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21-05-2012 | Hospice medicine | Article

Intervention addresses restraint overuse in nursing homes

Abstract

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MedWire News: A multifaceted evidence-based intervention has shown promise for reducing the use of physical restraints in nursing homes, German researchers report.

The team calls for a "culture change" in attitudes to physical restraints and says efforts such as the one tested here may need to be reinforced by stricter implementation of laws and penalties.

"Physical restraints, such as bilateral bed rails, belts, and fixed tables in a chair, are regularly applied in German nursing homes even though German legislation clearly requires that residents have free body movement and despite evidence for their lack of effectiveness and safety," write Sascha Köpke (University of Lübeck) and co-authors in JAMA.

"Thus, legal regulations do not appear to adequately protect nursing home residents. For US nursing homes, a recent survey reported physical restraint rates of more than 20%."

For the study, Köpke's team developed and evaluated a multicomponent intervention designed to reduce the use of physical restraints. The intervention was based on the best available evidence from guidelines and the theory of planned behavior and comprised group sessions for all nursing staff, additional training for nominated key nurses, and supportive material for nurses, residents, relatives, and legal guardians.

In all, 36 nursing homes in two German cities, with a total of 4449 residents, were randomly assigned to use the intervention or not (control) over a 6-month period. The use of restraints was assessed through direct, unannounced observation by blinded investigators on three occasions during 1 day.

At baseline, 31.5% of residents in the intervention group and 30.6% in the control group were being physically restrained.

By far the most common form of restraint was the use of restrictive bed rails, used in 29.2% and 28.3% of intervention and control residents, respectively. All other restraints were used in no more than 3.9% of residents overall.

By 6 months, the use of restraints had declined significantly, to 22.6%, in the intervention group but was unchanged, at 29.1%, in the control group. This difference gave an adjusted odds ratio of 0.71 in favor of the intervention.

Further analysis indicated that the intervention was associated with significant reductions in each of the types of restraint, and that the reductions became statistically significant as early as 3 months after baseline.

Secondary outcomes, including falls, fall-related fractures, and use of psychotropic medication, did not change over the course of the study in either of the study groups.

In their discussion, Köpke and colleagues note that the use of restraints varied greatly at baseline, with some "best practice" centers applying few restraints. "Reasons for differences between centers are unclear, but the 'culture of care,' as reflected in the attitudes and beliefs of nursing staff, may determine observed variation," they write.

"Accordingly, a 'culture change' has been demanded for nursing homes because avoidance of physical restraints is mandatory from a professional point of view."

They conclude: "As it seems infeasible to further optimize the intervention with justifiable effort, more pronounced reduction or even complete prevention of physical restraint use may require more stringent implementation of legal regulations with clear penalties."

By Joanna Lyford

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