Care indicators - Physical restraints

Physical restraints

Physical restraints are resources or interventions that are applied, with or without the client’s permission, to limit a client’s autonomy, freedom of movement and behaviour. In the LPZ measurement these resources and measures are only defined as restraints if clients cannot remove or undo the resource or intervention on their own.
Methods applied in clinical practice involve physical measures such as side rails on beds, nursing blankets, belt restraints, beds and chairs with integrated table-tops, wheelchair brakes, deep chairs, isolation, and non-physical measures such as domotics (e.g. infrared warning systems), behaviour-influencing medication (such as calming medication) and individual measures. In most cases, however, this involves securing residents or patients with waist straps. This is regarded as a highly restrictive measure and is strongly advised against.

Resources or measures are used in unforeseen and acutely dangerous situations. Unfortunately they are applied more often than strictly necessary. They can result in both physical and psychological damage. Negative consequences can include: causing incontinence, pressure ulcers, contractures, depression, aggression and agitation. Moreover, physical passivity leads to a strong deterioration in cognitive ability, sleep-wake rhythms and mood among residents (Hamers et al. 2009; Scherder et al. 2009).

For details on the careful use of physical restraints within the legal framework we refer to the CBO guideline ’Het gebruik van vrijheidsbeperkende interventies in de zorg.’ (The use of restraints in care situations.) For the Home Care and Nursing sector we refer to the new quality framework expected in January 2016.

In 2015 physical restraints are applied in general hospitals, in special housing, care and welfare institutions and in home care for 2.9%, 30.3% and 0.2% of the clients respectively. The incidence of injuries relating to physical restraint is 0%. In general hospitals and in special housing, care and welfare institutions, physical restraints are almost always used to prevent falls and injuries resulting from falls (62.5% and 66% respectively). Nonetheless, the use of immobilising measures is undesirable because in the longer term the risk of falling is actually increased (strong reduction in muscle mass due to muscles not being used and reduced balance due to the patient not standing and walking). This creates a vicious circle, because when the resident falls again this is seen as confirmation that physical restraint is the right solution. Moreover, the risk of serious injury (such as a hip fracture) is overestimated by healthcare providers, as the injury risk among frequent fallers (who are much more likely to be tied down) is actually lower than among residents who seldom fall. There are much more humane fall-preventing measures that can replace physical restraint (Capezuti et al. 2002; CBO, 2004; Neyens 2007; Gulpers 2013). Research at Maastricht University has led to the effective EXBELT method. The key elements of this intervention include a ‘ban’ on the use of straps, additional training for healthcare providers (doctors, paramedics, nursing staff, care providers) and the availability of alternative interventions (such as a low bed, an infrared system, domotics) tailored to the individual resident. This has shown that education can strongly reduce the use of immobilising measures without this having negative consequences. In the Netherlands an increasing number of nursing homes are applying a non-restraint policy. An overview of these institutions can be found at www.innovatiekringdementie.nl and www.zorgvoorbeter.nl.

Incidence measurement for physical restraints

The LPZ measurement measures the incidence of physical restraints over a period of 30 days. In addition the applied physical restraints and the reasons for use are charted. An institution can use the results of this incidence measurement to see where policy improvements can be made or have already been achieved. By annually measuring the incidence of physical restraints, care organisations can evaluate and monitor their interventions and thus continue to deal with the issue of physical restraints within the institution with sufficient continuity.

Figure 1 gives an overview of the application of physical restraints in general hospitals (red), special housing, care and welfare institutions (blue) and home care (green) in the period 2007–2015.

Incidence of physical restraint in 2007-2015
Fig.1 Incidence of physical restraint in 2007-2015 (%) (Halfens et.al. 2015)

References

  • Capezuti, E., Maislin, G., Strumpf, N., Evans, L.K. 2002. Side rail use and bed-related fall outcomes among nursing home residents. Journal of the American Geriatrics Society 50, 90-96.
  • Capezuti, E. 2004. Minimizing the use of restrictive devices in dementia patients at risk for falling. Nursing Clinics of North America 39, 625-647.
  • CBO. 2001. Richtlijn vrijheidsbeperkende interventies in de zorg. Utrecht, CBO.
  • CBO. 2004. Richtlijn Preventie van valincidenten bij ouderen. Utrecht, CBO.
  • Engberg, J., Castle, N.G., McCaffrey, D. 2008. Physical restraint initiation in nursing homes and subsequent resident health. The Gerontologist 48, 442-452.
  • Evans LK, Strumpf NE, Allen Taylor SL, Capezutti E, Maislin G, Jacobsen B. 1997. A clinical trial to reduce restraints in nursing homes. J Am Geriatric Society 45: 675-681.
  • Gulpers, M. 2013. EXBELT: Expelling belt restraint from psychogeriatric nursing homes. Maastricht, Universiteit Maastricht (academisch proefschrift).
  • Halfens RJG, van Nie NC, Meijers JMM, Meesterberends E, Neyens JCL, Rondas AALM, Rijcken S, Wolters S en Schols JMGA (2014). Landelijke Prevalentiemeting Zorgproblemen Rapportage resultaten 2014. Maastricht University. ISBN 978-94-90411-04-6
  • Hamers, J.P.H., Gulpers, M.J.M., Strik, W. 2004. Use of physical restraints with cognitively impaired nursing home residents. Journal of Advanced Nursing 45, 246-251.
  • Hamers, J.P.H., M.J.M. Gulpers, M. Bleijlevens, A.R. Huizing, E.J. Scherder, H. Houweling en E. Van Rossum. 2009. Het reduceren van vrijheidsbeperking in verpleeghuizen. Tijdschrift voor Ouderengeneeskunde 34,156-9
  • IGZ 2008. Zorg voor vrijheid: terugdringen van vrijheidsbeperkende maatregelen kán en moet. Den Haag, IGZ.
  • Neyens, J. 2007. Fall prevention in psychogeriatric nursing home residents. Maastricht, Universiteit Maastricht (academisch proefschrift).
  • Neufeld RR, Libow LS, Foley WJ, Dunbar JM. Cohen C, Breurer B. 1999. Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatric Society 47: 1202-1207.
  • Pellfolk TJ, Gustafson Y, Bucht G et al. 2010. Effects of a restraint minimization program on staff knowledge, attitudes, and practice: a cluster randomized trial. Journal of the American Geriatrics Society 58: 62-69.
  • Scherder, E., Bogen, Th., Eggermont, L., Hamers, JPH, Swaab, D. 2010. The more physical inactive, the more agitation in dementia. International Psychogeriatrics 22: 1203-1208.

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