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

2. 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?

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. HISTORY
The 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). Workshouses
These 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. Chemical
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

8. Current practice
Between 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 days
Source: 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 or
delirium superimposed on dementia.
Other reasons were preventing falls, controlling
agitation, prevent wandering and prevent injury to staff or other patients.
Main restraint used was bedrails (62%) followed by
chemical 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 old
Multiple restraint useage
Restrained 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 inadequate
Mott, Poole & Kenrick Int. J Nurs. Prac Vol. 11, p95-101

11. What leads to restraint?
In an attempt to…..
To control an episode of behaviour
To prevent falls
To protect from injury
To maintain treatment regimes
Meet request by families

12. Effects of restraint Physical effects pressure sores
loss of muscle strength
Incontinence
falls, balance and coordination
Cardiac arrest
Infection
asphyxiation and death.
These are negative effects of restraint that is poorly managed

13. Effects of restraint Psychological effects Demoralisation Humiliation
Depression
Aggression (fear?)
Agitation
impaired functioning
Isolation
Legal / ethical factors
Duty of care

14. RPH Guidelines – Nursing Practice Standard (NPS)
Acute care setting
RPH 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 restraints
Assessment A comprehensive multi disciplinary patient assessment of mental state, mobility and behavioural cues can minimise the use of restraints
Anticipation Knowledge of treatment interventions and therapeutic goals can minimise the use of restraints.
Avoidance Accomplish goals without physical restraint

15. Individual Assessment
Comprehensive
Assessment
Team approach
Identify BOC
Develop NEW care
plan without use
Restraint
Consultation
Consider Triggers
Plan of care
developed
Minimal restraint
Applied (Short term)
Ongoing
monitoring
Assess need for use
& reduce risk

16. If restraint is used Consent Authorisation Close monitoring
Short term strategy
Ongoing assessment
Clear & ongoing communication with staff, families, GP
Document
Care of the person being restrained

17. Alternatives to restraint
Environmental
Improved lighting, that are easy to use.
Non-slip flooring
Carpeting in high use areas
ensure clear pathway
Easy access to safe outdoor areas
Activity areas at end of corridors
Signage – clear
Comfortable and appropriate seating

18. Alternatives to restraint
Quiet areas
Reduce environmental noise
Familiar objects from residents home
‘Snoozelen’ room

19. Alternatives to restraint
Activities and programs to meet the needs of individuals, such as;
Rehabilitation or exercise
Regular ambulation
Appropriate outlets for industrious people
Facilitate safe wandering behaviour
falls prevention program

20. Alternatives to restraint
Care interventions
Improved observation skills
Regular evaluations
Individualised routines
Strategies 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 regularly
Appropriate footwear
Hip protectors
Improved communication – ‘make the bubble bigger’
Concave mattresses
Mattress on the floor
Large pillows

22. Alternatives to restraint
Physiological strategies
Comprehensive physical review
Medication review
Treat infections
Pain management ‘Pain Detective’
Physical alternatives to sedation – warm drink, comfort/TLC, soothing music

23. Alternatives to restraint
Psychosocial considerations
Companionship
Active listening
Visitors
Staff/resident interaction
Sensory aids
Massage
Relaxation programs

24. Management responsibilities
Keep on
the agenda
Decision
making
about
restraint
Policy &
Procedures
Prevent &
respond
BOC
Best
practice
Team
Approach
Promote
Safe working
environ
Education
Family support
Prevention
Programs

25. Case Study 1 What steps would you take?
86 year old lady admitted from a
nursing home, with CALD background with a
diagnosis of dementia admitted for cellulitis.
Patient continually attempting to get out of
bed and mobilise which she was unsafe to
do. Vest restraint placed on patient, she
remained agitated.
What steps would you take?

26. Case Study - 2 What next steps would you take?
82 year old gentleman admitted with
chest infection. Confused, unco-operative,
combative at times. Patient restrained with
Wrist restraints but was reported as
continuing to be uncooperative.
What next steps would you take?

27. Resources available
Robb, 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 People
Irish 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 Care
Special thank you too
Margaret Brown – Dementia Care CNC, South Eastern Sydney Illawarra NSW Health
Esther Vance – NSW Falls intervention network, Sydney, NSW
RPH – Nursing Practice Standard for minimising the use of and management of patient restraints, Nov 2007
Carol 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 communicate
Source: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care 4(4)