Deadly Restraint’ transmits heads-up for HCFA
Zero tolerance for deaths from restraints’
According to a 50-state survey conducted by the Hartford (CT) Courant newspaper late last year, 142 deaths were linked to the inappropriate use of restraints between 1988 and 1998. Among the investigative team’s findings:
• 23 patients died after being restrained in a face-down position.
• 20 died after being placed in wrist and ankle cuffs or vests and ignored for hours.
• Children made up 26% of 114 cases for which patient age was confirmed.
(The entire state-by-state database "Deadly Restraint" is posted at www.courant.com/news/ special/restraint/death_data.stm.)
The Joint Commission on the Accreditation of Healthcare Organizations added information to that revelation recently when the agency issued an analysis of sentinel events related to restraint use. Since it began tracking sentinel events three years ago, the agency’s accreditation committee has reviewed 20 cases of restraint death.
Root cause analyses of those sentinel events indicated that most of the deaths (12) occurred in psychiatric hospitals, followed by six in general hospitals and two in long-term care facilities. Nearly half of the deaths were caused by asphyxiation, and that condition was typically related to putting excessive weight on the backs of prone patients, placing a covering over patients’ heads to protect from spitting or biting, or obstructing patients’ airways when pulling their arms across their necks.
Identified root causes of each restraint death were inadequate patient assessment, inadequate care planning, lack of patient observation procedures, and staff-related factors, such as insufficient orientation, training, competency review, or credentialing, or insufficient staffing levels. Equip-ment-related factors were causes as well — use of unprotected split side rails, use of two-point rather than four-point restraints, use of high-neck vests, incorrect application of a restraining device, or a nonworking monitor or alarm.
The Joint Commission makes these recommendations for reduced restraint-related incidents:
• Intensify efforts to reduce the use of restraints and develop procedures for their consistent application.
• Revise procedures for assessing psychiatric patients.
• Enhance staff orientation and training regarding alternatives to restraints and their proper application.
• Consider age and gender of patients when setting policies.
• Continuously observe restrained patients.
• If a patient must be restrained in the supine position, ensure the head is free to rotate to the side, and elevate the head of the bed to minimize the risk of aspiration.
• If a patient must be restrained in the prone position, ensure the airway is unobstructed at all times. Do not cover the patient’s face. 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 high vests and waist restraints.
• Remove all smoking materials from a patient’s access.
[Editor’s note: If you want to contact the Joint Commission with questions or concerns regarding the use of physical restraints, call (800) 994-6610 between 8:30 a.m. and 5:00 p.m. CST, weekdays; or e-mail [email protected].]
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