. A team approach appears to be valuable in managing these incidents.     

Comparison of integrated electromyographic activity and lumbar curvature during standing and during sitting in three chairs

The purposes of this study were to monitor the integrated electromyographic activity of the erector spinae (ES) muscles and to measure lumbar curvature (LC) during static and dynamic postures in three chairs--a Balans Multi-Chair (BC), and office chair (OC), and a straight-back chair (SBC)--and during standing. Integrated electromyographic data were recorded in relaxed and erect postures at L2 and L5 in 20 volunteers. Lumbar curvature was measured with a flexible ruler. Analyses of variance for repeated measures (p = .05) and paired t tests were used to compare the IEMG and LC measurements. During relaxed postures, there was more IEMG activity and greater LC in standing than in the OC or the SBC. During erect postures, there was more IEMG activity in standing than in the OC and no difference in LC between chairs. The IEMG activity at L5 was greatest on the left side across chairs. In typing and writing, significant differences in IEMG activity were found between sides, but not between chairs. The LC was greater in the BC than in the SBC in relaxed sitting, typing, and writing. The pattern of IEMG activity is not similar to corresponding LC measurements. Care and prevention of low back injury is a critical focus in physical therapy. The BC could contribute to treatment. Further research is needed to support its use in back care programs.     

The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff

Inpatient aggression on mental health wards is common and staff–patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n = 85 inpatients and n = 65 nurses were recruited from adult, low‐ and medium‐secure wards of a secure forensic mental health service. Participants completed validated self‐report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3‐month follow‐up period were extracted from clinical records. Dyadic nurse–patient relationships were anticomplementary. Patients' self‐reported anger and staff‐rated hostile interpersonal style were significantly positively correlated; staff self‐reported anger and patient‐rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.     

肇事肇祸精神病患者临时保护性约束措施特征分析

目的：探讨被采取临时保护性约束措施的肇事肇祸精神病人群的特征,为相关制度的不断完善提供支撑。方法对新《刑事诉讼法》实施2年间北京地区110例采取临时保护性约束措施的肇事肇祸精神病患者的相关资料进行回顾性调查分析。结果该群体男性居多,文化水平偏低,以青壮年、无配偶者为主,外来人口占比明显偏高;肇事肇祸行为中80％以上为恶性暴力事件;鉴定意见以精神分裂症占绝对多数。结论依法被采取临时保护性约束措施的肇事肇祸精神病患者应得到及时的专业治疗,既能避免再次出现肇事肇祸行为,又可以防止病情延误。