View
26
Download
0
Category
Preview:
DESCRIPTION
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. Disclosures. Trained in the UK - PowerPoint PPT Presentation
Citation preview
The use of Physical Restraints in acute
medical careDr Lynn Alison Lambert
BSc., MB ChB, FRCP (UK) DTM&HConsultant Physician (GIM)
Foothills Medical Centre and University of Calgary
DisclosuresTrained 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
Not a new topic1980
“Restrained in Canada- Free in Britain”
Editorial in Health Care 1980, 22, 22
What are restraints?Any device attached or adjacent to the person
preventing free bodily movement
Common devicesVestsWaist beltsWrist and ankle tiesTip back chairs Fixed chair traysBedrails
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??
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
Why are restraints harmfulThey 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.
Principles of Biomedical Ethics
Autonomy
Beneficence
Non-maleficence
Justice (equity)
The use of restraints violates the first 3 of these principles
AutonomyBased 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??)
Beneficence and Non-maleficence
Beneficence requires us to do good 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
What are the harms from restraints? Physical
Direct impact: bruising, lacerations, nerve damage, ischaemic injury, asphyxiation, death by strangulation
Indirect impact from forced immobilisationDVT, pressure ulcers, incontinence, loss of muscle tone, loss of independence
What are the harms from restraints?
PsychologicalHumiliation anger depression demoralisation
What are the benefits of restraints?
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”
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
Alternatives to restraintsModify the treatment
Is the iv line, NG tube, iv drug, Foley catheter really necessary?
Sedate early and appropriately if requiredTreat alcoholics, drug users before symptoms are
out of controlPut in the hearing aid, put on the glasses,
introduce yourself, find someone who speaks the language
Alternatives to restraintsModify the environment
Better lighting (reduces confusion and agitation)Nursing assistant /family member with patientLow level bed/mattress on the floor (less far to fall)Modified rooms - hazards removedChoose the correct room for patient
Some better in a group setting, others need single room
Discuss it with nursing staffExplain why restraints are not part of your treatment
plan and stop them
Conclusion
Restraints have no place in modern internal medicine
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 Acta Psychiatrica 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
Recommended