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Am Fam Physician. 1998;57(3):538-540

Use of physical restraints in nursing homes is often rationalized as necessary to prevent falls, to prevent resistance to treatment and to manage uncontrollable behavior. However, research clearly shows that prolonged use of restraints is associated with adverse events, such as fall-related injuries and decreased physical and psychologic function. Evans and colleagues prospectively studied whether an educational and interventional program in nursing homes would have an effect on the use of physical restraints.

Three nursing homes were included in the study. Staff in one nursing home received no intervention, staff in the second nursing home received restraint education and staff in the third nursing home received restraint education and were provided with interventional consultation that was customized for patients who were particularly problematic.

The six-month, 10-session restraint education program was taught by a gerontologic nurse specialist. The 30- to 40-minute sessions focused on the effects of physical restraints, the behavior of residents, ways to minimize the risk of falls and ways to cope with problem behaviors such as wandering and agitation. Interventional consultation was provided for 12 hours each week. The consultations focused on residents who posed a challenge because of their behavior.

The greatest reduction in restraint use occurred in the nursing home in which the staff received education and consultation. The average absolute decline in restraint use at this nursing home was 18 percent, and this reduction was maintained during the follow-up period. Use of vest restraints decreased by 41 percent in the nursing home that provided education sessions and by 77 percent in the nursing home that provided education and consultation. Geriatric chair use was not signficantly affected by any of the interventions.

No change occurred in the number of staff hours per resident, and no increase was seen in psychoactive drug use in the two nursing homes that underwent intervention. The baseline rate of falls was lowest in the control nursing home but, after the interventions, this nursing home had a higher rate of falls than the other two nursing homes. The rate of falls in the control nursing home was 53.3 percent in the three to six months after the intervention period, compared with rates of 32.2 percent in the nursing home that provided restraint education and 37.8 percent in the nursing home that provided restraint education and consultation.

The authors conclude that a combination of staff education and consultation leads to a decrease in the use of physical restraints in nursing homes, without a concomitant increase in staff time, use of psychoactive drugs or injuries related to falls. In an accompanying editorial, Williams and Finch discuss the effects of “restraint stress”: functional decline, psychologic distress, agitation, impaired circulation, incontinence, immobility and serious accidents. Evidence also suggests that restraint stress can heighten memory impairment. They emphasize that the fairly widespread goal of “restraint reduction” or “restraint alternatives” will not, in fact, come near to achieving what should be the true goal: a restraint-free facility. They state that restraint-free care is most likely to be achieved if the director of nursing and the facility administrator are committed to it. The medical director and attending physicians must support the leaders of the nursing home in this endeavor.

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Copyright © 1998 by the American Academy of Family Physicians.

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