Presentation on theme: "Restraint across the aged care spectrum"— Presentation transcript:
1 Restraint across the aged care spectrum 1 July, 2009Presented by Philippa Whartonfor WA Dementia Training Study Centre
2 This presentation will cover IntroductionWhat is restraint?HistoryTypes of restraintCurrent practice – RACF and Acute care settingWhat leads to restraint?Exploring therapeutic interventionsSo what next?
3 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
4 HISTORYThe strait waist-coat or strait jacket was heralded in the late 18th century as an advance in the management of the insane. Here is an image of the strait jacket from that period.Lunacy and Madhouse Acts, rounding up all lunatics together (France). WorkshousesThese are our origins
5 Types of restraint? Physical / mechanical Examples, posey vests, wrist ties, lap belts, trays in chairs, soft padded limb restraints, bedrails, hand mitts, seat belt on chair.
6 Environmental 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.
7 ChemicalKey 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 personThe 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
8 Current practiceBetween 3.4% and 21% (average 10%) of acute care patients were subject to some form of physical restraint during their period of hospitalisation.Restraint during ranged from 2.7 days to 4.5 days.In residential care, proportion of residents restrained ranged from 12 % to a max of 47% (average 27%) Ranging in duration from 1 to 350 daysSource: JBI 2002
9 Restraint use in acute care Restraints were used in 9.4% of patients over 62 years and 33% in over 85 years.Main reason for use was cognitive impairment ordelirium superimposed on dementia.Other reasons were preventing falls, controllingagitation, prevent wandering and prevent injury to staff or other patients.Main restraint used was bedrails (62%) followed bychemical restraints and vests.85% of Nursing staff did not consider bedrails a form of restraint.Irving 2004 Australian Journal of Advanced Nursing Vol.21, No.4 p23-27
10 Restraint use in acute care Agitation reported in > 60% of hospitalised patients over 65 years oldMultiple restraint useageRestrained patients tended to have longer hospital stay, more complications and increased likelihood of discharge to residential care.Nursing staff were not well equipped to deal with patients with challenging behaviours.Staff education on restraints and alternatives torestraints and the management of difficult patients was found to be inadequateMott, Poole & Kenrick Int. J Nurs. Prac Vol. 11, p95-101
11 What leads to restraint? In an attempt to…..To control an episode of behaviourTo prevent fallsTo protect from injuryTo maintain treatment regimesMeet request by families
12 Effects of restraint Physical effects pressure sores loss of muscle strengthIncontinencefalls, balance and coordinationCardiac arrestInfectionasphyxiation and death.These are negative effects of restraint that is poorly managed
13 Effects of restraint Psychological effects Demoralisation Humiliation DepressionAggression (fear?)Agitationimpaired functioningIsolationLegal / ethical factorsDuty of care
14 RPH Guidelines – Nursing Practice Standard (NPS) Acute care settingRPH Guidelines – Nursing Practice Standard (NPS)Consider the Four A’s of restraint education:Attitude An attitude of ‘last resort not first choice’ reduces the use of restraintsAssessment A comprehensive multi disciplinary patient assessment of mental state, mobility and behavioural cues can minimise the use of restraintsAnticipation Knowledge of treatment interventions and therapeutic goals can minimise the use of restraints.Avoidance Accomplish goals without physical restraint
15 Individual Assessment ComprehensiveAssessmentTeam approachIdentify BOCDevelop NEW careplan without useRestraintConsultationConsider TriggersPlan of caredevelopedMinimal restraintApplied (Short term)OngoingmonitoringAssess need for use& reduce risk
16 If restraint is used Consent Authorisation Close monitoring Short term strategyOngoing assessmentClear & ongoing communication with staff, families, GPDocumentCare of the person being restrained
17 Alternatives to restraint EnvironmentalImproved lighting, that are easy to use.Non-slip flooringCarpeting in high use areasensure clear pathwayEasy access to safe outdoor areasActivity areas at end of corridorsSignage – clearComfortable and appropriate seating
18 Alternatives to restraint Quiet areasReduce environmental noiseFamiliar objects from residents home‘Snoozelen’ room
19 Alternatives to restraint Activities and programs to meet the needs of individuals, such as;Rehabilitation or exerciseRegular ambulationAppropriate outlets for industrious peopleFacilitate safe wandering behaviourfalls prevention program
20 Alternatives to restraint Care interventionsImproved observation skillsRegular evaluationsIndividualised routinesStrategies such as ‘Best Friends’ (key to me), Person Centered Care etc… (truly gettign to know the person to understand their unmet need)
21 Alternatives to restraint Check ‘at risk’ resident regularlyAppropriate footwearHip protectorsImproved communication – ‘make the bubble bigger’Concave mattressesMattress on the floorLarge pillows
22 Alternatives to restraint Physiological strategiesComprehensive physical reviewMedication reviewTreat infectionsPain management ‘Pain Detective’Physical alternatives to sedation – warm drink, comfort/TLC, soothing music
23 Alternatives to restraint Psychosocial considerationsCompanionshipActive listeningVisitorsStaff/resident interactionSensory aidsMassageRelaxation programs
25 Case Study 1 What steps would you take? 86 year old lady admitted from anursing home, with CALD background with adiagnosis of dementia admitted for cellulitis.Patient continually attempting to get out ofbed and mobilise which she was unsafe todo. Vest restraint placed on patient, sheremained agitated.What steps would you take?
26 Case Study - 2 What next steps would you take? 82 year old gentleman admitted withchest infection. Confused, unco-operative,combative at times. Patient restrained withWrist restraints but was reported ascontinuing to be uncooperative.What next steps would you take?
27 Resources availableRobb, B Sans everything - a case to answer. London: Nelson.Alzheimer’s Australia report by Access Economics. April, 2009.Making Choices - Future dementia care: projections, problems and preferences.Australian Society for Geriatric Medicine, 2005 (revised) – Position Statement No 2: Physical restraint Use in Older PeopleIrish Nurses Organisation Focus Group from the Care of the Older Person Section, May Guidelines on the use of restraint in the care of the older person.JBI – Best Practice, Evidence Based Practice Information Sheets for Health Professionals – Physical restraint Part 1 and 2, use in Acute and Residential Care facilities.DOHA, Decision-making tool: Responding to issues of restraint in Aged CareSpecial thank you tooMargaret Brown – Dementia Care CNC, South Eastern Sydney Illawarra NSW HealthEsther Vance – NSW Falls intervention network, Sydney, NSWRPH – Nursing Practice Standard for minimising the use of and management of patient restraints, Nov 2007Carol Douglas – Residential Care Line
28 If we spent as much time trying to understand behaviour as we spent trying to manage or control it, we might discover that what lies behind it is a genuine attempt to communicateSource: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care 4(4)