Preventing belt restraint use in newly admitted residents in nursing homes: A quasi-experimental study

Abstract

Background

Physical restraints are commonly used in psychogeriatric nursing home residents despite reports of negative consequences. Most research has focused on restraint reduction without addressing methods to prevent initiation of restraints in nursing homes. EXBELT has been found to decrease belt restraint use but should also be evaluated for its use in preventing restraints.

Objective

To investigate the effectiveness of the EXBELT intervention to prevent the use of belt restraints on psychogeriatric residents newly admitted to nursing homes.

Design

Quasi-experimental study design.

Setting

Twenty-six nursing home wards from thirteen Dutch nursing homes.

Participants

Newly admitted residents (n = 104) during a four month period.

Interventions

Fifteen wards (intervention group) implemented the EXBELT intervention, which consisted of four components: a policy change, education, consultation and the availability of alternative interventions.

Methods

Data on the use of belt restraints, other types of physical restraints, falls and fall-related injuries and psychoactive drug use were collected at T2 (4 months) and T3 (8 months) after baseline (T1) for those resident who were newly admitted after baseline and before T2 (4 months). Physical restraint use data were collected by a trained, blinded observer four times during a 24-h period.

Results

A total of 104 residents were newly admitted after baseline (T1) and before T2. Of those, 82 were present on T2 and T3. Informed consent was obtained from legal representatives of 49 out of the 82 residents. In the control group (n = 20), 15% and 20% used belts at T2 (4 months) and T3 (8 months), respectively. In the intervention group (n = 29), these proportions were 3% and 0%, respectively (OR = 0.08; 95% CI (0.01–0.76); p = 0.03). There was no increase in the intervention group in the use of other physical restraints, falls and fall-related injuries or psychoactive drug use.

Conclusion

The EXBELT intervention effectively seems to prevent the use of belt restraints in newly admitted residents in psychogeriatric nursing homes.

Introduction

Of the estimated 235,000 people suffering from dementia in the Netherlands, about 40,000 reside in psychogeriatric nursing homes (Alzheimer's and Association, 2010). Psychogeriatric nursing homes are institutions providing nursing care 24 h a day, assistance with activities of daily living and mobility, psychosocial and personal care, paramedical care, such as physiotherapy and occupational therapy, as well as room and board (Ribbe et al., 1997). They mainly serve very frail, older adults with psychogeriatric disorders, especially people with dementia, that affect autonomous personal care, mobility, continence, and cognitive functioning (Schols and Van der Schriek-van Weel, 2006). Physical restraints are often used in this population; estimates range from 15% to 66% (Capezuti et al., 2007, Hamers et al., 2004, Huizing et al., 2006). The large variance in prevalence estimates can be explained by the usage of different definitions of physical restraint use (e.g. in some studies bedrails were excluded as a physical restraint measure) and differences in data collection methods (resident observations versus questionnaires to nursing home staff about restraint use), next to differences in national restraint policies and characteristics of nursing homes and their residents.

Poor mobility, high dependency and impaired cognitive status are the strongest predictors of restraint usage (Burton et al., 1992, Capezuti, 2004, Gallinagh et al., 2002, Hamers et al., 2004, Sullivan-Marx et al., 1999). Several studies demonstrated that in almost all cases, physical restraints are used as safety measures (Capezuti, 2004, Hamers et al., 2004, Werner, 2002), mainly to prevent falls (more than 90%) (Capezuti, 2004, Hamers et al., 2004, Werner and Mendelsson, 2001). Other uses include the prevention of wandering, the control of restless and aggressive behaviour and maintenance of a resident's position while seated in a chair (Capezuti, 2004, Castle et al., 1997, Gallinagh et al., 2002, Hantikainen, 1998, Ryden et al., 1999). In nursing homes physical restraints in most cases are used for more than three months and as a routine measure (Hamers et al., 2004). It seems that it is difficult to remove physical restraints once they are deployed. Many negative physical, psychological and social consequences of restraint use have been reported, such as problems with balance and coordination, incontinence, demoralisation, depression, aggression and impaired social functioning. The use of restraints may even increase the risk of serious injury and death (Evans et al., 2003, Healey et al., 2008, Miles and Irvine, 1992, Mohler et al., 2011). In the light of the accumulating evidence regarding the adverse consequences of physical restraint use, their use should be recognized as inappropriate (Hamers et al., 2004, Hamers and Gulpers, 2009, Meyer et al., 2009, Sullivan-Marx, 2001). In addition, physical restaints usage affects human rights which should enable us live full lives with maximum dignity and respect (Hughes, 2008).

Knowing that the use of physical restraints has been shown to be ineffective and sometimes even hazardous, attention must be focused on interventions that can effectively reduce current usage as well as prevent initiation of restraints in newly admitted residents. Up until now, however, attention has mainly focused on the reduction of physical restraint use. Only one study (Huizing et al., 2009b) reported on the prevention of physical restraint use in newly admitted residents. In this study, an educational programme combined with consultation provided by a nursing specialist did not prevent the use of physical restraints in newly admitted residents to psychogeriatric nursing home wards (Huizing et al., 2009b). Most studies that aim to reduce restraint use also have mostly used education and consultation interventions. In studies that aimed to reduce restraint use, in general the most frequently used interventions were also education and consultation. The results of these studies are conflicting: some reported positive effects (Evans et al., 1997, Testad et al., 2005), while others found no effect (Evans et al., 1997, Huizing et al., 2006, Testad et al., 2010). Recent studies confirmed that education alone is not enough to ensure a reduction in the use of restraints (Huizing et al., 2009a, Pellfolk et al., 2010, Testad et al., 2010). The availability of alternative interventions seems to be an important additional prerequisite for eliminating restraint use (Becker et al., 2003, Capezuti et al., 1999, Freeman, 2004, Hoffman et al., 2003). In some countries such as Denmark, Scotland and the US belt restraint use is only permitted under strict conditions (Hamers and Huizing, 2005). These measures seem to have contributed to a reduction in restraint use in these countries (Bower et al., 2003, Castle, 1998, Castle, 2002, Dunn, 2001). However, the challenge of finding the ideal combination of interventions to avert the use of physical restraints from clinical practice still remains (Hamers and Huizing, 2005).

Based on the outcomes and implications from previous studies we developed a comprehensive strategy called the EXBELT intervention to reduce and prevent initiation of the use of belt restraints. The strategy includes a policy change, education, consultation and the availability of alternative interventions. The implementation of the EXBELT intervention resulted in a 50% reduction in belt use (odds ratio = 0.48, 95% confidence interval = 0.28–0.81; p = .005) (Gulpers et al., 2011). The aim of the present study was to examine the effect of EXBELT intervention on the prevention of belt restraint use in newly admitted residents of psychogeriatric nursing home wards.