Section 7 of the Health Care Consent Act (1996)[i] provides direction for restraint and confinement in a care facility. It states: “This Act does not affect the common law duty of a caregiver to restrain or confine a person when immediate action is necessary to prevent serious bodily harm to the person or to others.”
Nonetheless, the Patient Restraints Minimization Act (2001)[ii] was passed in Ontario to discourage the use of physical restraint and encourage hospitals and other facilities to use alternative strategies whenever it is necessary to use confinement to prevent serious bodily harm by a patient to himself/herself or to others.
In Ontario hospitals, the current management of COVID-19 involves isolation precautions to reduce the risk of virus transmission. In my experience and others elsewhere, this has resulted in increased use of physical restraints of seniors with delirium or dementia.[iii] Physical restraints are measures used to control the physical activity of a person to limit their movement. Physical restraint of non-violent seniors is typically achieved with minimal means, such as with a seat belt or table tray applied to a Geri–chair (medical recliner). They are still commonly used in hospitals to address unsafe behaviour in confused patients who are unable to follow redirection but are not necessarily aggressive toward self or others. In my experience and others elsewhere,[iv] only a small number of patients account for the majority of physical restraint use in hospital settings.
Physical restraints are supposed to be used as a last resort and for the shortest duration of time needed to keep the individual and/or others safe. When restraint use is unavoidable, the least restrictive form of restraint should be used.
In Ontario, restraints must be ordered by a doctor or nurse practitioner and evaluated every 24 hours. The preferred restraint used in a hospital bed is the Pinel lap with pelvic strap and extender which has a waist belt that attaches around the patient’s waist and prevents them from falling out of bed. The attached pelvic strap and extender prevents the restraint from riding up to the neck. For patients in the Pinel restraint in bed, the patient will be in a supine position with the head of the bed at 30 degrees and full side rails up. Patient observation is required while in the Pinel restraint in bed, which involves close observation every 15 minutes by either an unregulated care provider (UCP, referred to as a “sitter”), by security, or by nursing staff. Nursing documentation is required every 15 minutes using an approved Restraint and/or Observation Flowsheet. Restraint in a Geri-chair is done so with a seat belt or table tray and the patient must be visible to staff at all times and nursing documentation is also required every 15 minutes.
Physical restraints certainly can have harmful consequences. [v] Restraints can have negative effects on behaviour, including worsened agitation and confusion. Short-term restraint use has been associated with sudden death arising from deep vein thrombosis and pulmonary embolism.[vi] Prolonged use of restraints can provoke serious physical consequences, including skin pressure ulcers, limb contractures and/or deconditioning that can lead to weakness, higher risk of falling, and even permanent immobility.
In hospitals, one of the most common reasons for use of physical restraint of confused seniors is to prevent falls. This remains so despite the lack of scientific evidence that physical restraint actually protects elderly patients against injuries from falls.[vii] [viii] [ix]
Hospitalized patients with dementia often wander: aimless or disoriented ambulation throughout a facility without a discernible purpose. The aetiology of wandering is poorly understood and there remains no reliably effective pharmacologic or non-pharmacological intervention to treat or prevent dementia related wandering.[x] Non-pharmacologic interventions that focus on sensory stimulation, assessment of unmet needs, and individualized behaviour plans may reduce the need for physical restraint of confused, elderly patients who wander. However, at times even a sitter continuously with a patient cannot prevent wandering, especially for those with a tendency towards responsive physically aggressive behaviours. In those cases, physical restraint may be required.
Permitting an essential family/friend caregiver to be with the confused patient could potentially assist with the management of wandering and reduce the need for physical restraint. However, current Ministry of Health & Long Term Care (MOH<C) directives implemented during the pandemic prohibit family visitors to hospitals unless the patient is acutely dying. This was due to the risk that increased visitation posed for increasing infection rates and the need to manage personal protective equipment supplies (which were initially thought to be insufficient).
In my experience, physical restraint of confused seniors in hospital has been used more frequently than pre-pandemic. I suggest the public health directive prohibiting hospital visitation may have contributed to this. While I also suggest the prohibition of visitors in general was necessary, it demonstrates the lack of recognition by the MOH<C of the role of the essential family/friend caregiver for confused seniors in hospitals. Physical restraint of confused seniors may indeed have helped reduce the spread of contagion in hospitals which was very valuable. However, the unintended negative consequence of increased physical restraint use in Ontario hospitals may be to increase morbidity and mortality of seniors, which has not yet been fully recognized. Moving forward, I suggest a lesson learned from the pandemic is for the MOH<C to better consider the valued role of the essential family/friend caregiver for confused seniors in hospitals.
[iv] White C, Weingarden J, Perry I, Wallace Sensory Interventions for Outliers At-Risk Of Falls and Restraints on Geriatric Psychiatry Inpatient Unit. American Journal Geriatric Psychiatry, M. Poster Number: NR – 27: volume 28, issue 4, supplement, S141-S143. April 1, 2020.
[v] Pellfolk, T. J., Gustafson, Y., Bucht, G., & Karlsson, S. (2010). Effects of a restraint minimization program on staff knowledge, attitudes, and practice: A cluster randomized trial. Journal of the American Geriatrics Society, 58(1), 62-69.
[vi] Dickson, B. C. & Pollanen, M. S. (2009). Case report: Fatal thromboembolic disease: A risk in physically restrained psychiatric patients. Journal of Forensic and Legal Medicine, 16(5), 284-286.
[vii] Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616-625.
[viii] Wang, WW Moyle, W. Physical restraint use on people with dementia: a review of the literature [online]. Australian Journal of Advanced Nursing, The, Vol. 22, No. 4, 2005 Jun-Aug: 46-52.
[ix] Bai X, Kwok TC, Ip IN, Woo J, Chui MY, Ho FK. Physical restraint use and older patients’ length of hospital stay. Health Psychol Behav Med. 2014; 2:160–170. doi:10.1080/21642850.2014.881258
[x] Cipriani G, Lucetti C, Nuti A, Danti S. Wandering and dementia. Psychogeriatrics 2014; 14: 135–142, doi:10.1111/psyg.12044.