How to do it... Physical restraints

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EDITOR'S NOTE: Point 4 of this article has been modified from its original version to clarify speakers' comments.

Since passage of healthcare reforms in OBRA 1987, the incidence rate of resident restraints has dropped considerably, to less than 5%, with a mantra to lower it further. Still, there are instances when physical restraints are valid and proper. Caregivers must strike a balance between residents' rights to be free of unnecessary physical and chemical restraints and the need for safety. Experts tell how here.

1. First, come to grips with the dangers of unnecessary physical-restraint use. 

Restraints can result in loss of mobility and strength, stiffness, lower bone mass, incontinence or constipation, agitation, depression, and loss of dignity and selfrespect. Restrained residents in supine or prone positions also add risks of aspiration and suffocation, respectively. 

Moreover, there is clear evidence that restraints do not lower the risk of falls. It wasn't that long ago that this was not commonly known or discussed. 

“When I was a nursing assistant back in the '80s, before OBRA '87, it was common practice to tie residents in wheelchairs to the hand rails in the hallways, as well as lock their wheelchairs because it limited their movement,” recalls Debi Damas, RN, group product manager, postacute care, for Relias Learning. 

2. There are, in fact, quite valid and acceptable reasons for using restraints. Residents prone to violent behavior or those who risk serious personal injury when ambulating top the list. But there are others. 

“When a resident is receiving medical care such as IV antibiotics and attempts to pull out the tubing, it may be appropriate to place a mitt on the opposite hand,” notes Patricia Howell, RN, a member of McKesson's Clinical Resource Team. Howell urges, however, to exhaust other non-restraint methods first. Even nurses who face injury from an aggressive resident are advised to remove themselves from the situation before considering a restraint. 

“The facility should use evidence- based care and avoid the use of restraints whenever possible,” Howell says. 

3. The American Nurses Association recommends that devices be applied safely and appropriately. The resident should be assessed and monitored, as well as comforted and reassured. 

Mary Madison, RN, clinical consultant, long-term care/senior care assisted living for Briggs Healthcare, advises that nursing home staff fully understand regulatory language that ties restraint use with specific medical symptoms. 

“Even today, we are somewhat left twisting in the wind,” she notes. Relias Learning's Damas agrees: “There needs to be a clear medical symptom present or the resident has self-injurious behavior to justify the need for a restraint.” 

4. Recognize there are a host of effective "subtle restraints." Howell's list includes bed/chair alarms preventing rising, low beds, secured units, lockable wheelchairs, and simply placing beds against walls and chairs against tables. Others include “bedrails to wedge cushions to posture vests,” adds Damas. “It's important to remember it's not the device itself that is the restraint. It is the effect it has on the person it is being used on.” 

5. Though patient safety and care are paramount, facilities should take any and all measures to minimize their exposure to liability. 

A recent Health and Human Services report strongly advises thorough assessments that justify the need for their use; a complete facility awareness of why and with whom restraints are being used; as well as documentation on restraint use and reduction, including residents' consent to have restraints removed. The OIG also advises close collaborations with physicians and pharmacists (for chemical restraints). 

It's critical to evaluate each resident individually, Madison cautions. “Each restrained resident's medical record and care plan should very clearly map the progression of things like restraint evaluation, past interventions, conversations and informed consent, leaving no doubt in any reviewer's mind that due diligence was and is in progress so that each resident attains/maintains the highest practicable well-being,” she says.