Restraint across the aged care spectrum

1. Restraintacross 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

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 - 2007

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. 2005 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.

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

14. Acute care setting RPH Guidelines – Nursing Practice Standard (NPS) Consider the Four A’s of restraint education: • AttitudeAn attitude of ‘last resort not first choice’ reduces the use of restraints • AssessmentA comprehensive multi disciplinary patient assessment of mental state, mobility and behavioural cues can minimise the use of restraints • AnticipationKnowledge of treatment interventions and therapeutic goals can minimise the use of restraints. • AvoidanceAccomplish 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 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 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. 1967. 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. www.alzheimers.org.au • 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 2003. Guidelines on the use of restraint in the care of the older person. • JBI – Best Practice, Evidence Based Practice Information Sheets for Health Professionals. 2002 – Physical restraint Part 1 and 2, use in Acute and Residential Care facilities. • DOHA, 2004. 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)