The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion.

BACKGROUND: Patients in inpatient psychiatry settings are uniquely vulnerable to harm. As sources of harm, research and policy efforts have specifically focused on minimizing and eliminating restraint and seclusion. The Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting (IPFQR) program attempts to systematically measure and reduce restraint and seclusion. We evaluated facilities' response to the IPFQR program and differences by ownership, hypothesizing that facilities reporting these measures for the first time will show a greater reduction and that ownership will moderate this effect. METHODS: Using a difference-in-differences design and exploiting variation among facilities that previously reported on these measures to The Joint Commission, we examined the effect of the IPFQR public reporting program on the use and duration of restraint and seclusion from the end of 2012 through 2017. RESULTS: There were a total of 9705 observations of facilities among 1841 unique facilities. Results suggest the IPFQR program reduced duration of restraint by 48.96% [95% confidence interval (95% CI), 16.69%-68.73%] and seclusion by 53.54% (95% CI, 19.71%-73.12%). There was no change in odds of zero restraint and, among for-profits only, a decrease of 36.89% (95% CI, 9.32%-56.07%) in the odds of zero seclusion. CONCLUSIONS: This is the first examination of the effect of the IPFQR program on restraint and seclusion, suggesting the program was successful in reducing their use. We did not find support for ownership moderating this effect. Additional research is needed to understand mechanisms of response and the impact of the program on nontargeted aspects of quality.

Factors associated with the use of physical restraint in intensive care patients.

OBJECTIVE: To verify the frequency of physical restraint in patients and the factors associated with its use in the intensive care unit. METHOD: An observational and prospective study on the use of restraint in patients observed over two days, considering the variables: age and gender, personal and clinical characteristics, devices, adverse event and restraint use. The frequency was verified in three groups of patients with different conditions by applying the Chi-Squared, Likelihood Ratio or Kruskal-Wallis tests. The association of the variables was verified with the Multinomial Logistic Regression. RESULTS: Eighty-four (84) patients participated. Restraint was observed in 77.4% of the 84 analyzed patients, and was more frequent in the presence of sedation, agitation and invasive devices. The chance of being restrained was at least five times higher in sedation conditions, whether in weaning or daily awakening, mechanical ventilation weaning, agitation or the presence of invasive devices. CONCLUSION: Restraint use was high and was associated with female gender, sedation, agitation and invasive airway. It is emphasized and important to apply policies to reduce restraint use in intensive care.

Contenção mecânica de idosos na atenção domiciliar: revisão de literatura / Mechanical restriction of older adults in domiciliary attention: literature review

Objetivos: Identificar na literatura publicações que abordem o uso de contenção mecânica na atenção domiciliar. Métodos: Revisão integrativa da literatura realizadas nas bases de dados MEDLINE, LILACS, CINAHL e SCOPUS, no período de 2008 a 2018. Resultados: As prevalências de contenção física variavam entre 20% a 40%, a alta variação ser refere as distintas metodologias e legislações vigentes quanto à pratica de contenção física. A grade lateral é a contenção mais comum e as razões mais citadas para conter foram segurança do paciente, para evitar quedas e pedido dos familiares. Identificou- -se que 16,7% dos profissionais afirmaram ter aconselhado aos cuidadores o uso de restrições e, que 93% destes não souberam identificar alternativas para esta prática. Conclusão: Recomenda-se orientações específicas ao cuidado domiciliar centradas nas famílias, evitando a transposição inadequada do meio hospitalar para o âmbito domiciliar, e disseminar intervenções alternativas à contenção. (AU)

Objectives: To identify in the literature publications that address the use of mechanical restriction in home care. Methods: Integrative literature review carried out in the MEDLINE, LILACS, CINAHL and SCOPUS data bases from 2008 to 2018. Results: The prevalence of physical restraint ranged from 20% to 40%, the high variability refers to the different methodologies and legislation regarding the practice of physical restraint. The lateral grid is the most common containment and the most cited reasons to contain were patients afety, to avoid falls and family members' request. It was identified that 16.7% of the professionals stated that they advised caregivers to use restrictions, and that 93% of them did not know how to identify alternatives for this practice. Conclusion: Specific guidelines for household-centered care are recommended, avoiding the inadequate transposition of the hospital environment into the home, and disseminating alternative interventions to containment. (AU)

Factors associated with mechanical restraint in the hospital environment: a cross-sectional study.

OBJECTIVE: To estimate the prevalence of mechanical restraint in the hospital environment and the factors associated with its performance. METHOD: A cross-sectional, observational study with patients from a public hospital from the medical clinic, surgical clinic and intensive care unit evaluated by descriptive, univariate and multivariate analyses. RESULTS: One hundred eleven (111) patients participated in the study. The prevalence of mechanical restraint was 51.4%; bilateral rails on the bed were used in 100% of the restraints, and bilateral wrist restraints were also observed in 29.8%. The most common justifications were the risk of falls (100.0%) and the risk of non-scheduled removal of invasive devices (57.9%). The restrained patients differ significantly from those not restrained by the following associated factors: male gender; age; stroke diagnosis; the hospitalization unit; ambulation capacity; the use of sedative medication; and the use of invasive devices. CONCLUSION: This study estimated a high mechanical restraint prevalence in the hospital environment and determined factors associated with the risk of a patient being restrained. A medical restraint evaluation team is recommended for an in-depth analysis of indication and therapy.

Restrição física em pacientes nas Unidades de Terapia Intensiva: estudo exploratório-descritivo / Physical restraint in patients in Intensive Care Units: exploratory - a descriptive study

Objetivo: analisar os critérios para uso e monitorização de restrições físicas em pacientes internados na Unidade de Terapia Intensiva (UTI). Método: a pesquisa teve caráter exploratório, descritivo e qualitativo e foi realizada em duas UTIs da Bahia, com 85 profissionais de enfermagem. Os dados foram organizados com base na análise temática. Resultado: a equipe de enfermagem justifica a utilização da restrição física para a segurança do paciente. Como critério para seu uso, verificam-se o nível de consciência, o grau de agitação e/ou a desorientação. Para a monitorização, observam-se a integridade cutânea e as alterações do nível de consciência. Por isso, a avaliação neurológica foi a técnica mais empregada pelos profissionais para verificar a necessidade de restrição. O conhecimento da equipe em relação aos instrumentos legais que regem esse procedimento se mostrou superficial. Conclusão: identificaram-se fragilidades nos critérios de monitorização e suspensão da restrição física, visto que o conhecimento ainda é incipiente e que não há protocolos definidos. (AU)

Aim: to analyze the criteria for the use and monitoring of physical restrictions in patients admitted to Intensive Care Units (ICUs). Method: the research had an exploratory, descriptive and qualitative character and was performed in two ICUs in Bahia, with 85 nursing professionals. The data were organized based on thematic analysis. Result: the members of the nursing team justified the use of physical restraint for patient safety, reporting the checking of the level of consciousness, agitation and/or disorientation as criteria for its use. For monitoring, they observed patients' skin integrity and changes in the level of consciousness. Therefore, neurological evaluation was the technique most commonly used by professionals to verify the need for restriction. The knowledge of the team regarding the legal instruments that govern this procedure was superficial. Conclusion: we identified weak spots in the criteria for monitoring and - making use of physical restraint, since the knowledge is still incipient and there are no defined protocols.. (AU)

Uso de restrições físicas em instituições de longa permanência para idosos: percepção de profissionais de saúde e cuidadores de idosos / Use of physical restraints in nursing homes: perception of health professionals and elderly caregivers

Restrições físicas (RF), definidas como equipamentos que restringem a liberdade de movimento do indivíduo, são comumente observadas em instituições de longa permanência para idosos (ILPI). Objetivou-se averiguar e descrever a percepção de profissionais graduados na área de saúde e de cuidadores que atuam em instituições asilares quanto à definição, à utilização, à prescrição e a características positivas e negativas de RF junto a idosos residentes em ILPI. A pesquisa, caracterizada como exploratória e descritiva, utilizou como instrumento para coleta dos dados um questionário semiestruturado elaborado pelos pesquisadores. A amostra foi composta por 10 indivíduos, dos quais 40% eram profissionais de saúde e 60% cuidadores de idosos. Restrições físicas foram definidas como objetos para prender idosos, evitar suas quedas, mantê-los quietos e zelar por sua segurança e seu cuidado. Foram elencados como pontos positivos o cuidado e a segurança para com os idosos. Seis (60%) dos participantes não relataram haver pontos negativos, enquanto um (10%) participante considerou negativa a existência de atrofia muscular, um (10%) evidenciou favorecimento de déficit circulatório, um (10%) revelou constrangimento por parte do idoso e um (10%) reportou ansiedade e irritação por parte do idoso. O terapeuta ocupacional foi considerado pela maioria dos participantes o profissional mais indicado para prescrever e acompanhar o uso de RF. Observou-se que um pequeno número de profissionais de saúde e cuidadores de idosos apresenta familiaridade com a temática abordada neste estudo, o que ilustra a necessidade de condução de estudos posteriores sobre o assunto. (AU)

Use of physical restraints in nursing homes: perception of health professionals and elderly caregivers Physical constraints (PR), defined as equipments that restrict the freedom of the movement of a person, are commonly observed in nursing homes. The study aimed to investigate and describe the perception of health professionals and caregivers who work in nursing homes regarding the definition, use, prescription and positive/negative characteristics of PR. The research, characterized as quantitative, exploratory and descriptive, used a semi-structured questionnaire developed by the researchers to collect the data. The sample consisted of 10 individuals of which 40% were health professionals and 60% were elderly caregivers. Physical restraints were defined as objects to arrest the elderly, avoid their falls, keep them quiet and ensure their safety and care. The participants listed as a positive aspect related to the use of PR the care and safety of the elderly. Considering the negative aspects of PR, six (60%) participants listed no negative aspects, while one (10%) of them considered the existence of muscular atrophy, one (10%) said circulatory deficit, one (10%) recognized the embarrassment by aged people and one (10%) reported anxiety and irritation. The occupational therapist was considered by most participants as the professional indicated to prescribe and monitor the use of RF. It was observed a reduced number of health professionals and caregivers who dominate the topic approached on this study. This illustrates the need to conduct further studies on the subject. (AU)

Dental needs and management of children with special health care needs according to type of disability.

PURPOSE: The purpose of this study was to investigate the dental needs and management of special health care needs children in Rio de Janeiro, Brazil, according to the type of disability. METHODS: Records of 428 0- to 19-year-old patients who received dental treatment at the Patients Special Care Needs Clinic (Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro) from 1996-2009 were analyzed. Information about the type of disability, use of medication, dental exam findings, management during treatment, dental treatment performed, and follow-up examinations were collected. Children were divided into 2 groups: those with medical conditions and those with intellectual disability. RESULTS: Patients with medical conditions used more medications and were older than those with intellectual disability. The most common dental treatments received were dental restorations (63%) and extractions (47%). There was no association between the type of disability and dental treatment needed. Children with intellectual disability were 3 times more likely to need general anesthesia and 7 times more likely to need physical restraint for dental care than the other group. CONCLUSIONS: Children with intellectual disability have a greater chance of requiring advanced management techniques during dental treatment. The development of effective oral health programs is recommended as well as a specific education program for their parents.

Child safety restraint use among children attending day care centers.

OBJECTIVE: To estimate the prevalence of child safety restraint use and factors associated. METHODS: Observational cross-sectional study using a stratified sampling conducted in the city of Maringá, Southern Brazil, between March and May 2007. Each day care center was visited at one day only. The outcome was use of child safety restraints by children under four. Vehicles (N=301) driving children under four were approached and information was collected using semi-structured questionnaires. Variables regarding child and adult seat distribution, use of safety restraints by occupants and driver's gender were analyzed. Data analyses included Fisher's exact test, Mantel-Haenszel chi-square test, and logistic regression. RESULTS: Of the drivers approached, 51.8% were using seat belts (60.4% among women, 44.9% among men). Among children, 36.1% were using child safety seats, 45.4% were unrestrained during traveling, 16.0% were seated on an adult lap, and 2.7% were using seat belts. The logistic regression showed the following factors affecting child safety restraint use: child age under 15 months (OR = 3.76); seat belt use by the driver (OR = 2.45); and children from socio-occupational condition with higher income and education (OR = 1.37). CONCLUSIONS: Child safety restraint use was associated to child age, seat belt use by the driver, and socio-occupational condition of day care centers. The finding of low rates of child safety restraint use poses a challenge to preventive medicine in Brazil, requiring attention and action to promote its widespread use.

Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms.

OBJECTIVE: To examine factors associated with physical restraint in psychiatric emergency rooms. METHOD: We extracted variables likely to predict use of physical restraints from a large randomised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro. We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints. RESULTS: Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first 2 h of admission. In Rio, younger people (OR=1.03 for each year younger), exhibiting intense (OR=2.53) or extreme agitation (OR=7.71), thought to result from substance misuse (OR=1.75) or diagnoses other than psychosis (OR=1.88), arriving in the morning (OR=1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained. CONCLUSION: Restraint practices in Rio are predictable and based on a limited clinical assessment. Predictive factors for physical restraint may vary worldwide, but should be monitored and studied to assist training, and to establish programs to evaluate and refine this controversial practice.

Contenção física: o papel de variáveis éticas, clínicas e sociodemográficas / Physical restraint: the role of ethnic, clinical and socio-demografic variables

Introdução: Ainda que a contenção física em psiquiatria seja um ato cotidiano, não foram encontrados estudos sobre este tema realizados no país. Objetivos: O presente estudo tem como objetivos: 1) caracterizar em que circunstâncias ocorre a contenção física de pacientes na Unidade Psiquiátrica no HC/Unicamp; 2) caracterizar o grupo dos pacientes contidos e diferenciáðlo de um grupo de pacientes nãoðcontidos. Material e método: O estudo realizado foi retrospectivo, com base na análise de prontuários e de um banco de dados informatizado na qual constam escalas como BPRS, GAS e MMSE. a amostra utilizada foi de cem internações selecionadas aleatoriamente de um total de 344 internações consecutivas ocorridas entre 1996 e 1997. Resultados: O grupo dos pacientes contidos durante o período de hospitalização não apresentou diferenças significativas quanto a idade, escolaridade ou número de internações anteriores em relação aos pacientes nãoðsubmetidos a este procedimento. Pacientes do sexo feminino, com menor tempo de uso de psicofármacos e internados pela última vez havia mais tempo foram mais freqüentemente contidos. Pacientes negros e mulatos foram significativamente entre os dois grupos. Discussão e conclusão: Há uma possibilidade de variáveis étnicas e sociodemográficas, como cor do paciente, interferirem nas condutas médicas. Procedimentos como contenção física devem ser protocoladas e mais estudados em nosso meio