Tuesday, February 28, 2012

Fall Risks and restraints

The culture of nursing homes and assisted living facilities has shifted far away from the use of restraints; most places are restraint-free by law these days. The hospital is one of the only places I can imagine restraints remaining in use, and that is simply because of the acuity (how sick) our patients there are. They cannot afford to be pulling out the lines that are giving them IV antibiotics and blood transfusions, because without those things, they will die.

Even at the hospital, restraints are considered a last resort. They frequently utilize one-to-one 'sitters' to watch and maintain safety of very difficult patients. I was pulled from my regular duties to act as one last night, for a confused elderly person who would not stop climbing out of bed (and was a fall risk), pulling out lines, and removing their much-needed supplementary oxygen tubing. Even with me there, the patient was very agitated, and trying to literally climb over the furniture to get out of the bed. I was willing to let her get up, but she was so damn fast she was apt to get away before I could gather up all the things that were attached to her so I could ferry them along after her to prevent them from ripping out.

Finally the MD returned the page from the nurse, and ordered a small dose of an antipsychotic. It didn't stop the patient from trying to get up, it just calmed the patient down enough to stop physically shoving me out of the way, which was good enough.

This was one of those situations where I think that chemical restraints would be so much more effective than physical. My patient has such poor short-term memory that s/he would forget what I had said literally 20 seconds before. Putting someone like that in physical restraints is going to be a huge safety risk because they're still anxious and panicky and energetic, and will focus all of that onto getting out of the restraints one way or another.

Whereas a strong sedative seems highly appropriate and could allow this person the time to absorb their antibiotics, fluids, and oxygen in order to begin healing.

Unfortunately, I don't think we have a specific policy and protocol for chemical restraints the way we do for physical ones. I understand they're risky in terms of oversedation; you don't want to accidentally kill someone! But I wonder, if I were the physician getting paged in the middle of the night, whether I'd view the sedatives I'm prescribing as restraints or 'sleep aids' or what?

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