Restraint across the aged care spectrum 1 July, 2009 Presented by Philippa Wharton for WA Dementia Training Study Centre.

RestraintRestraintacross the aged care across the aged care

spectrumspectrum

1 July, 20091 July, 2009

Presented by Philippa Wharton Presented by Philippa Wharton for WA Dementia Training Study Centrefor WA Dementia Training Study Centre

This presentation will cover•Introduction

•What is restraint?

•History

•Types of restraint

•Current practice – RACF and Acute care setting

•What leads to restraint?

•Exploring therapeutic interventions

•So what next?

What is restraint?Restraint may be defined as any device, material or equipment attached to or near a person's body and which cannot be controlled or easily removed by the person, and which deliberately prevents or is intended to prevent a person's free body movement to a position of choice and/ or a person's normal access to their body.

(Australian Society of Geriatric Medicine, 2005)

Restraint is always applied to intentially restrict the free movement of decision making ability of a person

HISTORY

Types of restraint?Types of restraint?

Physical / mechanicalPhysical / mechanical

Examples, posey vests, wrist ties, Examples, posey vests, wrist ties, lap belts, trays in chairs, soft lap belts, trays in chairs, soft padded limb restraints, bedrails, padded limb restraints, bedrails, hand mitts, seat belt on chair.hand mitts, seat belt on chair.

EnvironmentalEnvironmental Limiting a person to a particular environment

(eg – confining a resident to their bedroom or excluding resident from an area to which they want to go.

Perimeter restraints (least restrictive) –fenced areas with locked gates. Key codes & pads.

ChemicalChemical Key factor that differentiates restraint from other forms of care or medical treatment is that it is always applied intentially to restrict the movement or behaviour of a person

The appropriate use of drugs to reduce symptoms in the treatment of medical conditions such as anxiety, depression or psychosis DOES NOT constitute restraint. Public Advocate Position Statement - 2007

Current practiceCurrent practiceBetween 3.4% and 21% (average 10%) of acute Between 3.4% and 21% (average 10%) of acute care patients were subject to some form of care patients were subject to some form of physical restraint during their period of physical restraint during their period of hospitalisation. hospitalisation.

Restraint during ranged from 2.7 days to 4.5 Restraint during ranged from 2.7 days to 4.5 days.days.

In residential care, proportion of residents In residential care, proportion of residents restrained ranged from 12 % to a max of 47% restrained ranged from 12 % to a max of 47% (average 27%) Ranging in duration from 1 to 350 (average 27%) Ranging in duration from 1 to 350 daysdays

Source: JBI 2002

Restraint use in acute careRestraint use in acute care Restraints were used in 9.4% of patients over 62 Restraints were used in 9.4% of patients over 62

years and 33% in over 85 years.years and 33% in over 85 years. Main reason for use was cognitive impairment orMain reason for use was cognitive impairment or delirium superimposed on dementia.delirium superimposed on dementia. Other reasons were preventing falls, controllingOther reasons were preventing falls, controlling agitation, prevent wandering and prevent injury to agitation, prevent wandering and prevent injury to

staff or other patients.staff or other patients. Main restraint used was bedrails (62%) followed byMain restraint used was bedrails (62%) followed by chemical restraints and vests.chemical restraints and vests. 85% of Nursing staff did not consider bedrails a 85% of Nursing staff did not consider bedrails a

form of restraint.form of restraint.Irving 2004 Australian Journal of Advanced Nursing Vol.21, No.4 p23-27Irving 2004 Australian Journal of Advanced Nursing Vol.21, No.4 p23-27

Restraint use in acute careRestraint use in acute care Agitation reported in > 60% of hospitalised Agitation reported in > 60% of hospitalised

patients over 65 years oldpatients over 65 years old Multiple restraint useageMultiple restraint useage Restrained patients tended to have longer Restrained patients tended to have longer

hospital stay, more complications and increased hospital stay, more complications and increased likelihood of discharge to residential care.likelihood of discharge to residential care.

Nursing staff were not well equipped to deal with Nursing staff were not well equipped to deal with patients with challenging behaviours.patients with challenging behaviours.

Staff education on restraints and alternatives Staff education on restraints and alternatives torestraints and the management of difficult torestraints and the management of difficult patients was found to be inadequatepatients was found to be inadequate

Mott, Poole & Kenrick Int. J Nurs. Prac. 2005 Vol. 11, p95-101Mott, Poole & Kenrick Int. J Nurs. Prac. 2005 Vol. 11, p95-101

What leads to restraint?What leads to restraint?

In an attempt to…..In an attempt to…..

To control an episode of behaviourTo control an episode of behaviour To prevent fallsTo prevent falls To protect from injuryTo protect from injury To maintain treatment regimesTo maintain treatment regimes Meet request by familiesMeet request by families

Effects of restraintEffects of restraint

Physical effectsPhysical effects pressure sorespressure soresloss of muscle strengthloss of muscle strengthIncontinenceIncontinencefalls, balance and coordinationfalls, balance and coordinationCardiac arrestCardiac arrestInfection Infection asphyxiation and death.asphyxiation and death.

Effects of restraintEffects of restraint

Psychological effectsPsychological effects

DemoralisationDemoralisationHumiliationHumiliationDepressionDepressionAggression (fear?)Aggression (fear?)Agitation Agitation impaired functioningimpaired functioningIsolationIsolation

Legal / ethical factorsLegal / ethical factors Duty of careDuty of care

Acute care settingAcute care setting

RPH Guidelines – Nursing Practice Standard (NPS)RPH Guidelines – Nursing Practice Standard (NPS)

Consider the Consider the Four A’s Four A’s of restraint education:of restraint education: AttitudeAttitude An attitude of ‘last resort not first choice’ An attitude of ‘last resort not first choice’

reduces the use of restraints reduces the use of restraints AssessmentAssessment A comprehensive multi disciplinary A comprehensive multi disciplinary

patient assessment of mental state, mobility and patient assessment of mental state, mobility and behavioural cues can minimise the use of restraints behavioural cues can minimise the use of restraints

AnticipationAnticipation Knowledge of treatment interventions Knowledge of treatment interventions and therapeutic goals can minimise the use of and therapeutic goals can minimise the use of restraints.restraints.

AvoidanceAvoidance Accomplish goals without physical Accomplish goals without physical restraint restraint

Individual Assessment Individual Assessment

Identify BOC

Comprehensive Assessment

Team approach

Consider TriggersConsultation

Plan of care developedMinimal restraint

Applied (Short term)

Ongoing monitoringAssess need for use

& reduce risk

Develop NEW care plan without use

Restraint

If restraint is usedIf restraint is used

ConsentConsent AuthorisationAuthorisation Close monitoringClose monitoring Short term strategyShort term strategy Ongoing assessmentOngoing assessment Clear & ongoing communication with staff, Clear & ongoing communication with staff,

families, GPfamilies, GP DocumentDocument Care of the person being restrainedCare of the person being restrained

Alternatives to restraintAlternatives to restraint

EnvironmentalEnvironmental Improved lighting, that are easy to use.Improved lighting, that are easy to use. Non-slip flooringNon-slip flooring Carpeting in high use areasCarpeting in high use areas ensure clear pathwayensure clear pathway Easy access to safe outdoor areasEasy access to safe outdoor areas Activity areas at end of corridorsActivity areas at end of corridors Signage – clearSignage – clear Comfortable and appropriate seatingComfortable and appropriate seating

Alternatives to restraintAlternatives to restraint

Quiet areasQuiet areas Reduce environmental noiseReduce environmental noise Familiar objects from residents homeFamiliar objects from residents home ‘‘Snoozelen’ roomSnoozelen’ room

Alternatives to restraintAlternatives to restraint

Activities and programs to meet the Activities and programs to meet the needs of individuals, such as;needs of individuals, such as;

Rehabilitation or exerciseRehabilitation or exercise Regular ambulationRegular ambulation Appropriate outlets for industrious Appropriate outlets for industrious

peoplepeople Facilitate safe wandering behaviourFacilitate safe wandering behaviour falls prevention programfalls prevention program

Alternatives to restraintAlternatives to restraint

Care interventions Care interventions Improved observation skillsImproved observation skills Regular evaluationsRegular evaluations Individualised routinesIndividualised routines Strategies such as ‘Best Friends’ (key Strategies such as ‘Best Friends’ (key

to me), Person Centered Care etc… to me), Person Centered Care etc… (truly gettign to know the person to (truly gettign to know the person to understand their unmet need) understand their unmet need)

Alternatives to restraintAlternatives to restraint

Check ‘at risk’ resident regularlyCheck ‘at risk’ resident regularly Appropriate footwearAppropriate footwear Hip protectorsHip protectors Improved communication – ‘make Improved communication – ‘make

the bubble bigger’ the bubble bigger’ Concave mattressesConcave mattresses Mattress on the floorMattress on the floor Large pillowsLarge pillows

Alternatives to restraintAlternatives to restraint

Physiological strategiesPhysiological strategies Comprehensive physical reviewComprehensive physical review Medication reviewMedication review Treat infectionsTreat infections Pain management ‘Pain Detective’ Pain management ‘Pain Detective’ Physical alternatives to sedation – Physical alternatives to sedation –

warm drink, comfort/TLC, soothing warm drink, comfort/TLC, soothing musicmusic

Alternatives to restraintAlternatives to restraint

Psychosocial considerationsPsychosocial considerations CompanionshipCompanionship Active listeningActive listening Visitors Visitors Staff/resident interactionStaff/resident interaction Sensory aidsSensory aids MassageMassage Relaxation programsRelaxation programs

Management Management responsibilitiesresponsibilities

Policy &Procedures

Education PreventionPrograms Family support

TeamApproach

Best practice

Keep on the agenda

Decision making about

restraint

Prevent & respond

BOC

PromoteSafe working

environ

Case Study 1Case Study 1

86 year old lady admitted from a86 year old lady admitted from anursing home, with CALD background with a nursing home, with CALD background with a diagnosis of dementia admitted for cellulitis. diagnosis of dementia admitted for cellulitis. Patient continually attempting to get out of Patient continually attempting to get out of bed and mobilise which she was unsafe to bed and mobilise which she was unsafe to do. Vest restraint placed on patient, she do. Vest restraint placed on patient, she remained agitated.remained agitated.

What steps would you take? What steps would you take?

Case Study - 2Case Study - 2

82 year old gentleman admitted with82 year old gentleman admitted with

chest infection. Confused, unco-chest infection. Confused, unco-operative,operative,

combative at times. Patient restrained combative at times. Patient restrained withwith

Wrist restraints but was reported asWrist restraints but was reported as

continuing to be uncooperative. continuing to be uncooperative.

What next steps would you take?What next steps would you take?

Resources availableResources available Robb, B. 1967. Robb, B. 1967. Sans everything - a case to answerSans everything - a case to answer. London: Nelson.. London: Nelson. Alzheimer’s Australia report by Access Economics. April, 2009. Alzheimer’s Australia report by Access Economics. April, 2009. Making Choices - Future dementia care: projections, problems and Making Choices - Future dementia care: projections, problems and

preferencespreferences. . www.alzheimers.org.auwww.alzheimers.org.au Australian Society for Geriatric Medicine, 2005 (revised) – Australian Society for Geriatric Medicine, 2005 (revised) – Position Statement Position Statement

No 2: Physical restraint Use in Older People No 2: Physical restraint Use in Older People Irish Nurses Organisation Focus Group from the Care of the Older Person Irish Nurses Organisation Focus Group from the Care of the Older Person

Section, May 2003. Section, May 2003. Guidelines on the use of restraint in the care of the older Guidelines on the use of restraint in the care of the older person. person.

JBI – Best Practice, Evidence Based Practice Information Sheets for Health JBI – Best Practice, Evidence Based Practice Information Sheets for Health Professionals. 2002 – Professionals. 2002 – Physical restraint Part 1 and 2, use in Acute and Physical restraint Part 1 and 2, use in Acute and Residential Care facilities. Residential Care facilities.

DOHA, 2004. DOHA, 2004. Decision-making tool: Responding to issues of restraint in Aged Decision-making tool: Responding to issues of restraint in Aged CareCare

Special thank you tooSpecial thank you too Margaret Brown – Dementia Care CNC, South Eastern Sydney Illawarra NSW Margaret Brown – Dementia Care CNC, South Eastern Sydney Illawarra NSW

HealthHealth Esther Vance – NSW Falls intervention network, Sydney, NSWEsther Vance – NSW Falls intervention network, Sydney, NSW RPH – Nursing Practice Standard for minimising the use of and management RPH – Nursing Practice Standard for minimising the use of and management

of patient restraints, Nov 2007of patient restraints, Nov 2007 Carol Douglas – Residential Care Line Carol Douglas – Residential Care Line

If we spent as much time trying to If we spent as much time trying to understand behaviour as we spent trying understand behaviour as we spent trying

to manage or control it, we might discover to manage or control it, we might discover that what lies behind it is a genuine that what lies behind it is a genuine

attempt to communicateattempt to communicate

Source: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care Source: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care 4(4)4(4)