JCAHO: Zero tolerance on restraint deaths
The president of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is issuing a clear warning to health care providers, saying there should be "zero tolerance" for deaths related to the use of restraints.
Dennis O’Leary, MD, recently testified before the Labor, Health and Human Services, Education and Related Agencies Subcommittee of the Senate Appropriations Committee on the issue of deaths related to the use of restraints in mental health care facilities. He referred to a recent series of newspaper articles that have drawn attention to the hazards of restraint use.
"There should be zero tolerance for the types of deaths we have all read about in the Hartford Courant series," he said. Noting that many of the 142 patients cited in the series who died in relation to the use of restraints were children and adolescents, O’Leary said the horror stories were "nothing less than a call to action for all in the health care system who have not already taken serious steps to change the status quo."
O’Leary told the subcommittee that "the most immediate and obvious issue is that the litigious atmosphere in which health care is provided in this country constrains the willingness of accredited organizations to self-report sentinel events and, in a very real sense, to run the risk of self-indictment through sharing their sentinel event analysis with a private sector accrediting body." Recent actions to protect root-cause analyses from discovery have helped encourage providers to self-report, O’Leary said, "but even stronger medicine is needed to bring these tragic occurrences to the surface and deal with them."
He went on to say that the Joint Commission supports the Freedom from Restraint Act of 1999 (S.736), which incorporates and expands upon the strategic concepts in the Patient Protection Act respecting sentinel event reporting. "We believe S. 736 would provide the groundwork for a public/private sector partnership that could strengthen the value of voluntary accreditation in promoting patient safety and extend the most successful aspects of the sentinel event program to nonaccredited health care organizations participating in Medicare and Medicaid," he told the subcommittee.
Asphyxiation shown to be common problem
The Joint Commission recently issued an analysis of sentinel events related to restraint use in hope that the data would help providers decrease the likelihood of injury or death from restraint use. Since it began tracking sentinel events two years ago, the accreditation committee of the Joint Commission’s board of commissioners has reviewed 20 cases related to deaths of patients who were physically restrained. The root-cause analyses indicated most of the events occurred in psychiatric hospitals (12), followed by general hospitals (6) and long-term care facilities (2).
In 40% of the cases, the cause of death was asphyxiation. The Joint Commission reports asphyxiation was related to factors such as putting excessive weight on the back of the patient in a prone position, placing a towel or sheet over the patient’s head to protect against spitting or biting, or obstructing the airway when pulling the patient’s arms across the neck area.
The other deaths were caused by strangulation, cardiac arrest, or fire. All of the strangulation deaths were of geriatric patients, and in half of those cases, the patients died when they slipped between unprotected split side rails. All of the fire deaths were male patients who were attempting to smoke or were using a cigarette lighter to burn off the restraints. Two-point, four-point, or five-point restraints were used on extremities in 40% of the cases related to restraint deaths. A therapeutic hold was used in 30% of the cases, a restraint vest was used in 20%, and a waist restraint was used in 10%.
The Joint Commission reports that the following factors may increase the risk of death from restraints:
• restraining patients who smoke;
• restraining patients with deformities that preclude the proper application of the restraining device. This is especially risky with vest restraints;
• restraining a patient in the supine position, which may lead to aspiration;
• restraining a patient in the prone position, which can cause suffocation;
• restraining a patient in a room that is not under continuous observation by staff.
Root causes include poor assessments
As part of the sentinel event investigations, the providers identified these root causes of each restraint death:
• inadequate patient assessment, such as incomplete medical assessment or incomplete examination of the individual (for example, failure to identify contraband, such as matches);
• inadequate care planning, such as alternatives not fully considered, restraints used as punishment, and inappropriate room or unit assignment;
• lack of patient observation procedures or practices;
• staff-related factors, such as insufficient orientation or training, competency review or credentialing, or insufficient staffing levels;
• equipment-related factors, such as use of split side rails without side rail protectors, use of two-point rather than four-point restraints, use of a high-neck vest, incorrect application of a restraining device, or a monitor or an alarm not working or not being used when appropriate.
To counter these problems, the Joint Commis sion recommends that providers redouble efforts to reduce the use of physical restraint and therapeutic hold through risk assessment and early intervention with less restrictive measures. The Joint Commission makes these recommendations as well:
• Revise procedures for assessing the medical condition of psychiatric patients.
• Enhance staff orientation/education regarding alternatives to physical restraints and proper application of restraints or therapeutic holding.
• Consider age and sex of patients when setting therapeutic hold policies.
• Revise the staffing model.
• Develop structured procedures for consistent application of restraints.
• Continuously observe any patient who is restrained.
• If a patient must be restrained in the supine position, ensure the head is free to rotate to the side and, when possible, the head of the bed is elevated to minimize the risk of aspiration. If a patient must be restrained in the prone position, ensure the airway is unobstructed at all times. For example, do not cover or "bury" the patient’s face. Also, ensure that expansion of the patient’s lungs is not restricted by excessive pressure on the patient’s back. Special caution is required for children, elderly patients, and very obese patients.
• Never place a towel, bag, or other cover over a patient’s face as part of the therapeutic holding process.
• Do not restrain a patient in a bed with unprotected split side rails.
• Discontinue use of certain types of restraints, such as high vests and waist restraints.
• Ensure all smoking materials are removed from patient’s access, including those supplied by family and friends.
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