What is a restraint?
- A device that restricts movement such as straitjackets for violent patients
- A deprivation of freedom or liberty
- The state of being physically constrained
- “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body” (CMS)
What are some types of restraints?
- Vests (Poseys)
- Wrist/ankle restraints
- Bed rails (when all four are in use)
- Trays (Lap Buddies) or seatbelts – any devices that the pt. cannot remove easily and that prevent him/her from rising
- A low chair (that pt. cannot rise from)
- Tucked in sheets (if pt. cannot remove)
- Chemical- Haldol, Ativan, Versed
How did restraints come into use?
- To prevent harm to the patient
- To control behaviors
- To minimize facility risks/litigation
- Lack of training regarding alternatives
- Lack of staff
What are some problems associated with the use of restraints?
- Strangulation
- Loss of Muscle Tone
- Pressure Sores
- Agitation/Psychological Distress
- Reduced Bone Mass
- Nerve Injuries
- Contractures
- Frustration
- Loss of Dignity
- Incontinence
- Constipation
- Falls
What is OBRA?
Omnibus Budget Reconciliation Act of 1987
What did OBRA say about the use of restraints?
Restraints may only be imposed:
(1) to ensure the physical safety of the resident or other residents, and
(2) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used.”
Some provisions of OBRA Include:
- Emphasis on a resident’s quality of life as well as the quality of care
- Expectations that each resident’s ability to walk, bathe, and perform other activities of daily living will be maintained or improved absent medical reasons
- A resident assessment process leading to development of an individualized Plan of care
- Rights to remain in the nursing home absent non-payment, dangerous resident behaviors, or significant changes in a resident’s medical condition
- The right to organize and participate in a resident or family council
- The right to be free of unnecessary and inappropriate physical and chemical restraints
- Uniform certification standards for Medicare and Medicaid homes
- New remedies to be applied to certified nursing homes that fail to meet minimum federal standards
What are some circumstances that would warrant a restraint?
- State of confusion
- Suicidal patient
- Hostile patient
- Intoxicated patient
- Intubated patient
- Provision of emergency treatment
- Altered level of consciousness
Under which circumstance should a restraint not be used (1)
To compensate for a shortage in staff
What are the HCFA guidelines for use of restraints?
- Only physicians or other licensed independent practitioners can order restraint
- A physician or other licensed independent practitioner must see and evaluate the need for restraint within one hour of the intervention
- Written orders for restraint are limited to four hours for adults
- Orders must indicate the specific reason for the restraint
- Orders may be renewed for up to a total of 24 hours.
- Nursing home guidelines: patient in restraints should be checked every 30 min. and an account kept of this surveillance
- Opportunity for exercise should be provided for a period of not < 10 min. every 2 hours (except at night)
What are some alternatives for restraints?
- Lowering beds to reduce risk of injury in event of a fall
- Use of alarms
- Toileting schedules
- Scheduled exercise
- Placement of patients in proximity of nursing/PT staff
- Use of family or hired persons to provide companionship
- Provision of distractions
True / False- “Restraining an intubated patient will prevent self-extubation
False- In a twelve month study in a general ICU of intubated patients, survey results found self-extubation occurred despite the use of sedation and restraints.
Are drugs good alternatives for physical restraints?
NO- in a survey conducted with nurses, most of the nurses reported that they would rather sedate a patient with prescriptive medication than physically restrain them. However, sedation can affect the patient’s level of consciousness, respiratory effort and other vital signs.
Do restrained patients have a shorter or longer hospital stay?
Restrained patients are hospitalized twice as long as those who are not restrained, and the mortality increases in those patients who are restrained.
True / False- Elderly patients in the ICU are more likely to need restraint”
False- however, an elderly patient is 8X more likely to be restrained than a younger one. Also the act of restraining may itself contribute to a manifestation of agitation.
True / False- Routinely using restraints not only protects the patient, but the practice/ facility as well
False
Court cases citing negligence in failing to use physical restraints for patients are not common.
Successful legal claims have resulted from the inappropriate ordering of restraints.
true or false- Only physicians or other licensed independent practitioners can order restraint
True
Within what time frame must a physican or other license independent practitioner see patient prior to administration of restraints?
A physician or other licensed independent practitioner must see and evaluate the need for restraint within one hour of the intervention
Written orders for restraint are limited to what time frame?
Four (4) hours for adults
Orders must indicate the specific reason for the restraint
Orders may be renewed for up to a total of 24 hours.
Nursing home guidelines for a patient in restraints
Patient should be checked every 30 min. and an account kept of this surveillance
Opportunity for exercise should be provided for a period of not < 10 min. every 2 hours (except at night)
