Reducing Physical Restraints in Older Adults on an Acute Care of the Elderly Service: A Pragmatic Before–After Quality Improvement Initiative

BACKGROUND: Physical restraints are sometimes used in acute medical wards despite being ineffective and potentially harmful. We conducted a quality improvement project to decrease physical restraint use in hospitalized older adults admitted to an academic acute care of the elderly medical service. METHODS: In this non-randomized, before-after project, restrained patients were identified in routine morning rounds and assigned to the geriatric nurse practitioner on the team. Individualized approaches to decrease restraint use were derived. Discussions with substitute decision makers highlighting the harms and ineffectiveness of physical restraints were held, and their input informed decision making on restraint use. This discussion was documented in the medical record. The hospital restraint policy was also modified to require a physician order for all restraints and the expiration of these orders after 24 h. Patients were followed throughout their hospitalization, and physical restraint use (torso, pelvic, or limb restraints) was compared in two similar 6-month periods, prior to (Period 1) and after (Period 2) introducing this initiative. RESULTS: In controlled analyses the percentage of patients who were ever restrained decreased from a level of 44.9% (95% CI: 41.2%-48.6%) to 37.2% (95% CI: 33.7%-40.7%) (p < 0.003), and median length of time spent in restraints decreased from 2.27 (95% CI: 1.94-2.61) days to 1.48 days (95% CI: 1.28-1.67) (p < 0.001). There was no accompanying increase in the use of benzodiazepines or neuroleptics (trend toward less drug use in Period 2) or falls. There were fewer violent events in Period 2 (p < 0.05). CONCLUSIONS: Physical restraint use was decreased in older adults on an acute care of the elderly medical service, through various strategies. This suggests that physical restraints should be monitored and that hospitals should implement quality improvement programs to decrease physical restraint use.