What are the best practices for reducing restraint use in medical and geriatric psychiatric units?

Systematic reviews

Mechanical restraint-which interventions prevent episodes of mechanical restraint?-a systematic review. Bak J, Brandt-Christensen M, Sestoft DM, Zoffmann V.  Perspect Psychiatr Care. 2011 Apr 19.

Interventions for preventing and managing aggressive patients admitted to an acute hospital setting: a systematic review.  Kynoch K, Wu CJ, Chang AM.  Worldviews Evid Based Nurs. 2011 Jun;8(2):76-86.

Special care units for dementia individuals with behavioural problems.  Lai CK, Yeung JH, Mok V, Chi I.   Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006470.

Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far a review of the literature.  Scanlan JN.  Int J Soc Psychiatry. 2010 Jul;56(4):412-23.

Changing the practice of physical restraint use in acute care.  Park M, Tang JH.
J Gerontol Nurs. 2007 Feb;33(2):9-16

A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments.  Nelstrop L, et al.  Worldviews Evid Based Nurs. 2006;3(1):8-18.

Other recent studies on reducing restraint use:

The effect of staff training on agitation and use of restraint in nursing home residents with dementia: a single-blind, randomized controlled trial.  Testad I, Ballard C, Brønnick K, Aarsland D.  J Clin Psychiatry. 2010 Jan;71(1):80-6.

A cluster-randomized trial of an educational intervention to reduce the use of physical restraints with psychogeriatric nursing home residents.  Huizing AR, Hamers JP, Gulpers MJ, Berger MP.  J Am Geriatr Soc. 2009 Jul;57(7):1139-48.

 

Is use of color in the healthcare environment effective at reducing the rate of falls in inpatients?

Bottom line:  No published research has been identified on the use of color  in hospital settings to reduce falls other than to alert healthcare staff, but there is research on the ability to perceive color in adults with visual impairment, which affects many older patients.

Summary:  For a review of perception of color and discussion of implications for healthcare environments, see
J Clin Nurs. 2009 Feb;18(3):366-72.
Källstrand-Ericson J, Hildingh C. Visual impairment and falls: a register study.
Discussion on p. 369 includes review of literature on color perception in visual impairment.

Searched Joanna Briggs, PubMed, CINAHL, and Web of Science

Reviewed 4/9/2014 ldt

What is the prevalence of falls for hospitalized psychiatric and geriatric patients?

Observational studies:

Enloe M, et al.  Falls in Acute Care: An Academic Medical Center Six-Year Review.  J Patient Safety.  2005; 1(4): 208-214.
Retrospective study of falls at an academic medical center over 6 years.  RESULTS:  Table 2 shows the unadjusted annual fall rates were 5.86/1,000 patient days on the psychiatry units and Table 3 shows that broken down by age (regardless of service the patient was on), the fall rate for patients age 55-74 was 2.90/1,000 patient days and the rate for patients ages 75 and older was 4.08/1,000 patient days.

Schwendimann R, et al.  Characteristics of hospital inpatient falls across clinical departments.  Gerontology. 2008;54(6):342-8
Prospective study at 1,300 bed academic hospital over 13 weeks.  RESULTS:  Rate of falls on geriatrics units was 10.7/1,000 patient days.

Kerzman H, et al.  Characteristics of falls in hospitalized patients.  J Adv Nursing 2004; 47(2), 223–229.
Retrospective study of falls at a 2000-bed medical center in 1998.  RESULTS:  The rates of falls was 115/1,000 hospital admissions in the geriatric wards and 91 per 1,000 admissions in the psychiatric wards.  Rates per 1,000 inpatient days were not reported.

Is there evidence for optimal frequency for monitoring sedation level?

Bottom line:  There is little published evidence evaluating frequency of monitoring level sof sedation.

Joanna Briggs did not have any information.

CINAHL and PubMed had guidelines and validation studies evaluating the various sedation assessment scales, but none of that literature addresses how frequently to perform assessments.

DynaMed references recommendations of American Hospital Formulary Service.

Most relevant results

Brook AD, et al.  Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med. 1999 Dec;27(12):2609-15.
Reassessment every 4 hours is part of the protocol; outcomes were reduced time on mechanical ventilator, length of stay in ICU, and rate of tracheostomy for the protocol group compared to the standard care group

DynaMed

Propofol drug information.
Recommends assessing level of sedation at least daily.  See Warning and Precautions>General Precautions>Critical Care Sedation

Guidelines and additional validation studies:

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.  Crit Care Med. 2002 Jan;30(1):119-41
-recommends using a validated scale to monitor level of sedation, but cites a systematic review of scales to state that there was no gold-standard scale for assessing sedation level at time of these guidelines.  Does not recommend specific frequency for monitoring patients.  Objective Assessment of Sedation section reviews evidence of Motor Activity Assessment Scale, Riker Sedation-Agitation Scale, and Ramsay Scale and Vancouver Interaction and Calmness Scale.  Does not include the Richmond Agitation-Sedation Scale.

Ely EW, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).  JAMA. 2003 Jun 11;289(22):2983-91.
-Confirmed interrater reliability and validity of RASS in medical ICU patients.

Vender JS.  Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review.  Crit Care Med. 2004 Nov;32(11 Suppl):S554-61.
-Includes discussion of scales in context of patients with sepsis

What are nurses’ attitudes toward peer accountability?

A search of CINAHL and PubMed for these concepts:
peer accountability or peer review or peer evaluation
nurses
attitudes OR psychology OR perspectives OR beliefs

Results

CINAHL – Including these studies
Peer evaluation in nurses’ professional development: a pilot study to investigate the issues.Full Text Available (includes abstract); Vuorinen R; Tarkka M; Meretoja R; Journal of Clinical Nursing, 2000 Mar; 9 (2): 273-81 (journal article – research, tables/charts) ISSN: 0962-1067 PMID: 11111619

Using Synergy in peer review: a staff nurse’s perspective.Detail Only Available (includes abstract); Packard S; Excellence in Nursing Knowledge, 2004 Aug-Sep. (2p)