Secondary Logo

Journal Logo

The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review

JBI Database of Systematic Reviews and Implementation Reports: Volume 8 - Issue 34 - p 1–26
doi: 10.11124/jbisrir-2010-696
Systematic Review Protocol
Free

Primary reviewer/contact

Tang Wing Sze, BScN (Hons) student.

Alice Lee Centre for Nursing Studies, National University of Singapore, Yong Loo Lin School of Medicine

Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574

The Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A

Collaborating Centre of the Joanna Briggs Institute

Telephone: +65-97721812

Email: u0707518@nus.edu.sg

Secondary reviewer

Dr Chow Yeow Leng, Assistant Professor.

Alice Lee Centre for Nursing Studies, National University of Singapore, Yong Loo Lin School of Medicine

Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574

The Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A

Collaborating Centre of the Joanna Briggs Institute

Telephone: +65-94526773

Email: yeow_leng_chow@nuhs.edu.sg

Third reviewer

Dr Serena Koh Siew Lin, Adjunct Associate Professor.

Alice Lee Centre for Nursing Studies, National University of Singapore, Yong Loo Lin School of Medicine

Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574

The Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A

Collaborating Centre of the Joanna Briggs Institute

Telephone: +65-91133702

Email: serena_koh@nuhs.edu.sg

Commencement date

October 2010

Expected Completion date

March 2011

Back to Top | Article Outline

Background

Falls are defined as unexpected, involuntary loss of balance by a person before coming to a rest at a lower or ground level1. They are the most commonly reported patient safety incidents and cause many serious problems among patients in many healthcare settings2.

Patient falls can result in injury and even death, particularly in elderly patients. In United States, approximately half of the 1.6 million residents in nursing homes fall each year3. Out of these, 30 to 40% have fallen more than twice and 11% suffer from serious injuries related to falls4. Furthermore, fall rates range from 1.7 to 25 falls per 1000 patient days in hospital setting, accounting for 6.6% of total falls. All these fall incidents led to a median of 7.5-day rise in total length of stay and a median increase of $6402 USD in total revenue loss to the hospital5. Apart from the additional cost and physical injuries, psychological problems such as ‘Post-fall syndrome’ which causes confidence loss and hesitancy following by loss of independence and mobility may arise6. Even so, their loved ones may worry over various issues such as the patients’ ability to regain independence, safety and options of long-term care7. Because of these detrimental consequences resulting from falls, it is important to implement effective interventions in preventing or minimizing severity of injuries from falls.

Dizziness, confusion, weakness, poor vision, environmental dangers, postural hypotension and unsteady gait are common risk factors for falling8. By assessing these risk factors, appropriate interventions are implemented accordingly and one of these is physical restraint. A physical restraint is defined as any device adjacent or attached to the patient's body whereby freedoms of movement and access to one's body are inhibited9. Therefore, the patients who are on physical restraints are less likely to fall and potentially harm themselves. Some examples of physical restraints are usage of vest or chest restraints, wrist or ankle ties, ‘geriatric’ chair with table, belts tied to a chair or a bed and bed rails.

Since its introduction, physical restraint is being recognized as the primary measure to maintain patient safety in preventing falls in nursing homes and acute care hospitals. Many subsequent studies also supported this claim10-15. As a result, the primary outcome measure of this systematic review would be the number of individuals receiving restraints who fall, or the rate or number of falls in acute care hospitals and nursing homes. For the purpose of further synthesis, secondary outcomes measures would be evaluated and they are complications of physical restraint use, such as functional loss, delirium, pressure sores, asphyxiation, immobility and agitation; severity of falls, classified according to 9- level taxonomy16, mainly non-injurious, psychological/functional injury only, abrasion/contusion, laceration/ haematoma, non-surgical fracture and orthopaedic injury, fracture requiring casting, fracture requiring surgery, intracranial injury as well as multiple injuries; and deaths related to physical restraint use.

Although it is claimed that the physical restraints are primarily used to prevent falls in acute care hospitals, there are restrictions on their usage. Joint Commission of Accreditation of Healthcare Organisation (JCAHO) recommends that restraints are permitted only if there is a need for improvement in the patient's well-being and less restrictive interventions are found to be ineffective17. Before using a restraint, personnel must carry out a full assessment and document that the patient has a medical condition or symptom that shows a need for protective intervention. Therefore, any physical restraints should only be used when they are evident to be more effective than alternatives or the patients are medically indicated for physical restraints.

Physical restraint was originally used in the management of aggressive patients. Due to the introduction of psychotropic medications in the 1960s, the usage decreased tremendously among the psychiatric patients. Conversely, it remains commonplace among adult patients from all healthcare settings since this intervention is believed to prevent falls18. However, a few studies have shown that physical restraints are related to increased rates of complications such as functional loss, immobility, delirium, pressure sores, agitation, asphyxiation, and even death19. This form of restraint may further compromise patients' safety, dignity and autonomy20. Even so, more evidence derives the possibility of restraints enhancing the risk of falling or sustaining an injury from a fall15.

Due to the adverse effects and indiscriminate use of physical restraints, the usage was greatly affected throughout 1980s. Many European countries challenged the use of restraints by initiating restraint-free care. At the same time, the North American legislation declared that all the residents deserved rights to be free from restraints regardless of disciplinary measure or convenience purposes21. Alternatives to restraint use have been introduced into some long-term care facilities and the most common ones are environmental implementations such as wheelchair adaptations and seating; nursing interventions such as additional assistance and supervision; physiological aspects such as treatment of infection; psychosocial aspects such as reality orientation; and activities such as participation in structured activities22. Furthermore, many other interventions have been recommended for preventing falls in the acute care settings and they include reviewing medication, encouraging regular exercises, using safer footwear, introducing targeted fall care plans, environmental modifications such as railings and non-slip surfaces, and early detection and treatment of incontinence, eyesight problem, delirium and osteoporosis23. However, as pointed out by Werner et al (1994), the implementation of these care alternatives and the removal of physical restraint are expensive and complicated processes22.

In spite of all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. It was evident that over 65% of the nursing home residents remained restrained in a few ways, mainly by the use of bedrails, despite the implementation of restraint-free policy24. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling. Although many systematic reviews on evaluations of fall prevention interventions in various settings are published25-28, no recent in-depth evidence on effectiveness of physical restraints in fall preventions has been presented to date. Hence, the aim of this systematic review is to determine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.

Back to Top | Article Outline

Review Questions/Objectives

The overall aim of this review is to critically appraise, synthesize and present the best available evidence with regards to the effectiveness of physical restraints, in terms of fall rate, among adults in acute care hospitals and nursing homes.

More specifically, the review question is:

  • What is the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes?
Back to Top | Article Outline

Inclusion Criteria

Types of studies

This review will consider any randomised controlled trials that examine the effectiveness of physical restraints on fall reduction among adults in acute care hospitals and nursing homes.

In the absence of RCTs, other research designs of quantitative nature, such as non-randomised controlled trials, before and after studies, cohort studies, case control studies, descriptive studies, case series/reports, will be considered for inclusion to enable the identification of current best evidence regarding the effectiveness of physical restraints in reducing falls among adults in acute hospitals and nursing homes. There is no limit in selection of the publication timeframe.

Back to Top | Article Outline

Types of participants

This review will consider studies that include male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes. Hospital participants refer to those who are admitted to in-patient wards only. Findings show that restrained patients are more prone to fall during hospitalisation leading to increased length of hospitalisation29, 30. Hence the main focus of this review is on the inpatients and therefore patients from emergency and outpatient departments will be excluded.

Back to Top | Article Outline

Types of interventions

This review will consider studies that focus on the application of physical restraints on adults in acute care hospitals and nursing homes. More specifically, ‘physical restraints’ in the context of this systematic review refers to any devices, such as a ‘geriatric’ chair with table, belts tied to a chair or a bed and bed rails, adjacent or attached to the patient's body whereby freedom of movement is inhibited.

Back to Top | Article Outline

Types of outcome measures

The outcomes of interest in this review will include the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.

Studies that reported those participants who sustained more than one fall due to physical restraint will also be included. The primary and secondary outcomes are as listed.

Back to Top | Article Outline
Primary outcomes
  • Number of falls
Back to Top | Article Outline
Secondary outcomes
  • Complications of physical restraint use, such as functional loss, delirium, pressure sores, asphyxiation, immobility and agitation
  • Severity of falls, classified according to 9- level taxonomy16, mainly non-injurious, psychological/functional injury only, abrasion/contusion, laceration/haematoma, non-surgical fracture and orthopaedic injury, fracture requiring casting, fracture requiring surgery, intracranial injury as well as multiple injuries
  • Deaths related to physical restraint use
Back to Top | Article Outline

Search strategy

The search strategy aims to find studies and papers which are published in English language only, due to translational restrictions. There is no limit in selection of the publication timeframe.

A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. A hand search of relevant key journals not indexed in the databases will not be conducted due to resource and time constraints unless the retrieved articles are insufficient for data synthesis.

Because of economic and time limitations, databases such as Mednar and ProQuest will be excluded in the search. In addition, conference proceedings and any grey literature will not be included in this review.

The databases to be searched include:

1. CINAHL

2. PubMed

3. Expanded Academic ASAP

4. Scopus

5. Wiley-Interscience

6. OvidSP

7. ScienceDirect

8. PsycINFO

9. Evidence Based Medicine

10. Springerlink

11. Web of Science

Initial keywords to be used are as listed.

1. Physical Restraint

2. Restraint

3. Restraint, Physical

4. Immobilization

5. Bed Rail

6. Table

7. Chair

8. Belt

9. Hospital

10. Aged, Hospitalized or Aged, Hospitalised

11. Nursing Home

12. Home Nursing

13. Nursing Home Patients

14. Fall Rate

15. Fall Incidence

16. Falls

17. Accidental Falls

18. Injuries

The combinations of keywords and search strategies are demonstrated in Appendix I. During the process of conducting the search, various terminology and spelling of keywords will be taken into consideration as it may affect the identification of relevant studies.

All studies identified during the database search will be assessed for relevance to the review based on the information provided in the title, abstract, and descriptor/MeSH terms. For papers that meet the inclusion criteria, a full report for the paper will be retrieved. Studies identified from reference list searches will be assessed for relevance based on the review objective.

Back to Top | Article Outline

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II, III, IV). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (Dr Serena Koh).

Back to Top | Article Outline

Data extraction

Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI.

The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. The JBI Data Extraction Form for Experimental/ Observational Studies will be used for extracting data from papers included in the review (See Appendix V). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (Dr Serena Koh).

Back to Top | Article Outline

Data synthesis

Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.

Back to Top | Article Outline

Potential conflict of interest

There are no conflicts of interest regarding this systematic review.

Back to Top | Article Outline

References

1. Lamb SE, Jørstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the prevention of Falls Network Europe consensus. Journal of the American Geriatrics Society. 2005;53(9):1618-22.
2. Commodore DIB. Falls in the elderly population: a look at incidence, risks, healthcare costs, and preventive strategies. Rehabilitation Nursing. 1995;20(2):84.
3. Currie LM. Fall and injury prevention. Annual Review of Nursing Research. 2006;24:39-74.
4. Rask K, Parmelee PA, Taylor JA, Green D, Brown H, Hawley J, et al. Implementation and evaluation of a nursing home fall management program. Journal of the American Geriatrics Society. 2007;55(3):342-9.
5. Tzeng H, Yin C, Grunawalt J. Effective assessment of use of sitters by nurses in inpatient care settings. Journal of Advanced Nursing. 2008;64(2):176-83.
6. Cannard G. Falling trend… fall prevention. Nursing Times. 1996;92(2):36-7.
7. Kelly A, Dowling M. Reducing the likelihood of falls in older people. Nursing Standard. 2004;18(49):33-40.
8. Hill-Westmoreland EE, Gruber-Baldini AL. Falls documentation in nursing homes: agreement between the Minimum Data Set and chart abstractions of medical and nursing documentation. Journal of the American Geriatrics Society. 2005;53(2):268-73.
9. Miles SH, Meyers R. Untying the elderly. Clinics in Geriatric Medicine. 1994;10(3):513-25.
10. Sullivan-Marx EM, Strumpf NE. Restraint-free care for acutely ill patients in the hospital. AACN Clinical Issues: Advanced Practice in Acute & Critical Care. 1996;7:572-8.
11. Martin B. Restraint use in acute and critical care settings: changing practice. AACN Clinical Issues: Advanced Practice in Acute & Critical Care. 2002;13(2):294-306.
12. Fletcher K. Use of restraints in the elderly. AACN Clinical Issues: Advanced Practice in Acute & Critical Care. 1996;7:611-20.
13. Minnick AF, Mion LC, Leipzig R, Lamb K, Palmer R. Prevalence and patterns of physical restraint use in the acute care setting. Journal of Nursing Administration. 1998;28:19-24.
14. Choi E, Song M. Physical restraint in a Korean ICU. Journal of Clinical Nursing. 2003;12:651-9.
15. Park M, Tang JH. Evidence-based guideline changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing. 2007;33(2):9-16.
16. Sorensen SV, de Lissovoy G, Kunaprayoon D, Resnick B, Rupnow MFT, Studenski S. A taxonomy and economic consequences of nursing home falls. Drugs & Aging. 2006;23(3):251-62.
17. Sowers WP. Restraints, seclusion, and patient rights standards for hospital under the Medicare/ Medicaid programme. 1999 [27 October 2010]; Available from: http://www.vsb.org/sections/hl/sowers.pdf.
18. Wang W, Moyle W. Physical restraint use on people with dementia: a review of the literature. Australian Journal of Advanced Nursing. 2005;22(4):46-52.
19. Oliver D. Preventing falls and fall injuries in hospital: a major risk management challenge. Clinical Risk. 2007;13(5):173-8.
20. Shanahan D, Evans A. An audit of bedrail use and implications for practice. British Journal of Nursing (BJN). 2009;18(4):232-7.
21. Castle NG, Mor V. Physical restraints in nursing homes: A review of the literature since the Nursing Home Reform Act of 1987. Medical Care Research and Review. 1998;55(2):139-70.
22. Werner P, Cohen-Mansfield J, Koroknay V, Braun J. Reducing restraints: Impact on staff attitudes. Journal of Gerontological Nursing. 1994;20(12):19-24.
23. Healey F. The Third Report from the Patient Safety Observatory: Slips, Trips and Falls in Hospital. 2007 [cited 2010 18 October]; Available from: http://www.npsa.nhs.uk/nrls/alerts-and-directives/directives-guidance/slips-trips-falls/.
24. Koch S, Lyon C. Case study approach to removing physical restraint. Journal of Nursing Practice. 2001;7(3):156-61.
25. Stern C, Jayasekara R. Interventions to reduce the incidence of falls in older adult patients in acute-care hospitals: a systematic review. JBI Library of Systematic Reviews. 2009;7(21):941-73.
26. Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. Journal of the American Geriatrics Society. 2008;56(1):29-36.
27. Evans D, Hodgkinson B, Lambert L, Wood J, Kowanko I. Falls in Acute Hospitals: A Systematic Review. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery. 1998:7-53.
28. Harling A, Simpson JP. A systematic review to determine the effectiveness of Tai Chi in reducing falls and fear of falling in older adults. Physical Therapy Reviews. 2008;13(4):237-48.
29. Frengley JD, Mion LC. Incidence of physical restraints on acute general medical wards. Journal of American Geriatric Society. 1986;34:565-8.
30. Mion L, Frengley D, Jakovcic CA, Marino JA. A further explorationof the use of physical restraints in hospitalised patients. Journal of American Geriatric Society. 1989;37:949-56.
Back to Top | Article Outline

Appendices

Back to Top | Article Outline

Appendix I Initial Keywords to Be Used in Search Strategy

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Back to Top | Article Outline

Appendix II: JBI Critical Appraisal Checklist for randomised or quasi-randomised trials

Table

Table

Back to Top | Article Outline

Appendix III: JBI Critical Appraisal Checklist for Comparable Cohort/Case Control

Table

Table

Back to Top | Article Outline

Appendix IV: JBI Critical Appraisal Checklist for Descriptive/Case Series

Table

Table

Back to Top | Article Outline

Appendix V: JBI-MAStARI Data Extraction Form for Experimental/Observational Studies

Table

Table

Table

Table

© 2010 by Lippincott Williams & Wilkins, Inc.