Anna R. Huizing

Why do we use physical restraints in the elderly

The use of physical restraints in the elderly is a common practice in many countries. This paper summarizes the current knowledge on the use of restraints in home care, hospitals and nursing homes. Between 1999–2004 the reported prevalence numbers range from 41–64% in nursing homes and 33–68% in hospitals; numbers of restraint use in home care are unknown. Bed rails and belts have been reported as the most frequently used restraints in bed; chairs with a table and belts are the most frequently reported restraints in a chair. It is evident that physical restraints in most cases are used as safety measures; the main reason is the prevention of falls. In the hospital setting, the safe use of medical devices is also an important reason for restraint use. Predictors for the use of physical restraints are poor mobility, impaired cognitive status and high dependency of the elderly patient and the risk of falls in the nurses’ opinion. Furthermore, there are indications that restraint use is related to organizational characteristics. Finally, many adverse effects of restraint use have been reported in the literature, like falls, pressure sores, depression, aggression, and death. Because of the adverse effects of restraints and the growing evidence that physical restraints are no adequate measure for the prevention of falls, measures for the reduction of physical restraints are discussed and recommendations are made for future research. Die Anwendung von Fixierung ist in vielen Länder üblich. Dieser Artikel fasst unsere Kenntnis über die Anwendung von Fixierung in der häuslichen Pflege im Krankenhaus und im Pflegeheim zusammen. Zwischen 1999–2004 betrug die gemeldete Prävalenz 41–64% in Pflegeheimen und 33–68% in Krankenhäusern; die Prävalenz in der häuslichen Pflege ist unbekannt. Bettgitter und Fixierungsgurte werden am meisten angewendet im Bett; Stühle mit einem Brett und Fixierungsgurte werden am meisten angewendet im Stuhl. Es ist evident, dass eine Fixierung meistens als Sicherheitsmaßname angewendet wird; der Hauptgrund ist die Prävention von Stürzen. Die sichere Anwendung von medizinischen Interventionen ist ein wichtiger Grund zum Gebrauch der Fixierung im Krankenhaus. Eingeschränkte Mobilität, Verringerung der kognitiven Funktion, große Hilfsbedürftigkeit des älteren Patienten, und das Sturzrisiko nach der Meinung des Plegepersonals, sind Faktoren die die Anwendung von Fixierung voraussagen. Daneben gibt es Hinweise dass die Anwendung von Fixierung zusammenhängt mit organisatorischen Abläufen. Schließlich sind viele negative Konsequenzen von Fixierungsmaßnahmen in der wissenschaftlichen Literatur beschrieben wie Stürze, Dekubitus, Depressionen, Agression und Tod. Wegen dieser negativen Konsequenzen und dem verstärkten Beweis, dass eine Fixierung keine angemesse Intervention ist für die Prävention von Stürzen, werden Maßnamen zur Reduzierung von Fixierung besprochen und Empfehlungen gemacht für zukünftige Forschung.

A Cluster-Randomized Trial of an Educational Intervention to Reduce the Use of Physical Restraints with Psychogeriatric Nursing Home Residents

OBJECTIVES: To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents.

Attitudes of Dutch, German and Swiss nursing staff towards physical restraint use in nursing home residents, a cross-sectional study

OBJECTIVE To investigate the attitudes of nursing staff towards restraint measures and restraint use in nursing home residents, and to investigate if these attitudes are influenced by country of residence and individual characteristics of nursing staff. METHODS A questionnaire on attitudes regarding restraints (subscales: reasons, consequences, and appropriateness of restraint use) and opinions regarding the restrictiveness of restraint measures and discomfort in using them was distributed to a convenience sample of nursing staff in The Netherlands (n=166), Germany (n=258), and Switzerland (n=184). RESULTS In general, nursing staff held rather neutral opinions regarding the use of physical restraints, but assessed the use of restraints as an appropriate measure in their clinical practice. Gender and age were not related to attitudes of nursing staff, but we did find some differences in attitudes between nursing staff from the different countries. Dutch nursing staff were most positive regarding the reasons of restraint use (p<0.01), but were less positive than German and Swiss nursing staff regarding the appropriateness of restraint use (p<0.01). Swiss nursing staff were less positive than German nursing staff regarding the appropriateness of restraint use (p<0.01). Nursing staff with longer clinical experience showed a more negative attitude towards restraint use than nursing staff with less experience (p<0.05) and charge nurses had the least positive attitude towards restraint use (p<0.05). Opinions regarding restraint measures differed between the three countries. The use of bilateral bedrails was considered as a moderate restrictive measure; the use of belts was rated as the most restrictive measure and nursing staff expressed pronounced discomfort on the use of these measures. CONCLUSIONS Nursing staff from three European countries have different attitudes and opinions regarding the use of physical restraints. The results underline the importance of more tailored, culturally sensitive interventions to reduce physical restraints in nursing homes.

Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study

BackgroundEven though previous research has demonstrated improved outcomes of integrated care initiatives, it is not clear why and when integrated care works. This study aims to contribute to filling this knowledge gap by examining the implementation of integrated care for type 2 diabetes by two Dutch care groups.MethodsAn embedded single case study was conducted including 26 interviews with management staff, care purchasers and health professionals. The Context + Mechanism = Outcome Model was used to study the relationship between context factors, mechanisms and outcomes. Dutch integrated care involves care groups, bundled payments, patient involvement, health professional cooperation and task substitution, evidence-based care protocols and a shared clinical information system. Community involvement is not (yet) part of Dutch integrated care.ResultsBarriers to the implementation of integrated care included insufficient integration between the patient databases, decreased earnings for some health professionals, patients’ insufficient medical and policy-making expertise, resistance by general practitioner assistants due to perceived competition, too much care provided by practice nurses instead of general practitioners and the funding system incentivising the provision of care exactly as described in the care protocols. Facilitators included performance monitoring via the care chain information system, increased earnings for some health professionals, increased focus on self-management, innovators in primary and secondary care, diabetes nurses acting as integrators and financial incentives for guideline adherence. Economic and political context and health IT-related barriers were discussed as the most problematic areas of integrated care implementation. The implementation of integrated care led to improved communication and cooperation but also to insufficient and unnecessary care provision and deteriorated preconditions for person-centred care.ConclusionsDutch integrated diabetes care is still a work in progress, in the academic and the practice setting. This makes it difficult to establish whether overall quality of care has improved. Future efforts should focus on areas that this study found to be problematic or to not have received enough attention yet. Increased efforts are needed to improve the interoperability of the patient databases and to keep the negative consequences of the bundled payment system in check. Moreover, patient and community involvement should be incorporated.

Kwaliteit en patiëntervaringen van eerstelijns ketenzorg hart- en vaatziekten in de regio Maastricht-Heuvelland tussen 2010-2012

SamenvattingInleiding:Sinds 2010 zijn eerstelijns ketenzorgprogramma’s voor mensen met (een risico op) hart- en vaatziekten (HVZ) geïntroduceerd in Nederland. Onduidelijk is welke kwaliteit van zorg hiermee wordt geleverd. Ook patiëntervaringen met deze zorg zijn onbekend. Beoogd werd hier inzicht in te krijgen en eventuele verschillen tussen primaire (hoog risicopatiënten) en secundaire preventie (reeds gediagnosticeerde patiënten) te onderzoeken.Methoden:Uitkomst- en procesindicatoren werden retrospectief in kaart gebracht aan de hand van data (ncohort=1183 patiënten) uit het regionale keteninformatiesysteem in Maastricht-Heuvelland over 2010 (nulmeting) en 2012 (nameting). Patiëntervaringen werden cross-sectioneel in kaart gebracht met de PACIC-vragenlijst (n=402 patiënten).Resultaten:Op beide meetmomenten werd bij patiënten die op consult kwamen de zorg conform protocol in kaart gebracht. De regulatie van bloeddruk, LDL-cholesterol en rookstatus verbeterden. De gemiddelde BMI-waarde verslechterde. Geen evidente verschillen werden gevonden tussen primaire en secundaire preventie. Patiënten rapporteerden gemiddeld een 2,7 (range 1-5) voor de mate waarin zij op dit moment de ketenzorg ervaren. Het construct ‘opzet-van-het-zorgsysteem’ scoorde het hoogst (gemiddeld 3,4, range 1-5). De constructen ‘zorg-op-maat’ (gemiddelde 2,6) en ‘coördinatie-en-nazorg’ (gemiddeld 3,3) scoorden het laagst.Conclusie:De resultaten laten zien dat de eerste stappen ter verbetering van de kwaliteit van zorg zijn gezet. Een aantal uitkomstmaten lijkt te zijn verbeterd en de registratie van procesmaten is hoog bij patiënten die op beide meetmomenten aanwezig waren, zowel voor primaire als secundaire preventie. Nader onderzoek naar de lange termijn impact van ketenzorg en de kenmerken en beweegredenen van patiënten die niet (meer) op controle kwamen wordt aanbevolen.AbstractQuality of the delivered care and patients experiences with the integrated care programme for cardiovasculair risk management in the region Maastricht-Heuvelland in 2010 – 2012. Background: Since 2010 multiple integrated care programmes for cardiovascular diseases have been introduced in primary care in the Netherlands. However, the quality of the delivered care and patients experiences with integrated care programmes are still unknown. Methods: Data on process- and outcome indicators in 2010 and 2012 were collected retrospectively (n=1183 patients) from the regional clinical information system. Moreover, patient experiences with integrated care were examined cross-sectional using the PACIC-questionnaire (n=402 patients). Results: Process indicators were adequately registered in 2010 and in 2012. The regulation of the outcome indicators systolic blood pressure, LDL-cholesterol and smoking status have been improved significantly over time. No differences between primary and secondary prevention were found. Patients experiences with integrated care were scored as moderate (2,7±1,0;range 1-5). Delivery system design was scored highest (mean=3,4±1,0), while goal setting (mean=2,6±1,0) and follow-up/coordination (mean=2,3±1,1) were scored lowest. Conclusions: The first results of an integrated care programme for cardiovascular diseases show that intitial steps have been made in improving quality of care in the region Maastricht-Heuvelland. A number of outcome indicators have improved over time and the registration of process indicators is high for both primary and secondary prevention. Experiences of patients with integrated care programme are moderate. Yet, more insight into the impact over a longer period of time is recommended in order to further refine new and existing integrated care programmes in the Netherlands.