Over-Restaining Patients

nursesarah · Jul 23, 2006

i would die if my hospital instituted a zero restraint policy. on my floor we get a nice mix of confused/dementia patients, and drug/alcohol withdrawal. we had a patient come up from the ER in 5-point restraints and we kept him that way for 2 days while he came down off his high. it was more for the safety of the staff, as opposed to his own safety. he was very violent while he was high on these drugs.

i've had patients i've had to put in wrist restraints because they pull out their IVs and catheters. becuase of the conditions they are in, they need the fluids, and they do damage to themselves by pulling these things out (it's very messy when a man pulls out a catheter with the balloon fully inflated).

but i guess ultimately, the use of restraints in these situations are temporary because we are an acute setting, not long term. i cant imagine restraining someone for an excessive period of time. that's when you need to look at other options.

chadash · Jul 23, 2006

i would die if my hospital instituted a zero restraint policy. on my floor we get a nice mix of confused/dementia patients, and drug/alcohol withdrawal. we had a patient come up from the ER in 5-point restraints and we kept him that way for 2 days while he came down off his high. it was more for the safety of the staff, as opposed to his own safety. he was very violent while he was high on these drugs.
i've had patients i've had to put in wrist restraints because they pull out their IVs and catheters. becuase of the conditions they are in, they need the fluids, and they do damage to themselves by pulling these things out (it's very messy when a man pulls out a catheter with the balloon fully inflated).
but i guess ultimately, the use of restraints in these situations are temporary because we are an acute setting, not long term. i cant imagine restraining someone for an excessive period of time. that's when you need to look at other options.

I agree that restraints are just a unfortunate fact of life in a hospital setting. In that environment, you just don't have the ability to supervise the patient as you do in long term care. Long term care allows for long term solutions. You can manage a problem in many creative ways.

If a family member is uncomfortable with a restraint, suggest they hire a sitter. I sat all night with one of my home patients holding her hand so she would not pull out the IV. The patient was very peaceful and content. She had some dementia and was frightened by the wrist restraints.

Unfortunately, some families just can not provide this. For safety, you just have to do restraints.

mlnrs1 · Jul 23, 2006

Ok this is going to sound horrible but there are times where I miss restraints. Not for my convenience but sometimes, they are needed for patient safety. We have a ZERO restraint policy and we get yelled at just for putting both siderails up on a bed. We've been able to reword some things, like lap buddy's being an assistive device (they're listed as restraints at our facility). One doc thought it was used to restrain someone until he saw the resident without it and realized that she constantly leaned forward in her chair and it really was necessary not only for her safety, but also for her comfort. Without it she leaned across her overbed table all day. I miss the days of being able to use a soft vest for someone in a chair. Instead we've become experts at the one second sprint across the unit to catch someone who thinks they can still stand unassisted. Had to send a pt to the ER the other night because her mind refuses to wrap around the fact that she needs help transferring. I agree that restraints, as a whole, should be avoided at all costs but sometimes they truly are necessary.

I worked in LTC in Florida, and we called it the "Right to Fall". As for the "one second sprint" to catch somebody, I've done it too, but with the corporatization of LTC (cut-save-cut-save-slash-cut-save-transfer liability to the nurse), places are so chronically under-staffed that it is impossible to keep elderly/confused residents from falling.

I've worked in so many places where the most obvious sign of this is nursing stations that sit empty... just gutted, no phones, files, etc., they usually serve as a CNA lounge. What that empty nursing station says is that somebody at some point (who had more than the bottom line in mind) designed the facility to have xx number of patients per nurse (or per nursing station). But then when PowerGreedCare, Inc. came along and bought it they decided that they could save money by cutting the number of nurses (and nursing stations).

The surge in patients rights legislation and this corporatization happened at about the same time. It's a dangerous combination.

banditrn · Jul 24, 2006

I worked in LTC in Florida, and we called it the "Right to Fall". As for the "one second sprint" to catch somebody, I've done it too, but with the corporatization of LTC (cut-save-cut-save-slash-cut-save-transfer liability to the nurse), places are so chronically under-staffed that it is impossible to keep elderly/confused residents from falling.
I've worked in so many places where the most obvious sign of this is nursing stations that sit empty... just gutted, no phones, files, etc., they usually serve as a CNA lounge. What that empty nursing station says is that somebody at some point (who had more than the bottom line in mind) designed the facility to have xx number of patients per nurse (or per nursing station). But then when PowerGreedCare, Inc. came along and bought it they decided that they could save money by cutting the number of nurses (and nursing stations).
The surge in patients rights legislation and this corporatization happened at about the same time. It's a dangerous combination.

Hey!! I think that's the corporation I'm working for right now!!:rotfl:

nursespike · Jul 24, 2006

New here ...interesting and double edged topic. I currently run the restraint reduction team at the facility I work for. The development of this "team" was done to keep track of and review all patients that had any sort of restraint/device in use. We review psych meds as well or any other med that can contribute to falls. We do not always do reductions, and I ALWAYS have to do a monthly report (for QA). We will never be "restraint" free, that's not our goal, but we won't be using restraints for the wrong reasons either.

It sounds like you need to educate alot of people...start small...start a review committee...educate, educate, educate. You are going to have falls, sooner or later. The results of misused restraints are far worse than a fall and could result in the death of your patient. If you start a review committee, at least you will know who has what and why. You can ensure that all documentation and education is in place on the chart (therapy review, SS issues, behaviour issues, etc.). This way if you have an annual survey and they pick up on heavy restraint use you will have everything in place.

Hope this helps.. :mad:

achot chavi · Jul 25, 2006

I agree that some residents r/t their disease process cannot process that even though they walked their entire life upto now without falling that they cannot do it anymore, safely. I also agree that some restraints could be used for safety. But the states and federal system had to institute some kind of guideline to keep residents from being restrained unnecessarily. And it did start years ago when the states were pressured to keep residents safe. However, I think it is way out of proportion now, and it is hard to keep them safe. You can careplan and document with the ID team and get restraints with in reason for specific residents but it has to be documented with a full assessment and justification and a Drs. order.
Restraints are a big F-tag if not documented appropriately and used justly. Most managers just donot want to take the risk. tinkle

The problem is understaffing or lass than ideal staff to patient ratio.

achot chavi · Jul 25, 2006

this is a hot issue in healtcare. here are some websites of groups that are studying the problem and trying to find solutions that you might be interested in investigating. medicare will become directly involved in the issue when it involves medicare or mediaid beneficiaries. the idea is for facilities to do the right thing and work to solve these problems without waiting for laws to be passed. have you thought about doing some research on this and presenting evidence to your boss with suggestions on how to improve the patient falls in your facility?
http://www.cdc.gov/ncipc/duip/spotlite/falfacts.htm - national center for injury prevention and control. there are links here to facts about preventing falls, publications, statistics. click on "falls and hip fracture among the elderly" under fact sheets for information and references on this topic. also, suggest you explore the links under the tool kit for more information on preventing falls
http://www.macoalition.org/documents/restraintprojectbackground-overview.pdf - massachusetts coalition for the prevention of medical errors: best practice recommendations to improve patient safety related to restraint & seclusion use. http://www.macoalition.org/documents/restraintprinbestprac-definitions-final.pdf - this is the site where they list their conclusions regarding principles to improve patient safety related to restraint and seclusion use.
http://www.charlydmiller.com/lib05/1998hartfordinvestigation.html - deadly restraint: a hartford courant investigative report on the death of an 11-year old patient in a psychiatric hospital from restraint asphyxia. this is a complete report of the investigation.
http://www.charlydmiller.com/lib02/1998jcahoalert.html - jcaho sentinel event alert paper on preventing restraint deaths. includes strageties for reducing risks.
http://www.charlydmiller.com/ra/ralibrary.html#hartcourant - restraint asphyxia library. a list of links to information about restraints and asphyxia related injury.
http://www.mywhatever.com/cifwriter/content/66/4376.html - oregon restraint reduction project.
http://www.patientsafety.com/links.ps.html - patient safety. links to information about patient safety. includes falls.

thanks these were very helpful. i had once googled and found some of them but i guess the bottom line is that our don, med director and adm really want to boast a zero-falls-at-any-cost-facility. they are convinced and have convinced families that a fall will be costly and life threatening (true) and must be prevented even at the risk of curtailing himan rights to freedom. my don was a nursing instructor for years and has excellent connections so the inspectors look away and even oooh and aaah over the low fall statistics (which is my responsibility)

i was just looking for more ideas like wedge cushions and lap buddies to discourage falls without "restraints".

thanks a lot for your research i'm sure i will use it on my next inservice on restraints

Meerkat · Jul 25, 2006

The SAMHSA has a free training module on on CD to reduce restraint use. It is geared for mental health patients, but you may find it useful.http://www.samhsa.gov/news/newsreleases/060601_seclusion.htm

imisscoco · Jul 26, 2006

I hope when I get old and in the NH that someone will have pity on me and help me to lay down on my bed instead of making me sit up in a chair all day or have to sit up straight with a thing in front of me or lean over an overbed table.
Could this be the reason that some patients might be trying to get out of their chairs? Ya think?

I worked in a geripsych LTC facility for 8 years. so many patients were restrained after one fall it was pathetic. Once they are in that straight backed chair, they are in it for sometimes up to 16 hrs. a day. They are supposed to be released and toileted every 2 hrs. but often that didn't happen, especially if they were briefed. For dignity, ha! How dignified is it to spend your life sitting upright in a chair. And for those who tried to climb out of bed, they would be restrained sometimes for 24 hrs. I tried to fight with administration about this many times over. I finally decided to go back to school to get my masters and am about to sit for the GNP boards. I hope then I can get a position with a facility where I can educate the staff and make a difference for these poor folks that end their lives in this tragic condition. And by the way, this place got more than one perfect survey. Don't know how.

chadash · Jul 26, 2006

I worked in a geripsych LTC facility for 8 years. so many patients were restrained after one fall it was pathetic. Once they are in that straight backed chair, they are in it for sometimes up to 16 hrs. a day. They are supposed to be released and toileted every 2 hrs. but often that didn't happen, especially if they were briefed. For dignity, ha! How dignified is it to spend your life sitting upright in a chair. And for those who tried to climb out of bed, they would be restrained sometimes for 24 hrs. I tried to fight with administration about this many times over. I finally decided to go back to school to get my masters and am about to sit for the GNP boards. I hope then I can get a position with a facility where I can educate the staff and make a difference for these poor folks that end their lives in this tragic condition. And by the way, this place got more than one perfect survey. Don't know how.

You are my hero!

Please educate your staff about repositioning their patients at least every two hours, varying their activities, while respecting the patients desires. Even a patient who really really wants to stay in that ol' chair all day needs to be lifted out every two to release the pressure and to change their depend. Ugh! I can rant on and on about preventing pressure sores and just plain putting a bit of variety into the day! the idea that if they dont need toileted they dont need moved is scary:a wet depend just increases the risks!

And there, looming in the background of every care issue, is that ever

present spector of "UNDERSTAFFING"....

Restraints, though sometimes needed, can not replace your CNAs.

Diligence is needed to prevent pressure sores.

I am a women with an obsession. Sorry. You guys know multiples more than I will ever know about this, I am just ranting and raving.

My point being, this is not an all or nothing thing. Always: what is best for this particular patient, and, dog gone it, dont save money by understaffing. I am very uncomfortable with "lets tie them all down" as well as a no restraint no matter what policy. Just seems overly simplistic.

steelydanfan · Jul 26, 2006

I hope that when I get old someone will give me "the shot" instead of sticking me in a buddy chair in some nursing home!

achot chavi · Jul 26, 2006

The SAMHSA has a free training module on on CD to reduce restraint use. It is geared for mental health patients, but you may find it useful.http://www.samhsa.gov/news/newsreleases/060601_seclusion.htm

VERY HELPFUL- Mucho Gracias :monkeydance: