Editorials

Restraining Devices for Patients in Acute and Long-Term Care Facilities



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Am Fam Physician. 2009 Feb 15;79(4):254-256.

In the mid-1900s, many acute and long-term care facilities began routine adoption of physical restraints and bed side rails in an effort to curtail patient falls and reduce liability concerns. This adoption came from a common-sense notion that physical restraints and side rails improved patient safety. Eventually, policies were developed to standardize their use.1,2

A physical restraint is any device that restricts a patient’s movement and cannot be removed easily by the patient. Examples of restraints include vest or wrist restraints, geriatric chairs with tables, and bed side rails. The prevalence of restraint use in nursing homes and acute care hospitals is estimated between 25 and 85 percent.3,4 Risk factors for being restrained include impaired cognition, low body weight, frailty, older age, and functional dependence.4,5 Restraints are most commonly used to prevent falls, wandering, and disruption of therapy.3,6

Over the past 20 years, it has become increasingly clear that routine adoption of physical restraints and bed side rails for patient safety preceded evidence of their effectiveness.7 Newer evidence suggests that using physical restraints and side rails to prevent falls is misguided and may pose a significant safety hazard to patients.8,9 Several studies have found that restrained patients were more likely to fall than those without restraint orders.4,10 In addition, studies show that restraints may actually increase the risk of serious injury from bed-related falls4,5,10  and are associated with a number of well-known complications (Table 1 1016).

Table 1.

Complications of Restraints

Brachial plexus injury

Joint contractures

Deconditioning

Muscle weakness

Delirium

Pneumonia

Death

Pressure ulcers

Immobility

Psychological distress

Incontinence

Urinary tract infections


Information from references 10 through 16.

Table 1.   Complications of Restraints

View Table

Table 1.

Complications of Restraints

Brachial plexus injury

Joint contractures

Deconditioning

Muscle weakness

Delirium

Pneumonia

Death

Pressure ulcers

Immobility

Psychological distress

Incontinence

Urinary tract infections


Information from references 10 through 16.

In light of accumulated evidence, tradition alone is not adequate rationale for continued use of physical restraints or side rails. Federal regulations and practice guidelines are now consistent with the evidence, advising that restraints generally should not be used.1719 Restraints may, however, be temporarily required to control violent behavior or to prevent the removal of important equipment, such as endotracheal tubes, intra-arterial devices, and catheters.

Guidelines for restraint use suggest using the least restrictive device necessary, reassessing the patient’s response frequently, removing the restraint periodically, and renewing orders every 24 hours only after evaluation by a physician. Practice guidelines outline the need for care plan modification to compensate for restraint use, including frequent position changes and skin care, provision of adequate range of motion, and assistance with activities of daily living. Ongoing assessment of the underlying condition that prompted restraint use, early referral to a multidisciplinary team or geriatric specialist, and staff education are key to appropriate restraint use.20,21

Alternative strategies that may help reduce unnecessary and potentially hazardous physical restraint and side-rail use include fall prevention programs, new beds or bed modifications, and restraint-free environments, which employ a number of alternative measures for preventing and managing problematic behaviors (Table 2 20,2226). Fall prevention programs can include multifactorial interventions, such as staff education programs, gait training, review of appropriate use of assistive devices, and review and modification of medications. These have been shown to decrease the incidence of falls in long-term and assisted living settings.27 However, evidence is insufficient to make recommendations for or against multifactorial interventions in acute care settings.28

Table 2.

Alternatives for Preventing and Managing Problem Behaviors

Design the physical environment so that staff may closely observe patients

Enhance exercise programs

Improve comfort in bed with pillows, cushions, and leg separator pads

Increase staff awareness of patients’ individual needs

Modify environment to improve lighting and eliminate fall hazards

Use patient positioning alarms to alert staff when a patient tries to exit the bed

Use personal assistance devices, including hearing, visual, and mobility aids


Information from references 20 and 22 through 26.

Table 2.   Alternatives for Preventing and Managing Problem Behaviors

View Table

Table 2.

Alternatives for Preventing and Managing Problem Behaviors

Design the physical environment so that staff may closely observe patients

Enhance exercise programs

Improve comfort in bed with pillows, cushions, and leg separator pads

Increase staff awareness of patients’ individual needs

Modify environment to improve lighting and eliminate fall hazards

Use patient positioning alarms to alert staff when a patient tries to exit the bed

Use personal assistance devices, including hearing, visual, and mobility aids


Information from references 20 and 22 through 26.

Several new products that may help address fall risk are available. Electric adjustable-height beds are expensive, but may be appropriate for those at greatest risk of falling or side-rail entrapment. Lowering bed height has been shown to facilitate standing and may reduce the incidence of serious injuries from bed-related falls.29,30 Bed modifications such as assist bars, bed handles, trapezes, or transfer poles can also provide mechanical support for transfers from bed.15 Additional research is needed to demonstrate the effectiveness of these modifications in preventing fall-related injury.

Address correspondence to Lauren G. Collins, MD, Thomas Jefferson University, 1015 Walnut St., Suite 401, Philadelphia, PA 19107 (e-mail: Lauren.Collins@jefferson.edu). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Capezuti E, Evans L, Strumpf N, Maislin G. Physical restraint use and falls in nursing home residents. J Am Geriatr Soc. 1996;44(6):627–633.

2. Shorr RI, Guillen MK, Rosenblatt LC, Walker K, Caudle CE, Kritchevsky SB. Restraint use, restraint orders, and the risk of falls in hospitalized patients. J Am Geriatr Soc. 2002;50(3):526–529.

3. Minnick AF, Mion LC, Johnson ME, Catrambone C, Leipzig R. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30–37.

4. Tinetti ME, Liu WL, Ginter SF. Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities. Ann Intern Med. 1992;116(5):369–374.

5. Todd JF, Ruhl CE, Gross TP. Injury and death associated with hospital bed side-rails: reports to the US Food and Drug Administration from 1985 to 1995 [published correction appears in Am J Public Health. 1997;87(12):2052]. Am J Public Health. 1997;87(10):1675–1677.

6. Tinetti ME, Liu WL, Marottolli RA, Ginter SF. Mechanical restraint use among residents of skilled nursing facilities. Prevalence, patterns, and predictors. JAMA. 1991;265(4):468–471.

7. Rubenstein HS, Miller FH, Postel S, Evans HB. Standards of medical care based on consensus rather than evidence: the case of routine bedrail use for the elderly. Law Med Health Care. 1983;11(6):271–276.

8. Brush BL, Capezuti E. Historical analysis of siderail use in American hospitals. J Nurs Scholarsh. 2001;33(4):381–385.

9. Strumpf NE, Tomes N. Restraining the troublesome patient. A historical perspective on a contemporary debate. Nurs Hist Rev. 1993;1:3–24.

10. Neufeld RR, Libow LS, Foley WJ, Dunbar JM, Cohen C, Breuer B. Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc. 1999;47(10):1202–1207.

11. Minnick A, Leipzig RM, Johnson ME. Elderly patients’ reports of physical restraint experiences in intensive care units. Am J Crit Care. 2001;10(3):168–171.

12. Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc. 1997;45(7):797–802.

13. Mahoney JE. Immobility and falls. Clin Geriatr Med. 1998;14(4):699–726.

14. Inouye SK, Wagner DR, Acampora D, et al. A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med. 1993;8(12):645–652.

15. Hanger HC, Ball MC, Wood LA. An analysis of falls in the hospital: can we do without bedrails? J Am Geriatr Soc. 1999;47(5):529–531.

16. Miles SH. Deaths between bedrails and air pressure mattresses. J Am Geriatr Soc. 2002;50(6):1124–1125.

17. Omnibus Budget Reconciliation Act of 1987. Subtitle C, nursing home reform. Part 1: Medicare program. http://thomas.loc.gov/cgi-bin/bdquery/z?d100:HR03545:@@@D&summ2=m&|TOM:/bss/d100query.html. Accessed April 15, 2008.

18. U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Hospital conditions of participation: patients’ rights; final rule. http://www.cms.hhs.gov/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf. Accessed April 16, 2008.

19. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Restraint and seclusion: complying with the Joint Commission Standards (2002). http://www.jointcommission.org/accreditationprograms/behavioralhealthcare/standards/FAQs/default.htm. Accessed on April 28, 2008.

20. American Geriatrics Society Position Statement. Restraint use. http://www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml. Accessed April 15, 2008.

21. National Guideline Clearinghouse. Use of physical restraints in the acute care setting. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3515. Accessed April 15, 2008.

22. Hospital Bed Safety Workgroup. Clinical guidance for the assessment and implementation of bed rails in hospitals, long term care facilities, and home care settings. April 2003. http://www.ute.kendal.org/learning/documents/clinicalguidance_SideRails.pdf. Accessed April 15, 2008.

23. Levine JM, Marchello V, Totolos E. Progress toward a restraint-free environment in a large academic nursing facility. J Am Geriatr Soc. 1995;43(8):914–918.

24. Evans LK, Strumpf NE, Allen-Taylor SL, Capezuti E, Maislin G, Jacobsen B. A clinical trial to reduce restraints in nursing homes. J Am Geriatr Soc. 1997;45(6):675–681.

25. Capezuti E, Talerico KA, Strumpf N, Evans L. Individualized assessment and intervention in bilateral siderail use. Geriatr Nurs. 1998;19(6):322–330.

26. Sullivan-Marx EM, Strumpf NE, Evans LK, Baumgarten M, Maislin G. Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts. J Am Geriatr Soc. 1999;47(3)342–348.

27. Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72(1):81–88.

28. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001;49(5):664–672.

29. Capezuti E, Talerico KA, Cochran I, Becker H, Strumpf N, Evans L. Individualized interventions to prevent bed-related falls and reduce siderail use. J Gerontol Nurs. 1999;25(11):26–34.

30. U.S. Food and Drug Administration. A guide for modifying bed systems and using accessories to reduce the risk of entrapment. June 2006. http://www.fda.gov/cdrh/beds/modguide.html. Accessed April 15, 2008.


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