Reducing physical restraints in nursing homes: The Netherlands

Reducing physical restraints in nursing
homes: The Netherlands
Prof. dr. Jan PH Hamers
‘
When I’
m old and admitted
to a nursing home,
hopefully the nursing home staff will decide
to apply physical restraints,
when they think that is appropriate.’
AGREE / DISAGREE
Faculty of Health, Medicine and Life Sciences
Change in ‘
restraint policy’in Dutch
Health Care
•Legislation will be changed
–Letter of the minister of health to parliament on
September 30, 2008
–New law to parliament, June 30, 2009
–The use of physical restraints to prevent falls will
be prohibited!
•Declaration of intent, November 18, 2008
•Nursing organizations, nursing homes, medicine, health
insurance companies, inspectorate
–Belts will be expelled from clinical practice in 2011
Faculty of Health, Medicine and Life Sciences
1
Use of physical restraints in nursing
homes must be reduced!
•Prevalence all measures:
41-64%
–Traditional nursing home (61%)
versus small scale nursing
home (54%)
•Traditional NH: 41% bedrails
•Small scale: 28% infrared systems
•Traditional NH: 12% belts
•Small scale: 0,8% belts
(Verbeek et al. (2009). BMC Geriatrics 9:3)
Faculty of Health, Medicine and Life Sciences
Use of physical restraints in nursing
homes must be reduced!
• Negative side effects
•To prevent falls (and serious injuries) in 85%
•But stopping restraints does not lead to an increase in the
number of falls with serious injuries!
•‘
Vicious circle’
• Restraint use does not per se improve the patient’
s safety!
Faculty of Health, Medicine and Life Sciences
Restraint reduction: how?
• No ‘
magic bullet’
; the alternative is not available!
• No increase in psychoactive drug use and other
restrictive measures
• Alternative interventions focused on behavior and
client centred
– Infrared system, lower bed, sensor mats, matrass on floor,
hip protectors, stimulation (extra) movements, activitities,
outdoor light and air, GPS, extra excercises / balance
training, cameras
• Increasing expertise
– Educational interventions
• Increasing number of staff, focus on workload?
Faculty of Health, Medicine and Life Sciences
2
Bivariate relations
Restraints –Job & Ward characteristics
Variables
Restrained
(n=206)
Unrestrained
(n=165)
p-value
Workload
3.1 (0.3)
3.1 (0.3)
0.997
Autonomy
3.0 (0.3)
2.9 (0.3)
0.458
Social support
3.1 (0.2)
3.1 (0.2)
0.484
Job characteristics
Ward characteristics
FTE ratio
0.58 (0.12)
0.57 (0.12)
0.323
Percentage RNs
7.7 (4.4)
7.6 (4.8)
0.474
Percentage sickness
absence
4.1 (2.1)
4.3 (2.3)
0.547
Faculty of Health, Medicine and Life Sciences
Huiz ing et al. (2007). Social Science & Medicine 65: 924-933
Learning from other countries
•Positive experiences in USA (Evans et al.
1997) with educational program and nurse
specialist
•Translation into Dutch practice
–Educational program
•5 meetings (10 hours);
1 plenary session
–Consultation nurse
specialist
–Duration: 8 months
Faculty of Health, Medicine and Life Sciences
Evans et al. (1997). JAGS 45: 676-681; Huizing et al. (2006). BMC Geriatr 6:17
Percentag restrained
residents
Reduction of physical restraints
70
60
50
40
30
20
10
0
Control group
Experimental group
1
2
3
4
Measurements
Faculty of Health, Medicine and Life Sciences
3
Why didn’
t it work?
•Family demanding use of measures
•Colleagues & other caregivers
•Alternative measures not available
•Attitude
–Use of restaints is necessary
•Lack of clear view and policy!
•Cultural change is necessary
–Active contribution management!
•Facilitate alternatives
•Policy change, vision!
–Stringent regulations
Faculty of Health, Medicine and Life Sciences
Hamers et al. (2009). IJNS 46:248-255
Pilotproject ‘
Expel the belt!’
•Policy change via Board of Directors: use of
belts will be prohibited within 2 months from
now
–Communication family
–Communication caregivers
•Responsible for decision making: nursing
home staff
–Consultation 2 nurses
–Availability other measures
•Supervision Dutch Inspectorate for Health
Care
Faculty of Health, Medicine and Life Sciences
Hamers & Gulpers (2009). J Nutr Health Aging Suppl; 13: S17
Results pilotproject ‘
expel the belt’
14
12
10
8
6
4
2
0
s
nt
h
s
M
o
9
th
on
th
3M
M
on
1
B
as
el
i
n
e
Belts
Faculty of Health, Medicine and Life Sciences
4
‘
A miracle has occured:
I can walk again!’
Resident, 81 years old,
when the use of a belt was stopped after two years
Faculty of Health, Medicine and Life Sciences
Other results
• Also reduction bedrails
• No increase chair with a
table, deep chair
• Slight increase infraredsystems, sensor mats
• Slight increase low beds
• Slight increase number of
falls, but:
• No increase in number of
serious injuries
-Can the results be replicated on larger scale?
Faculty of Health, Medicine and Life Sciences
EXBELT-project (2008-2009)
• Aim: reduction and prevention of belts
– No increase in other restrictive measures (e.g. chair with a table)
and use of psychoactive drug
– Reduction of other restraint measures such as bed rails
• Key elements ‘
EXBELT’
– Policy change: use of belts will be prohibited
– Communication: residents’relatives and caregivers
– Availability alternative interventions
– Decision-making: nursing home staff
– Educational program by nurse specialists
– Coaching by specialist nurses
– Session Arion Int. (developer and distributer nursing aids)
• Quasi experimental design
– 24 wards (>700 residents) from 11 nursing homes from 4
different regions in the Netherlands
– Effect and process evaluation
Faculty of Health, Medicine and Life Sciences
Gulpers, Bleijlevens, Van Rossum, Capezuti & Hamers (2008). ZonMw
5
Conclusions
•The use of physical
restraints:
–is still common
practice
–must be reduced
–can safely
be reduced
•Strategies for reducing restraints should be
tailored (e.g., to countries and setting)
Faculty of Health, Medicine and Life Sciences
Get to work!
•Create committment
•Clear view / policy
•Adequate training
•Clear communication!
•Learn from best practices
•Deal with setbacks
•Be creative!
Faculty of Health, Medicine and Life Sciences
Viel erfolg mit ReduFix!
6