Efficient and Accurate Measurement of Physical Restraint Use in Acute Care

By Fogel, Joyce F.; Berkman, Cathy S. et al. | Care Management Journals, October 1, 2009 | Go to article overview

Efficient and Accurate Measurement of Physical Restraint Use in Acute Care


Fogel, Joyce F., Berkman, Cathy S., Merkel, Cindy, Cranston, Teresa, Leipzig, Rosanne M., Care Management Journals


Objectives: Describe and evaluate a method for assessing whether physical restraint prevalence differs by timing and frequency of data collection and to determine the minimum period of observation necessary to provide accurate prevalence estimates on both Intensive Care Unit (ICU) and medical-surgical units. Design: Two-period, cross-sectional design with repeated observations in year 1 for 18 consecutive days and in year 2 for 21 consecutive days with method modifications. Setting: 400-bed urban teaching hospital. Participants: All beds on general medical, surgical, and intensive care units. Measurement: Direct observation of patients, nurse interview, and medical record review conducted by trained observers. Results: There were no significant differences in mean restraint use prevalence rates comparing: (a) morning and evening periods; (b) weekdays and weekend days; and (c) observation periods of 7, 14, or 21 consecutive days or for 7 days using every 3rd day on either medical-surgical units or ICUs. Analyses using data from an increasing number of days of observation indicates that the mean prevalence rate stabilizes after 16 days. There were larger mean differences for comparisons on ICU-ventilator units and lack of significant differences may be due to low statistical power. Conclusion: Direct observation by trained observers, supplemented by nurse report and medical record documentation over brief monitoring periods, results in accurate, nonintrusive, cost-efficient estimates of physical restraint prevalence. As few as seven consecutive or nonconsecutive days in measuring restraint prevalence is sufficient to obtain accurate estimates, although the number of days may vary depending on patient mix and unit type.

Keywords: physical restraint; acute care; prevalence measurement

There has been heightened interest in reducing physical restraint use in acute care by regulatory and accrediting organizations, including the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Health Care Organizations ( JCAHO), and health care professionals and researchers. This concern was addressed in long-term care well before the awareness in hospitalized patients, as evidenced by the implementation of the Nursing Home Reform Act of 1987, resulting in a reduction of physical restraint use in these settings (Castle, 1998). In order to track and ultimately reduce restraint use in acute care, there must be accurate and efficient methods for measuring restraint prevalence. The study design and measures used in long-term care may not be optimal in acute care settings. The purpose of this article is to describe a method for a hospitalwide study of physical restraint use that implemented more rigorous methods of estimating prevalence than found in previous studies. We also present data on differences in prevalence use by time of day, day of the week, number of days of observation, and consecutive as compared with nonconsecutive days to determine what the minimum period(s) of observation are that provide accurate data for tracking restraint prevalence on both Intensive Care Units (ICU) and medical-surgical units.

The benefit or effectiveness of physical restraints is not supported by the literature (Frank, Hodgetts, & Puxty, 1996; Marks, 1992). Rather, the dangers of restraints are well documented, including longer length of stay, confusion, discomfort, pressure ulcers, nosocomial infections, and even death by strangulation and asphyxiation (Evans, Wood, & Lambert, 2003; Jensen et al., 1998; Lofgren, Macpherson, Granieri, Myllenbeck, & Sprafka, 1989; Miles & Irvine, 1992; Molasiotis, 1995; Strumpf & Evans, 1988; Sullivan-Marx & Strumpf, 1996). The Food and Drug Administration (FDA) has estimated that at least 100 deaths per year are caused by physical restraints (2003). The estimates of injuries caused by physical restraints are most likely low, due to underreporting and ambiguity about whether the injury was caused by the restraint. …

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