The use of Physical Restraints in acute medical care

1. The use of Physical Restraints in acute medical care Dr Lynn Alison Lambert BSc., MB ChB, FRCP (UK) DTM&H Consultant Physician (GIM) Foothills Medical Centre and University of Calgary

2. Disclosures • Trained in the UK • Never used restraints in 26 years of UK practice in GIM, elderly care and acute admission wards • Am fundamentally opposed to the use of restraints

3. Not a new topic • 1980 • “Restrained in Canada- Free in Britain” • Editorial in Health Care 1980, 22, 22

4. What are restraints? • Any device attached or adjacent to the person preventing free bodily movement • Common devices • Vests • Waist belts • Wrist and ankle ties • Tip back chairs • Fixed chair trays • Bedrails

5. Who gets them? • Old people • Confused people • People who don’t speak English • ICU patients • children • 6-25% of patients depending on type of unit assessed (12-47% in residential care) • Your patients??

6. Why are patients restrained? • Cultural reasons • “everybody does it” “what else would you do?” “we always do it this way” • Paternalism • “this treatment is good for you and you will have it” • “prevention of interference with therapeutic devices” • Laziness • easier than thinking of alternatives • “ward is short staffed” • Fear of legal action if not used • “maintains patients safety” • Belief that it is safe and provides benefits

7. Why are restraints harmful • They are unethical and harm the user as well as the patient • Physical harm to the patient • Psychological harm to the patient • Upsetting to relatives • European Committee for the Prevention of Torture and Inhumane and Degrading Treatment or Punishment states that application of restraints amounts to ill treatment.

8. Principles of Biomedical Ethics • Autonomy • Beneficence • Non-maleficence • Justice (equity) • The use of restraints violates the first 3 of these principles

9. Autonomy • Based on the principle of respect for persons • Patient or surrogate should give informed consent to treatment • Physician should take into account expressed wishes of patient where consent cannot be given • If no expressed wishes & no surrogate then determine what a patient would prefer • (Do your patients prefer to be tied down??)

10. Beneficence and Non-maleficence • Beneficence requires us to dogood or to further the patients interest • Non-maleficence requires us to avoid doing harm to the patient • Where there is a conflict between the 2 principles the principle of doing no harm takes priority

11. What are the harms from restraints? Physical • Direct impact: • bruising, lacerations, nerve damage, • ischaemic injury, • asphyxiation, death by strangulation • Indirect impact from forced immobilisation • DVT, • pressure ulcers, incontinence, • loss of muscle tone, loss of independence

12. What are the harms from restraints? • Psychological • Humiliation • anger • depression • demoralisation

13. What are the benefits of restraints?

14. Assumed benefits of restraints • “Falls prevention” • Studies show no difference in falls rates • Harm can be greater if patient climbs over cotsides (bed rails) and falls from greater height • Nurses have false sense of security that patient can’t move and won’t fall so check less often • Patient muscles weaker when restraints removed and therefore more likely to fall afterwards • “iv lines and NG tubes last longer”

15. What are the alternatives to restraints? Look for and treat the underlying cause of the confusion or agitation: • Hypoxia • pain, • infection • constipation, • opioid analgesics • drug or alcohol withdrawal

16. Alternatives to restraints • Modify the treatment • Is the iv line, NG tube, iv drug, Foley catheter really necessary? • Sedate early and appropriately if required • Treat alcoholics, drug users before symptoms are out of control • Put in the hearing aid, put on the glasses, introduce yourself, find someone who speaks the language

17. Alternatives to restraints Modify the environment • Better lighting (reduces confusion and agitation) • Nursing assistant /family member with patient • Low level bed/mattress on the floor (less far to fall) • Modified rooms - hazards removed • Choose the correct room for patient • Some better in a group setting, others need single room • Discuss it with nursing staff • Explain why restraints are not part of your treatment plan and stop them

18. Conclusion • Restraints have no place in modern internal medicine

19. References • Bak,J, Brandt-Christensen,Sestoft and Zoffman,. Mechanical restraint- A systematic Review. Perspectives in Psychiatric care 2012 48 83-94 • Steen, O., Opjordsmoen, S. Thrombosis associated with physical restraint ActaPsychiatrica Scand 2001 103 73-76 • Cheung,P., Yam, B., Patient Autonomy in Physical restraint, 2005, Journal of Clinical Nursing, 14 3a34-40 • Lofgren et al, 1989 AJPH79,735-738 • Langley, G. Schmollgruber,S., Egan, A. Intensive and critical Care, 2010 Restraints in Intensive care units • Beauchamp and Childress. Principles of Biomedical Ethics. Oxford Med Press • Rutledge ,DN, Donaldson, NE, Pravikoff, DS Use of restraints The online journal of clinical innovation 2003 6(2) 1-6