Restraint Use and Patient Safety

Running head: RESTRAINT USE AND PATIENT SAFETY Restraint Use and Patient Safety: Nursing Care of Elderly Patients with Delirium in Acute Care Settings University of Massachusetts Boston 1 RESTRAINT USE AND PATIENT SAFETY 2 Abstract This capstone paper integrates the current clinical problem of delirium in the hospitalized elderly patient with the associated QSEN nursing competency of safety by addressing and exploring the following question: Among elderly inpatients with delirium in the acute care setting, does the nurse’s use of alternative, restraint-free approaches to care as compared to the use of physical restraints lead to increased patient safety? After an introduction of the problem and its significance to patient safety, a review of current research literature that addresses both the problem of delirium and its possible nursing interventions is presented. Next, a case example of a patient cared for by the author during her senior preceptorship on a general medicine floor at an acute care facility is presented and applied to the clinical problem. The paper then concludes with a discussion of implications for future nursing practice, patient education, and further research on the clinical problem. Keywords: delirium, elderly, acute care, nursing, physical restraints, safety RESTRAINT USE AND PATIENT SAFETY 3 Restraint Use and Patient Safety: Nursing Care of Elderly Patients with Delirium in Acute Care Settings Introduction Delirium is a common patient problem in the acute care setting, particularly among the elderly population. According to the United States National Library of Medicine (2015), delirium is a state of “sudden, severe confusion due to rapid changes in brain function that occur with physical or mental illness” and individuals who experience this acute change in mental status can often become agitated. The onset of delirium signals the presence of other serious medical conditions or illness and nurses must be able to identify delirium and intervene both quickly and appropriately to treat and manage it (Chong, Chan, Tay, & Ding, 2014). Restraint Use and Patient Safety

At times, in an effort to ensure the safety of both patient and nurse, physical restraints such as full bed rails, wrist and ankle restraints, or vests are used. Physical restraints are defined as “any device attached to or adjacent to a person’s body that cannot be controlled or easily removed by the person and deliberately restricts a person’s freedom of movement” (Kwok et al., 2012, p. 645). Such restraints should be viewed as a last resort intervention, as their use can itself become a safety issue, often causing the patient additional distress and potentially resulting in injury (Cosper, Morelock, & Provine, 2015). It is the duty of every nurse to provide his or her patients with the safest possible care; therefore, the need for restraints should be carefully evaluated and restraints used only if other less restrictive options are unable to support patient safety. Safety is a core nursing competency identified by the Institutes of Medicine and defined by the QSEN Institute (2014) as providing care in a way that “minimizes the risk of harm to patients and providers through both system effectiveness and individual performance”. Competent nurses should always strive to place patient safety at the center of their practice and RESTRAINT USE AND PATIENT SAFETY 4 therefore, in light of the aforementioned concerns, the use of physical restrains in current nursing practice should be explored by asking the following clinical question: Among elderly inpatients with delirium in the acute care setting, does the nurse’s use of alternative, restraint-free approaches to care as compared to the use of physical restraints lead to increased patient safety? To address this question, a review of current research literature that explores both the problem of delirium and related nursing interventions is presented, followed by the presentation of a case example that highlights the patient problem and a concluding discussion of implications for future nursing practice, education, and research on the issue. Review of the Research Literature Patient Problem The problem of delirium experienced by elderly patients in acute care settings is significant and well-documented in the literature. To appreciate the problem, it is first important to understand the incidence of hospitalization for elderly individuals. According to Krall et al. (2012), the elderly are defined as individuals who are 65 years of age or older and a group that accounts for 40 percent of acute care hospital admissions. This geriatric population has unique needs and common cognitive impairments such as dementia and delirium necessitate specialized care (Krall et al., 2012). Rice et al. (2011) noted that delirium is recognized as the most common complication experienced by the hospitalized elderly patient in the United States and accounts for 17.5 million extra days of inpatient stays annually. More than 2 million older American adults suffer from episodes of delirium every year and the estimated yearly costs of treatment and follow-up healthcare needs are anywhere from $38 to $152 billion (Rice et al., 2011). Research conducted in Singapore by Chong et al. (2014) found that delirium is a significant problem seen frequently in the elderly population in acute care hospitals; they report that 11-24% RESTRAINT USE AND PATIENT SAFETY 5 of elderly inpatients are admitted with delirium and 5-35% more develop the condition during the course of their hospitalization. According to Gillies, Coker, Montemuro, and Pizzacalla (2015) elderly patients often have preexisting dementia and go on to develop acute delirium during their hospital stay that can result in behaviors that are challenging for nurses to manage, such as verbal outbursts, escape or elopement attempts, and resisting necessary medical care or nursing interventions. A wealth of current evidence on the incidence of delirium among elderly acute care inpatients strongly supports the claim that it is a significant clinical problem. To further appreciate the problem of delirium in the hospitalized elderly population, it is vital to understand its potential outcomes and implications for patient safety. The American College of Physicians has recognized its clinical significance, noting that elderly patients who experience delirium are at greater risk for developing complications like pneumonia and pressure ulcers, and according to First, are three times more likely to be moved to a long term care facility, such as a nursing home, on discharge and suffer a decline in their overall health status (as cited in Aguirre, 2010). Restraint Use and Patient Safety

Further underscoring the seriousness of delirium as a clinical problem is the fact that the Agency for Healthcare Research and Quality has identified it as a key indicator of quality and safety in patient care (as cited in Rice, 2011). A study by Flaherty and Little (2011) reported that delirium is a problem that cannot always be prevented and has multiple detrimental sequelae for patients, including falls, injury, reduced capacity to perform activities of daily living (ADL), increased length of stay in the hospital, and higher mortality rates. Patients suffering from delirium require more intensive monitoring by nursing staff and have a 25-33% mortality rate in the acute care setting, as well as a 35-40% rate by one year after discharge (Chong et al., 2014). These patients need to be closely monitored in order to ensure their safety, an intervention that cannot always be achieved given typical nurse-patient staffing RESTRAINT USE AND PATIENT SAFETY 6 ratios (Flaherty & Little, 2011). A study by Cosper et al. (2015) noted that delirium often leads to agitation and the use of potentially dangerous physical restraints if it is not diagnosed and treated quickly. Current evidence clearly illustrates the significance of delirium as a clinical problem in the elderly and one that has particularly important implications for patient safety. Nurses caring for delirious patients must be able to implement the safest possible nursing interventions to protect said patients from injury until the delirium resolves. Nursing Interventions Nursing interventions for the management of delirium in elderly hospitalized patients in acute care settings are extensively documented in the literature. Studies of both physical restraint use and alternative, restraint-free approaches to care can be found. The decision to use restraints is often motivated by the nurse’s desire to ensure patient safety. A systematic review of the literature on nurses’ attitudes towards physical restraints conducted by Möhler and Meyer (2014) revealed that concern for patient safety is a common theme reported by registered nurses (RNs) caring for geriatric patients; despite having negative feelings about physical restraint interventions, nurses identify their obligation to uphold patient safety as paramount and the primary reason for using such restraints. Restraint Use and Patient Safety

Möhler and Meyer’s research showed that most nurses believe physical restraints will help prevent falls, injury, and interruptions of necessary medical interventions for delirious elderly patients; however, the study noted that this belief is also affected by nurses’ lack of knowledge regarding alternative approaches as well as the issue of high nurse-patient ratios. Möhler and Meyer also found that most nurses do not routinely question physical restraint use and view them as an accepted, common nursing intervention. A similar descriptive case study of nurses’ and nursing assistants’ opinions of physical restraint usage in older adults by McCabe, Alvarez, McNulty, and Fitzpatrick (2011) revealed RESTRAINT USE AND PATIENT SAFETY 7 that overall, nursing staff are neutral to the use of restraints, with nurses having a more negative opinion of their use than nursing assistants. McCabe et al. also found that overall, interference with therapeutic interventions was identified as the primary reason for implementing restraints although nurses in the emergency department used restraints primarily for protecting themselves and other staff from combative patients. According to McCabe et al., restraints continue to be used in an effort to promote patient and staff safety despite research that shows restraint usage can have unintended negative consequences for the patient, such as bone fractures and soft tissue damage, and actually increase the elderly patient’s delirium and risk for falls and fall injury. A case study by Krall et al. (2012) discussed the implementation of an Acute Care for the Elderly (ACE) unit in one acute care hospital; the goal of this intervention was to promote safe, patient-centered care to confused elderly patients with delirium or dementia. Krall et al. described the ACE unit as a dedicated six-bed area on a larger medical-surgical floor staffed by Geriatric Resource Nurses (GRNs), located close to all supplies and the nurses station, with patients being observed by at least one caregiver at all times and a policy of not using any physical restraints. Three months after the ACE unit’s implementation, none of its patients had experienced a fall, whereas six falls occurred on the larger unit (Krall et al., 2012). Restraint Use and Patient Safety

Other safety indicators included no pressure ulcer development among ACE unit patients, prompt removal of restraints from restrained patients transferred from other units, and a lower average length of stay of 3.18 days compared to 3.90 days for the general unit (Krall et al., 2012). From a qualitative perspective, both nurses and family members reported feeling that patients receive higher quality and safer care on the ACE unit (Krall et al., 2012). Although there is concern among nurses that avoiding physical restraints altogether is unsafe and could lead to delirious patients suffering a fall injury, the ACE model illustrates that restraint-free care can actually be safer. RESTRAINT USE AND PATIENT SAFETY 8 A similar case study by Flaherty and Little (2011) involved the use of a dedicated four bed restraint-free Delirium Room (DR) within an ACE unit in two different acute care hospitals; the DRs were designed to enable constant observation by nursing staff and thus support patient safety and eliminate the use of physical restraints. According to Flaherty and Little, the use of physical restraints on delirious elderly patients can exacerbate the severity of their delirium and should be avoided at all costs. Flaherty and Little found that a “tolerate, anticipate, and don’t agitate” approach in the DR led to better patient outcomes; by allowing patients to initially engage in unsafe behavior with the nurse close by, the nurse could identify the potential unmet needs that were the root cause of the unsafe behavior, such as climbing out of bed to void, and thus intervene to resolve the issue without the use of restraints (p. S297). Flaherty and Little’s study showed that a restraint-free environment does not lead to increased falls as some fear it could; just two falls were reported in the DR in one year and 28 were reported on the rest of unit. The study also showed that length of stay and mortality rates for delirious patients in the DR were comparable to those of non-delirious patients (Flaherty & Little, 2011). Restraint Use and Patient Safety

Again, research shows that the fear of restraint-free care leading to an increase in falls is unfounded and that patient safety is upheld in such an environment. Another case control study of one acute care hospital by Chong et al. (2014) compared the outcomes of elderly patients with delirium on a special Geriatric Monitoring Unit (GMU) to those in non-GMU areas of the hospital. According to Chong et al., the GMU is a unique five bed unit designed for the specialized care of elderly patients with acute delirium and has low nurse-patient ratios to support constant supervision. Results of the study showed that patients in the GMU experienced no application of physical restraints and saw a fall rate of 1.3% even though 80% of said patients were experiencing hyperactive or mixed delirium, while the non- RESTRAINT USE AND PATIENT SAFETY 9 GMU group had a much higher restraint usage rate of 23.1% and a fall rate of 2.6%, with fewer patients (64%) classified as having hyperactive or mixed delirium that can manifest as agitation and combativeness (Chong et al., 2014). Once more, current research suggests that caring for delirious patients in ways that do not involve physical restraints actually improves their outcomes and supports their safety. A case study by Cosper et al. (2015) involved a physical restraint reduction program that was piloted in four separate acute care hospitals; it was noted that although patient safety is improving and injury and mortality rates associated with restraint use have been declining since 2009, such incidents are still among The Joint Commission’s 15 most commonly reported sentinel events. The use of physical restraints is a safety concern and has been associated with numerous types of injury including soft tissue damage, neuropathy, ischemia, pressure ulcer development, increased falls and fall injury (Cosper et al., 2015). By securing the support of senior hospital administrators, having a restraint reduction leader on each unit, promoting interdisciplinary rounds on delirious patients as well as hourly nursing rounds, instituting twicedaily delirium screenings, providing staff education on physical restraint usage (including legal and ethical considerations and potentially negative sequelae), and making restraint-free alternatives like bed alarms more readily available, the two larger hospitals saw a decrease in restraint use from 5.87% to 1.73% over two years and the smaller hospitals declined to 0% and 1.95% (Cosper et al., 2015). Study results also showed that neither fall rates nor rates of patient self-extubation increased after the use of patient restraints declined (Cosper et al., 2015). In light of this evidence, committing to restraint-free approaches to delirium management and obtaining multidisciplinary support for their use are clearly important steps that nurses can take to protect the safety of their patients. RESTRAINT USE AND PATIENT SAFETY 10 Finally, a retrospective case study by Kwok et al. (2012) found that a similar restraint reduction initiative in a large acute care hospital in Hong Kong led to a shorter length of stay in the facility for cognitively impaired patients, including patients with delirium. Kwok et al. noted that length of stay is often used as an indicator of quality care and so far no evidence exists to show that discharging patients sooner leads to negative outcomes or safety issues. Results of the study showed that from 2007 to 2009, the use of physical restraints with cognitively impaired patients decreased from 24.5% to 9%, the average length of stay decreased from 17 days to 14 days, and fall incidents decreased slightly from 1% to 0.5% (Kwok et al., 2012). Restraint Use and Patient Safety

Once again, the lack of physical restraints has been demonstrated to positively impact the safety of the delirious patient. After a thorough review of current research evidence it becomes clear that implementing restraint-free approaches to the management of delirium in elderly acute care patients protects the safety of said patients and demonstrates excellence in nursing care. Case Example The author is currently completing a nursing preceptorship on a 25 bed general medicine unit at Massachusetts General Hospital. The unit cares for patients with a wide variety of medical diagnoses but often admits patients with delirium, the majority of them elderly, for medical workup and resolution of their acute mental status changes. At times, such patients with altered mental status become agitated, combative, or repeatedly attempt to get out of their beds, thus placing themselves and their nurses in unsafe situations and at risk for injury. As a result, physical restraints such as soft wrist and ankle restraints are used to keep the patient in bed when nurses or other personnel are unable to be at the bedside around the clock to intervene and redirect the patient. RESTRAINT USE AND PATIENT SAFETY 11 On a night shift, a 76 year old male was admitted to the unit with the diagnosis of delirium after having arrived to the emergency department from a long term care facility with hyperglycemia (blood glucose in the low 400s) and an acute change in mental status. In the emergency department, where he stayed for several hours, the patient received insulin and was then sent to the unit for further monitoring and diagnostic workup of his delirium. The patient’s medical history included diabetes mellitus, recurrent urinary tract infections, hypertension, and multiple falls. Restraint Use and Patient Safety

Given his history of falls and current delirious state, the patient was placed on fall precautions, which included padded floor mats and the use of a bed alarm. Due to his need for a private room with contact precautions and bed availability constraints, the patient was not placed in a room close to the nurses’ station; however, frequent safety checks were made. Although he was confused, the patient was initially pleasant and relatively cooperative with care and, when not, was easily redirected. However, as the shift progressed he became increasingly agitated. The patient repeatedly attempted to get out of bed and was no longer responding to redirection; he began yelling and cursing at the nurses, refusing care, and attempting to remove necessary equipment such as his cardiac monitoring leads, oxygen saturation probe, and intravenous lines. In his confused state, the patient was convinced he was being held against his will without reason and that he needed to either go home to his mother or get dressed and go to work. Unfortunately, the patient had no family o …Restraint Use and Patient Safety