Saturday, March 21, 2009

Use of restraints


A recent research study has raised some fuss. The National Post & Calgary Herald, cite a study that claims that "physical restraints were used in Canadian homes on an average of 31.4% of residents in the previous seven days, compared to 6% in Switzerland, 9% in the United States, 20% in Hong Kong and 28% in Finland." A European study cites rates of 0 - 22%.

The Canadian data is from only 19 long-term-care homes and 41 continuing complex-care hospitals, most in Ontario, between 2003 and 2005. I would suggest that with such a wide range of type of institutions: Retirement Homes, Long-Term Care homes (LTC - formerly called nursing homes), as well as chronic care placements, we are unable to make a definitive categorical statement without much more information. In addition, we do not know how these homes and hospitals were selected compared with the other nations in the study.

Restraints can include bed rails, arm restraints, safety belts in wheel chairs, or pharmacological methods.

The National Post says, "Prof. Hirdes said he believes the results are representative of the whole country". I hope this is untrue. I know that in the Long-Term Care home where my father was housed, and the one in which my dear friend lives, I have not seen any situations like this. Several residents were unable to walk. Others were practically comatose. They need to feel safe and have protection. In complex-care or chronic care institutions residents are at risk for harming themselves and/or harming others. In these places we have a continuum of care that is highly individual.

I feel that in all the time I have spent in LTC in Muskoka, I can see that restraints are an important tool for caregivers to use. It is a decision that must be made on an individual basis. I fail to understand why we can conclude that restraints are overused, when we do not have information on the number, range, and types of (dis)abilities of care recipients.

In my father's case, he had delirium and dementia. He was unable to remember or understand how to use the call button in his LTC room. He continually fell out of bed, on the floor. We lowered his bed, but it did not help. He continually tried to get out of his wheelchair, and due to balance issues could not stay upright in the chair. This put him at great risk for falling and hurting himself.

In Ontario we have, for example, more than 600 LTC 'homes', and they are primarily (approximately 500) for-profit. These places are regulated by the Ontario LTC Act, and are monitored with results posted on-line.

An Elder Care blogger, in a blog, cites similar concerns over Elder Abuse and restraints in the UK. CSCI Professional (UK) has a report out, too. People are concerned around the world.

Somehow, some are equating restraints with elder abuse. I think this is wrong.
"Elder Abuse is a single or repeated act, or lack of appropriate action, occurring in any relationship where there is an expectation of trust that causes harm or distress to an older person”. (WHO)

There is a huge difference. The purpose is to keep a resident from falling, harming him/herself or other residents, or staff members. Pharmacological restraints, to prevent agitation can exacerbate a situation as the resident may have side effects. These cases must be monitored.

There is a push on in the US to reduce cases of unnecessary restraints. It is a good principal if it can be put into practice, especially in a country with no universal medicare. In this situation, we must ask further questions and determine the comorbidities that call for such restraints.

The answers lie is sufficient staffing and supervision, inspections, rigorous training for staff and family members, and respecting the independence, dignity, and self-determination of those with or without dementia, balancing the needs of those around the resident.

Resources

1. Brungardt GS. Patient restraints: new guidelines for a less restrictive approach. Geriatrics. 1994;49:43-50.
2. Capezuti E, Strumpf NE, Evans LK, Grisso JA, Maislin G. The relationship between physical restraint removal and falls and injuries among nursing home residents. J Gerontol Med Sci. 1998;53A:M47-M52.
3. Flaherty JH, Tariq SH, Raghavan S, et al. A model for managing delirious older inpatients. J Am Geriatr Soc. 2003;51:1031-1035.
4. Macpherson DS, Lofgren RP, Granieri R, Myllenbeck S. Deciding to Restrain Medical Patients. J Am Geriatr Soc. 1990;38:516-520.
5. Mion LC, Fogel J, Sandu S, et al. Outcomes following physical restraint reduction programs in two acute care hospitals. Jt Comm J Qual Improv. 2001;27:605-618.
6. Neufeld RR, Libow LS, Foley FJ, Dunbar JM, Cohen C, Breuer B. Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc. 1999;47:1202-1207.

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