IntroductionAll handling, physical and mechanical methods applied to the patient in order to reduce his freedom of movement or access to his own body, was defined as physical restraints by Health Care Financing Administration in 1992 (Weick, 1992). This could range from isolation of the patient in an enclosed space, the so-called seclusion room (not in use in Italy), to immobilization of the patient by the staff physically restraining him or applying mechanical restraints, such as handcuffs or cotton or leather ties. According to the literature, the aim of physical restraint should be limited to self-injuring behaviour, to prevention of violent behaviour directed at others and to promoting control of symptoms such as anxiety, delusion, aggressiveness (Fisher, 1994; Gutheil, 1987). This procedure is widely accepted when all therapeutic restrictive measures for the patient who is a danger to himself or others have failed (Kallert, 2008). The frequency of physical restraint in acute psychiatric wards is not similar among the Western Countries according to the different culture and organization of Mental Health Service (Steinert et al., 2009). There is a total lack of controlled trials about the beneficial effects of coercive measures in patients with violent behaviour, since this clinical practice procedure has not been investigated by means of well-designed randomized studies, (Jarrett, Bowers, & Simpson, 2008; Murilidharan, & Fenton, 2006), as evidenced by Cochrane’s systematic review of Sailas and Fenton (2000). The aim of this work is to analyze the use of physical restraint in an acute psychiatric unit during a period of 5 years, in order to evidence the variables of patients, staff and ward related to this procedure.MethodsThe ward and procedure of physical restraints The SPDC1 (Servizio Psichiatrico di Diagnosi e Cura 1) is a 15-inbed public acute psychiatric ward, located inside a General Hospital in Modena, which receives all patients from Modena and Castelfranco Emilia (population 250,000) affected by acute psychiatric diseases, compulsory or voluntary admitted (according to the “180” Italian Law). In our ward, physical restraint consists of immobilizing the patient in bed (never in face-down position) through handcuffs, leg ties and vest, applied according to hospital procedure: 1. this procedure could be prescribed only by a physician when other control measures had failed, after evaluation of the patient’s capacity to give his consent to treatment; 2. all staff had to focus attention on patient and staff safety, nurses had to continuously monitor the restrained patient and the physician had to re-evaluate every half hour the necessity for containment; 3. all above instructions and interventions had to be registered in the nurse restraint form and medical charts with the signature of each staff member, 4. during restraint, the necessary pharmacologic therapy and/or psychological support were prescribed with the aim to resolve the condition that had necessitated this procedure.The sample The sample was composed of all restrained patients admitted to SPDC1 of Modena from 1-1-2005 to 31-12-2009 (n=342). The variables The following variables, divided by year, were collected from medical charts and nurse restraint questionnaires and were relative to:1) restrained patients -age, gender, nationality; 2) admissions with physical restraint -diagnosis according to the Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) criteria, -voluntary state admission, with normal or altered state of consciousness due to intoxication or psycho-organic syndrome, or compulsory state admission, according to Italian Law “180”;3) physical restraints-clinical motivations for restraints, divided into the following categories, according to the most frequent reasons registered in our ward and the literature indications (Kaltila-Heino et al., 2003): A) control of dangerous, violent or aggressive behaviour, B) prevention of damages or necessity of urgent therapy;-time of restraints in comparison to the hospitalization day and to the three nursing shifts (Morning, from h 7 to h 13; Afternoon, from h 13 to h 20; Night, from h 20 to h 7)-duration of restraints-use of concomitant therapy-number of all admitted patients at the time of restraint use.We statistically analyzed the relationship between restraints and other variables; patients, admissions and staff. The following variables relative to restraints were statistically correlated: the motivations, the diagnosis, the state of admission and the day of hospitalization, the time of day (Chi square and Fisher tests) (Siegel, & Castellan, 1988). For the whole period, the number of physical restraints was statistically correlated to the number of all admitted patients at the moment this procedure was applied (Pearson correlation) (Armitage, & Berry, 1996). In order to describe the strength of association or non-indipendence of the variables above descripted with restraints, we measured the odds ratio (Mosteller, 1968) between restraint motivations (A: control of dangerous, violent or aggressive behaviour, B: prevention of damages or necessity of urgent therapy), restrained patient variables (age, gender, nationality), restraint procedure variables (time of restraints in comparison to the hospitalization day and to the three nursing shifts, duration of restraints, use of concomitant therapy) and state of admission (voluntary or compulsory).The data was processed by the SAS System Program.ResultsThe frequency of restrained patients was similar across the 5- year period but frequency of restrained male (p=0.045) and foreigner (p<0.001) patients increased in the last three years. Restraints were statistically significantly more frequently applied in Night shifts (p<0.0001) and during the first 72 h of hospitalization (p<0.001). More than 50% of physical restraints were prescribed in compulsory admissions or in voluntary hospitalizations of patients with altered state of consciousness. During the 5-year period, the most frequent diagnosis of restrained patients was “Schizophrenia and other Psychotic Disorders” (30%), followed by “Substance Abuse or Dependence and Substance induced Psychosis Disorders” (16%). In the whole observation period, the motivation of restraints, “control of aggressive behaviour”, was statistically significant more frequent than “prevention of damages or necessity of a not postponed therapy” independently from diagnosis (p<0.0001). Only the patients affected by “ Dementia” and other cognitive disorders were statistically significantly more frequently restrained due to prevention of damages or necessity of urgent therapy, in comparison to the other diseases (Chi square test, p <.0001). During nurse night shift, control of aggressiveness was the reason of restraint statistically significant more frequent (Chi square test, p <.0001) and duration of restraints was statistically significant more longer (> 4 hours) than during other nurse shifts(Chi square test, p <.0001). Physical restraints were associated in the 50 % of cases to a supplementary therapy: sedative therapy, antidote drugs, hydrating infusive therapy. The following variables were associated to restraints adopted in order to control of aggressiveness with an odd ratio >1: young age (<30 years old), male gender, compulsory admission, normal state of consciousness, morning shift, early time of admission (< 2 days), concomitant therapy, short duration (< 1.5 h). Finally, this procedure was not influenced by ward overcrowding, because the number of inpatients admitted did not influenced the number of restraints.Discussion and Conclusions The data of our 5-year analysis overlap those in the literature: physical restraint was most frequently applied in order to control the aggressive behaviour of psychotic patients (Monahan, 2003; Flannery, Rachlin, & Walker, 2002; Steinert, 2002; Winstanley, & Whittington, 2002; Nijman, 2002; Mignon et al., 2008). In our ward, physical restraint represented an usual tool of facing extreme clinical situations because its frequency and modality of applying was similar across the 5 years of observation, although it was adopted in acute situations. In fact, it was more frequently applied during the first days following admission with principle aim of controlling extreme situations of aggressive or dangerous behaviour in seriously ill patients. In our study, patients affected by “Schizophrenia and other Psychotic Disorders” and “Substance Abuse or Dependence and Substance induced Psychosis Disorders” were more frequently restrained than others in order to control aggressive behaviour. This data, similar to data found in the literature, indirectly shows that paranoid delusions or excited mood are the most frequent clinical situations which induce behaviour so dangerous that mechanical containment could often be required in order to avoid harmful conditions for others or the patient himself (Mignon, 2008). During the first days after admission, “the necessity of controlling an aggressive behaviour” was the prevalent reason for restraining, probably because the aggressiveness itself, which characterizes a wide range of psychiatric disorders, represented the prevalent reason for admission. During night shifts, physical restraints were more frequently applied in order to contain aggressive behaviour, the prevalent reason for restraint use during this period.
Influence of clinical situations and ward organization on physical restraint use in an acute psychiatric hospital / R., Di Lorenzo; Ferri, Paola; M., Ferrara; S., Mimmi; S., Baraldi. - STAMPA. - (2010), pp. 301-305. ((Intervento presentato al convegno Second International Conference on Violence in the Health Sector From awareness to sustainable action tenutosi a Amsterdam nel 27-29/10/2010.
|Data di pubblicazione:||2010|
|Titolo:||Influence of clinical situations and ward organization on physical restraint use in an acute psychiatric hospital|
|Autore/i:||R., Di Lorenzo; Ferri, Paola; M., Ferrara; S., Mimmi; S., Baraldi|
|Nome del convegno:||Second International Conference on Violence in the Health Sector From awareness to sustainable action|
|Luogo del convegno:||Amsterdam|
|Data del convegno:||27-29/10/2010|
|Citazione:||Influence of clinical situations and ward organization on physical restraint use in an acute psychiatric hospital / R., Di Lorenzo; Ferri, Paola; M., Ferrara; S., Mimmi; S., Baraldi. - STAMPA. - (2010), pp. 301-305. ((Intervento presentato al convegno Second International Conference on Violence in the Health Sector From awareness to sustainable action tenutosi a Amsterdam nel 27-29/10/2010.|
|Tipologia||Relazione in Atti di Convegno|
File in questo prodotto:
I documenti presenti in Iris Unimore sono rilasciati con licenza Creative Commons Attribuzione - Non commerciale - Non opere derivate 3.0 Italia, salvo diversa indicazione.
In caso di violazione di copyright, contattare Supporto Iris