Sustaining self-restraint until the middle of the COVID-19 pandemic in Tokyo.

We analyzed time-series changes in people's purpose-specific mobility characteristics owing to the COVID-19 pandemic in the Tokyo area of Japan, where only legally non-binding requests for self-restraint were enforced. A multiple regression analysis was conducted with the objective variable being the mobile population in the Tokyo area per 500 m square grid estimated from mobile spatial statistical data for 2 years from 10/01/2019 to 9/30/2021. This study period ranges from pre- to mid-pandemic. The explanatory variable was the number of buildings by type per 500 m square grid obtained from building statistical data to determine behavioral changes by mobility purpose. The analysis revealed that self-restraint was sustained until the middle of the COVID-19 pandemic in the Tokyo area regardless of the purpose of mobility and whether a state of emergency was declared.

Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis.

BACKGROUND: Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited. OBJECTIVES: To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use. DESIGN: Retrospective cohort study with a time series analysis. PARTICIPANTS: Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020. MAIN MEASURES: We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR). KEY RESULTS: We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83). CONCLUSIONS: The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.

Increase in coercive measures in psychiatric hospitals in Germany during the COVID-19 pandemic.

OBJECTIVE: To examine whether the pandemic in 2020 caused changes in psychiatric hospital cases, the percentage of patients exposed to coercive interventions, and aggressive incidents. METHODS: We used the case registry for coercive measures of the State of Baden-Wuerttemberg, comprising case-related data on mechanical restraint, seclusion, physical restraint, and forced medication in each of the State's 31 licensed hospitals treating adults, to compare data from 2019 and 2020. RESULTS: The number of cases in adult psychiatry decreased by 7.6% from 105,782 to 97,761. The percentage of involuntary cases increased from 12.3 to 14.1%, and the absolute number of coercive measures increased by 4.7% from 26,269 to 27,514. The percentage of cases exposed to any kind of coercive measure increased by 24.6% from 6.5 to 8.1%, and the median cumulative duration per affected case increased by 13.1% from 12.2 to 13.8 hrs, where seclusion increased more than mechanical restraint. The percentage of patients with aggressive incidents, collected in 10 hospitals, remained unchanged. CONCLUSIONS: While voluntary cases decreased considerably during the pandemic, involuntary cases increased slightly. However, the increased percentage of patients exposed to coercion is not only due to a decreased percentage of voluntary patients, as the duration of coercive measures per case also increased. The changes that indicate deterioration in treatment quality were probably caused by the multitude of measures to manage the pandemic. The focus of attention and internal rules as well have shifted from prevention of coercion to prevention of infection.

[Monitoring of coercive measures and compulsory treatment in Germany]. / Monitoring von Zwangsmaßnahmen und Zwangsbehandlungen in Deutschland.

Epidemiological registers on the burden of disease and adverse events (deaths, serious side effects, etc.) play an important role in the management, evaluation, and improvement of healthcare treatment for the population. This also applies to coercive measures in the psychiatric healthcare system. Such registers only became feasible on a broad basis due to the availability of electronic medical records and steadily increasing computing capacities; however, in most German states, registers have not been implemented. Data protection problems must be taken into account in the collation of person-related data but can be solved by appropriate pseudonymization procedures taking the prerequisites of data parsimony into account. Extensive data are now available from the Baden-Wuerttemberg register for coercive measures, which has been in existence since 2015 and which enabled, for instance, evaluating the consequences of the changes to the law following the 2018 ruling of the Federal Constitutional Court on mechanical restraint and the consequences of the coronavirus pandemic. In the meantime, there are also state-wide data collections in some other German states; however, unlike in Baden-Wuerttemberg, these registers do not include measures under guardianship law. A nationwide register for coercive measures, compulsory treatment and involuntary detention has justifiably repeatedly been demanded for a long time. A major obstacle is the historically developed separation between the responsibility of the German states for the detention regulated by public law and the Federal State for the scope of application of the guardianship law.

[Impact of family restrictions during COVID-19 pandemic on the use of physical restraint in an acute hospital: An observational study]. / Impacto de las restricciones de visitas de familiares de pacientes por la pandemia de COVID-19 sobre la utilización de la contención mecánica en un hospital de agudos: estudio observacional.

INTRODUCTION: During the worldwide pandemic of COVID-19 caused by coronavirus SARS-CoV-2, hospitals developed contingency plans that transformed and reorganized the hospital activity. One of the measures was to restrict access to family members of hospitalized patients. The presence of the patient's family is considered an alternative to physical restraint. The aim of this study is to compare the use of physical restraint in hospitalized patients in an acute care hospital during the previous period of the pandemic of COVID-19 with the post-confinement period with hospitals being still closed to family. MATERIAL AND METHODS: We made an observational study that compares the prevalence of physical restraint in an acute care hospital during the previous period to the alarm state (February 2020) with the second period, when visits where restricted (May 2020). From the clinical history of the patients with physical restraint we collected the following variables: sex, diagnostic, hospital admission unit, reason for using physical restraint, localization, length, type of material, registration in the medical record, information given to the family, alternatives to the physical restraint and injuries related to the physical restraint. RESULTS: We evaluated 690 patients: 388 during the previous period and 320 during the second period. From all patients, 29 needed physical restraint. The use of physical restraint went from 8 (2%) to 21 (7%) (p=0.003). In the second period, a not statistically significant increase in continuous physical restraint was identified compared to the first period. CONCLUSIONS: The physical restraint prevalence has been superior during the second period in which families were not present with the hospitalized patients.

An Educational Intervention to Decrease the Number of Emergency Incidents of Restraint and Seclusion on a Behavioral Health Unit.

BACKGROUND: The objective of this study was to implement an educational intervention on an inpatient, behavioral health care unit with the goal of reducing the number of crisis interventions of seclusion or restraint. METHOD: A quasi-experimental pretest and posttest design using De-escalate Anyone, Anywhere, Anytime training was employed with a focus of an increased understanding of a range of de-escalation techniques to use instead of restraint and seclusion. RESULTS: A convenience sample of 21 mental health employees participated in the training. The rates of restraint declined from a mean of 6 preintervention to 2 postintervention. The number of seclusions on the designated unit declined from a mean of 4.33 preintervention to a mean of 1.667 postintervention. CONCLUSION: These data suggest that an educational intervention to increase the knowledge of direct care staff in a broad range of de-escalation techniques resulted in a reduction in the use of restraint and seclusion. Ongoing training for nursing staff may reassure them of the efficacy of alternative methods for dealing with aggressive patients. [J Contin Educ Nurs. 2022;53(2):70-76.].

Seclusion Reduction on an Adult Inpatient Psychiatric Unit: A Quality Improvement Project.

Seclusion practices have traditionally been used in psychiatry to maintain patient and staff safety. Despite negative emotional consequences for all involved parties and the movement toward patient-centered care, these practices continue in in-patient psychiatric units across the United States. The purpose of the current quality improvement project was to decrease the rate of seclusion events on an adult inpatient psychiatric unit through the implementation of a standard debriefing process based on the National Association of State Mental Health Program Directors' Six Core Strategies for Reducing Seclusion and Restraint Use. In 2020, the seclusion rates at the project site were above state and national benchmarks. Post-intervention, the seclusion hours per 1,000 patient care hours increased by 16% (0.38 to 0.44); however, the mean duration of each seclusion episode decreased by 10% (158 minutes to 142 minutes). Intervention compliance was low, including interprofessional participation. These findings demonstrate the need to address seclusion practices with an evidence-based solution, such as debriefing, coupled with adequate support from interprofessional leadership. [Journal of Psychosocial Nursing and Mental Health Services, 60(6), 27-32.].

Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan.

INTRODUCTION: The coronavirus disease (COVID-19) pandemic has caused unprecedented challenges for the medical staff worldwide, especially for those in hospitals where COVID-19-positive patients are hospitalized. The announcement of COVID-19 hospital restrictions by the Japanese government has led to several limitations in hospital care, including an increased use of physical restraints, which could affect the care of elderly dementia patients. However, few studies have empirically validated the impact of physical restraint use during the COVID-19 pandemic. We aimed to evaluate the impact of regulatory changes, consequent to the pandemic, on physical restraint use among elderly dementia patients in acute care hospitals. METHODS: In this retrospective study, we extracted the data of elderly patients (aged > 64 years) who received dementia care in acute care hospitals between January 6, 2019, and July 4, 2020. We divided patients into two groups depending on whether they were admitted to hospitals that received COVID-19-positive patients. We calculated descriptive statistics to compare the trend in 2-week intervals and conducted an interrupted time-series analysis to validate the changes in the use of physical restraint. RESULTS: In hospitals that received COVID-19-positive patients, the number of patients who were physically restrained per 1,000 hospital admissions increased after the government's announcement, with a maximum incidence of 501.4 per 1,000 hospital admissions between the 73rd and 74th week after the announcement. Additionally, a significant increase in the use of physical restraints for elderly dementia patients was noted (p = 0.004) in hospitals that received COVID-19-positive patients. Elderly dementia patients who required personal care experienced a significant increase in the use of physical restraints during the COVID-19 pandemic. CONCLUSION: Understanding the causes and mechanisms underlying an increased use of physical restraints for dementia patients can help design more effective care protocols for similar future situations.

Interdisciplinary Perspectives on Restraint Use in Aged Care.

Restraint use in Australian residential aged care has been highlighted by the media, and investigated by researchers, government and advocacy bodies. In 2018, the Royal Commission into Aged Care selected 'Restraint' as a key focus of inquiry. Subsequently, Federal legislation was passed to ensure restraint is only used in residential aged care services as the 'last resort'. To inform and develop Government educational resources, we conducted qualitative research to gain greater understanding of the experiences and attitudes of aged care stakeholders around restraint practice. Semi-structured interviews were held with 28 participants, comprising nurses, care staff, physicians, physiotherapists, pharmacists and relatives. Two focus groups were also conducted to ascertain the views of residential and community aged care senior management staff. Data were thematically analyzed using a pragmatic approach of inductive and deductive coding and theme development. Five themes were identified during the study: 1. Understanding of restraint; 2. Support for legislation; 3. Restraint-free environments are not possible; 4. Low-level restraint; 5. Restraint in the community is uncharted. Although most staff, health practitioners and relatives have a basic understanding of restraint, more education is needed at a conceptual level to enable them to identify and avoid restraint practice, particularly 'low-level' forms and chemical restraint. There was strong support for the new restraint regulations, but most interviewees admitted they were unsure what the legislation entailed. With regards to resources, stakeholders wanted recognition that there were times when restraint was necessary and advice on what to do in these situations, as opposed to unrealistic aspirations for restraint-free care. Stakeholders reported greater oversight of restraint in residential aged care but specified that community restraint use was largely unknown. Research is needed to investigate the extent and types of restraint practice in community aged care.

Why are physical restraints still in use? A qualitative descriptive study from Chinese critical care clinicians' perspectives.

OBJECTIVES: To understand why critical care clinicians still implement physical restraints, to prevent unplanned extubation and to explore the driving factors influencing the decision-making of physical restraints use. DESIGN: A qualitative descriptive design was used. The data were collected through one-to-one, semistructured interviews and analysed through the framework of thematic analysis. PARTICIPANTS AND SETTING: The study was conducted from December 2019 to May 2020 at one general intensive care unit (ICU) and one emergency ICU in a general tertiary hospital with 3200 beds in Hangzhou, China. The sampling strategy was combined maximum variation sampling and criterion sampling. RESULTS: A total of 14 clinicians participated in the study. The reason why critical care clinicians implemented physical restraints to prevent unplanned extubation was that the tense healthcare climate was caused by family members' rejection of mismatched expectations. As unplanned extubation was highly likely to create medical disputes, hospitals placed excessive emphasis on unplanned extubation, which resulted in a lack of analysis of the cause of unplanned extubation and strict measures for dealing with unplanned extubation. The shortage of nursing human resources, unsuitable ward environments, intensivists' attitudes, timely extubation for intensivists, nurse experiences and the patient's possibility of unplanned extubation all contributed to the decision-making resulting in the use of physical restraints. CONCLUSIONS: Although nurses played a crucial role in the decision-making process of using physical restraints, changing the healthcare climate and the hospital management mode for unplanned extubation are fundamental measures to reduce physical restraints use.

COVID-19: A systematic evaluation of personal protective equipment (PPE) performance during restraint.

BACKGROUND: Restraint is widely practised within inpatient mental health services and is considered a higher-risk procedure for patients and staff. There is a sparsity of evidence in respect of the efficacy of personal protective equipment (PPE) used during restraint for reducing risk of infection. METHODS: A series of choreographed restraint episodes were used to simulate contact contamination in research participants playing the roles of staff members and a patient. For comparison, one episode of simulated recording of physical observations was taken. Ultraviolet (UV) fluorescent material was used to track the simulated contact contamination, with analysis undertaken using established image registration techniques of UV photographs. This was repeated for three separate sets of PPE. RESULTS: All three PPE sets showed similar performance in protecting against contamination transfer. For teams not utilising coveralls, this was dependent upon effective cleansing as part of doffing. There were similar patterns of contamination for restraint team members assigned to specific roles, with hands and upper torso appearing to be higher-risk areas. The restraint-related contamination was 23 times higher than that observed for physical observations. DISCUSSION: A second layer of clothing that can be removed showed efficacy in reducing contact contamination. PPE fit to individual is important. Post-restraint cleansing procedures are currently inadequate, with new procedures for face and neck cleansing required. These findings leave scope for staff to potentially improve their appearance when donning PPE and engaging with distressed patients.