Risk in the use of Restrictive practices: An overview of the research. Brodie Paterson PhD, M.Ed, BA(Hon) RMN,RNLD, FEANS Director, CALM Training.

Transcription

1 Risk in the use of Restrictive practices: An overview of the research Brodie Paterson PhD, M.Ed, BA(Hon) RMN,RNLD, FEANS Director, CALM Training.

2 Aims Reflect on what we know. Individual tragedies Biomechanical and physiological Research Identify Implication for Policy and Practice

3 Restrictive interventions An invisible Epidemic No effective regulation or mandatory accreditation Poor quality of published research Service / training providers do not publish injury / fatality rates Dangerously simplistic debate ( Moral panic?) technique X is safe / unsafe LD audit system (Post Winterbourne)

4 Abuse of Restrictive Interventions Corrupted Cultures: Used to compensate for inadequacies in supervision, training in PBS / Trauma informed care staffing ratios and unsuitable environments Existing guidance not rigorusly enforced 52% Scottish child care non complaint ( SCRC 2008) Certain methods of restraint repeatedly associated with increased risk of injury, abuse, fatality

5 Free Market Legal Implications Restraint training effectively mandatory Employers are obliged to reduce risk to the lowest level (HASAWA) Duty of Care to both staff and service users ( Civil Law) Product liability obligations on training suppliers

6 Restraint Safety CONTEXT STAFF SERVICE USERS

7 Restrictive Intervention Safety Unsafe staff + Unsafe Service Users + Unsafe Restraint Techniques + Unsafe Environments + Unsafe organisations = Fatality & Injury & Abuse

8 Restraint Safety SAFE/UNSAFE TECHNIQUES

9 Restraint Safety Key mechanisms of restraint injury/ fatality:- Joint injury ( e.g. close packed position ) Uncontrolled take downs Soft tissue injury Restriction of respiration ( Respiratory Triad)

10 The Respiratory Triad Diaphragm Airway Lungs

11 Paterson B. Leadbetter D., Restraint and Sudden Death From Asphyxia, Nursing Times, November 4(9), 62-64, 1998.

12 Paterson B. Leadbetter D., Restraint and Sudden Death From Asphyxia, Nursing Times, November 4(9), 62-64, 1998.

13 Paterson B. Leadbetter D., Restraint and Sudden Death From Asphyxia, Nursing Times, November 4(9), 62-64, 1998.

14 Paterson B. Leadbetter D., Restraint and Sudden Death From Asphyxia, Nursing Times, November 4(9), 62-64, 1998.

15 Paterson B. Leadbetter D., Restraint and Sudden Death From Asphyxia, Nursing Times, November 4(9), 62-64, 1998.

16 Recovery Position

17 Basket holds 1

18 Basket holds Mutation

19 Restraint Safety 1. Some restraint techniques dangerous for everybody all of the time: Forceful prone Hyperflexion- Choke Holds, Supine ( face up) 2. Some restraint techniques are dangerous for some people all of the time Prone if you are obese (and especially if you have a big belly!) 3. Some restraint techniques are dangerous for some people some of the time Prone in context of a prolonged struggle acute agitation. 4. Some restraint techniques are dangerous because they have a habit of mutating These are fragile techniques A technique is deemed fragile if small adjustment (movement or pressure) to the procedure (either intentionally or unintentionally) are likely to result in intentional, or unintentional injury or severe pain to an individual. (Martin et al 2008) 5. Some restraint techniques seem largely safe for most people most of the time Restraint remains an intrinsically high risk activity

20 Restraint Safety SAFE/UNSAFE STAFF

21 Tradi/onal Staff Causal Assump/ons CALM TRAINING BAD INDIVIDUAL JUDGEMENT POOR SOUL MAD 21

22 Attribution and Emotion Perceptions that the behaviour is a) Controllable by the person b) Internally caused ( actor/observer) Associated with a) Higher levels of anger b) Lower optimism c) Less willingness to help (Dagnan & Cairns, 2005; Dagnan & Weston, 2006; Wanless & Jahoda, 2006). May lead to sabotage of others efforts to help 22

23 Restraint Safety SAFE/UNSAFE ORGANISATIONS

24 Sentinel Event Statistics JCAHO Data

25 UNSAFE ORGANISATIONS Blame Cultures Corrupted cultures Leaderless cultures Standards either unmonitored or unclear Convenience cultures Mindless cultures Profit driven cultures

26 Restrictive Intervention Safety The Unsafe Service User? SAFE/ UNSAFE SERVICE USERS

27 Restraint Safety Physical / psychological RISK FACTORS

28 Equip for equality 2011 Of those with a pre-existing medical condition, nearly one-third had one or more medical conditions that contraindicated the use of restraint and should have prevented its use. current cardiac compromise (44%) obesity (41%) current respiratory compromise (30%).

29 Risk Assessment in Critical Incidents Positional asphyxia Excited delirium Acidosis - prolonged struggle Psychotropic medication Medical History Psychological reaction to restraint In only 14 cases did the records contain information on prior physical or sexual abuse. In half of those cases, trauma contraindicated the use of restraints.

30 Restrictive Intervention Safety Unsafe medication?

31 Scenario acute stress reaction which constitute a risk factor for death in its own right via the catecholamine stress on the heart (Howie 1968, Goodfriend and Wolpert 1976, Case 1986). altered pain sensation allowing exertion far beyond normal physiologic limits without the patient experiencing subjective fatigue resulting in a severe metabolic acidosis (Hick et al 1999 p241). restraint may evoke vigorously continued struggle with potential that they will continue to struggle until they collapse or die (Mohr and Mohr 2000).

32 Learning Disability Census The census shows that two thirds inpatients (68 % or 2,220) had been given anti-psychotic ( Neuroleptic?) medication 93 % (2,064) had been given them on a regular basis. 40 % (889 of 2,220) of those given these drugs had experienced at least one episode of hands on restraint,

33 Anti-Psychotics ( Neuroleptics) People who use newer antipsychotic drugs are twice as likely as those who don't use any antipsychotics to have sudden cardiac death. Ray WA Chung CP, Murray KT, Hall K, Stein CM.(2009) Atypical antipsychotic drugs and the risk of sudden cardiac death. N English J Med;360(3):

34 Implications for Practice Put emphases on primary and secondary prevention rather than tertiary prevention. (How much is your service spending on each?) Recognise that restraint is inherently a high risk activity and manage it as such Reduce use of high risk (fragile procedures) NB Law of unintended consequences Recognise that high risk cultures significantly affect the risk of restraints being used and being used in an unsafe manner and explicitly tackle corrupted cultures