Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

Background: In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects). Methods: A secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016–2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed. Results: The study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%. Conclusions: The use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible. Keywords: Hospitals, Multilevel analysis, Organisational culture, Quality of health care, Restrain

Attitudes of Nursing Staff in Hospitals towards Restraint Use: A Cross-Sectional Study

The attitude of nursing staff towards restraint use can be decisive for whether restraints are used. So far, nursing staff’s attitudes have been studied primarily in long-term and mental health care settings, while findings from somatic acute care hospital settings are largely lacking. Therefore, we aimed to investigate (a) the attitudes of hospital nursing staff towards restraint use, and (b) the construct validity and reliability of a measurement instrument for use in hospital settings that was developed and validated in long-term care settings (Maastricht Attitude Questionnaire (MAQ)). Using a cross-sectional design, the attitudes of 180 nursing staff towards restraint use were assessed. The data were analysed descriptively and by means of regression analysis and factor analysis. We found that nursing staff in hospitals have a neutral attitude towards restraint use and that the MAQ, with minor adaptations, can be used in hospital settings, although further testing is recommended. Neutral attitudes of nursing staff have also been observed in long-term and mental health care settings, where changing attitudes were found to be challenging. Interventions at the national level (e.g., legal regulations) and management level (e.g., providing alternatives and changing institutional culture) are suggested

Restraint practice in the somatic acute care hospital: A participant observation study

Aims and Objectives We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective. Background A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the ‘insider’ view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased. Design A qualitative observation study design was employed. Methods Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR). Results A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak. Conclusions The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful. Relevance to clinical practice The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies

Restraining patients in acute care hospitals: a qualitative study on the experiences of healthcare staff

Aim: The focus was to explore the perceptions and experiences of healthcare workers with respect to the use of restraints in acute care hospitals. Design: The study followed a qualitative design. Methods: Three topic-based focus group interviews were conducted, involving 19 participants from the fields of nursing, physical therapy and medicine. For data collection and analysis, the method of mapping techniques for rapid qualitative data analysis was used. After discussing and validating the individual mind maps, all data were condensed to identify the key findings. Results: Participants described restraints as safety measures for the patients. The implementation of most restraints was led by nurses. The use of restraints differed significantly, even in the interprofessional team. Attitudes and experiences were the main determinants for restraint use. Nurses asked for more discussion about restraints in the team, for more support at an interprofessional level and for better guidelines to help with the decision-making process

Restraint use as a quality indicator for the hospital setting: a secondary data analysis

INTRODUCTION: A reduction in restraint use is recommended for all health care settings. For this purpose, local or national quality measurement and improvement initiatives have been implemented in various countries, primarily in the mental health and long-term care settings. However, restraints are also frequently used in the somatic acute care hospital setting, and strong variations in their prevalence rates have been reported. Therefore, the aim of this study was to reanalyse existing data on restraint use in Swiss hospitals in order to assess the potential of restraint use as a national quality indicator for the hospital setting. METHODS: Using a cross-sectional, multicentre design, data were collected between 2016 and 2018 as part of the ANQ"s (Swiss National Association for Quality Development in Hospitals and Clinics) "falls and pressure ulcers" national prevalence measurement in acute care hospitals in Switzerland. The hospitals measured restraint use on a voluntary basis in addition to falls and pressure ulcers. All medical specialities and patients aged 18 and over who gave their informed consent were included in the measurement. Descriptive and multilevel regression analyses were performed using institutional, ward and patient-level data relating to restraint use. RESULTS: The sample consisted of 18,938 inpatients from 55 hospitals. The 30-day prevalence rate of patients with at least one restraint was 10.2% (n = 1933). The riskadjusted hospital comparison revealed that hospitals in Switzerland differ significantly in their restraint use, even after adjusting for patient characteristics. In total, 10 hospitals used restraints significantly less and 12 used them significantly more than the national average. CONCLUSION: Restraint use varies significantly between Swiss hospitals: 40% of all hospitals used restraints either significantly more or significantly less often than the average. In comparison to the other quality indicators, this is a very high value, indicating potential for improvements in the quality of care. Since restraint use is associated not only with quality of care, but also with human rights, these large differences seem questionable from a professional, ethical and legal point of view. Clearer and binding regulations in combination with monitoring and benchmarking of restraint use in hospitals, such as with a national quality indicator, seem necessary. These would help to ensure that restraint use is in alignment with professional values, as well as ethical and legal requirement

Which factors influence the prevalence of institution‐acquired falls? Results from an international, multi‐center, cross‐sectional survey

Purpose: Falls are a highly prevalent problem in hospitals and nursing homes with serious negative consequences such as injuries, increased care dependency, or even death. The aim of this study was to provide a comprehensive insight into institution-acquired fall (IAF) prevalence and risk factors for IAF in a large sample of hospital patients and nursing home residents among five different countries. Design: This study reports the outcome of a secondary data analysis of cross-sectional data collected in Austria, Switzerland, the Netherlands, Turkey, and the United Kingdom in 2017 and 2018. These data include 58,319 datapoints from hospital patients and nursing home residents. Methods: Descriptive statistics, statistical tests, logistic regression and generalised estimating equation (GEE) models were used to analyse the data. Findings: IAF prevalence in hospitals and nursing homes differed significantly between the countries. Turkey (7·7 %) had the highest IAF prevalence rate for hospitals and Switzerland (15·8 %), for nursing homes. In hospitals, our model revealed that IAF prevalence was associated with country, age, care dependency, number of medical diagnoses, surgery in the last two weeks, and fall history factors. In nursing homes, care dependency, diseases of the nervous system, and fall history were identified as significant risk factors for IAF prevalence. Conclusions: This large-scale study reveals that the most important IAF risk factor is an existing history of falls, independent of the setting. Whether a previous fall has occurred within the last 12 months is a simple question that should be included on every (nursing) assessment at the time of patient or resident admission. Our results guide the development of tailored prevention programs for persons at risk of falling in hospitals and nursing homes

Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: Secondary analysis of a prospective randomized trial.

BACKGROUND Among medical inpatients at risk of malnutrition, the use of individualized nutritional support during the hospital stay was found to reduce complications and improve mortality at short-term. We evaluated clinical outcomes at 6-months follow-up. METHODS We randomly assigned 2028 patients to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or hospital food as usual (control group) during the hospital stay. The intervention was discontinued at hospital discharge and further nutritional support was based on the discretion of the treating team. We had complete follow-up information of 1995 patients (98%), which were included in the final analysis. The primary endpoint was all-cause mortality at 6-months. Prespecified secondary end points included non-elective hospital readmissions, functional outcome and quality of life. RESULTS At 6-month, 231 of 994 (23.2%) intervention group patients had died compared to 246 of 999 (24.6%) control group patients, resulting in a hazard ratio for death of 0.90 (95%CI 0.76 to 1.08, p = 0.277). Compared to control patients, intervention group patients had similar rates of hospital readmission (27.3% vs. 27.6%, HR 1.00 (95%CI 0.84 to 1.18), p = 0.974), falls (11.2% vs. 10.9%, HR 0.96 (95%CI 0.72 to 1.27), p = 0.773) and similar quality of life and activities of daily living scores. INTERPRETATION While individualized nutritional support during the hospital stay significantly reduced short-term mortality, there was no legacy effect on longer term outcomes. Future trials should investigate whether continuation of nutritional support after hospital discharge reduces the high malnutrition-associated mortality rates in this vulnerable patient population. TRIAL REGISTRATION ClinicalTrials.gov number, NCT02517476