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