|
A restraint case study [This article appears here in its original form and with the permission of www.oltca.com. It appeared in the March 2009 issue of Long Term Care magazine.] By Eliana Caranci and Jennifer Allen June 2009- WP is an 85-year-old man who lives in a long-term care home. He has been diagnosed with dementia, multiple cerebral vascular accidents and a history of skin breakdown on his coccyx. WP uses a mechanical lift for transfers and requires nursing staff assistance for bed mobility. During the day, he uses a manual tilt wheelchair with an air cushion to facilitate proper positioning and comfort and to assist in shifting his weight to prevent further skin breakdown. Due to the weight and height of the wheelchair, WP requires assistance for wheelchair mobility. The wheelchair has a two-point ‘auto-style' seatbelt, which is not considered a restraint because WP can unbuckle it as he pleases. As a result of the dementia diagnosis, WP is deemed incapable of making his own health care decisions. WP's wife is his substitute decision maker (SDM) and has made an informed decision against using a wheelchair restraint. Staff begin to observe WP frequently unbuckling the seatbelt, which causes him to slide forward on the cushion and nearly fall out of the wheelchair. They also report that he is restless and agitated at times in the wheelchair. In an effort to protect him, the staff decide to use a temporary padded belt that can be fastened behind him. This belt is a form of restraint since WP cannot physically reach the buckle to unfasten it. The staff communicate their concerns regarding WP's safety and the lack of restraint to the occupational therapist (OT) who initially provided him with the wheelchair. After discussions with staff and reviewing the documentation in WP's chart regarding the number and details of these sliding occurrences, the OT decides to contact WP's wife. During their discussion, WP's wife is made aware that her husband is frequently sliding in the wheelchair—at times unbuckling the seatbelt—and is at risk for falls. The occupational therapist suggests reasons why this may be happening based on staff feedback, documentation and her professional opinion. WP's wife also provides helpful information about WP, stating that he used to be a very active man. She reports that he is upset about being in a wheelchair and being prevented from moving around independently. She worries that the use of a seatbelt that he cannot unbuckle might make him more upset or agitated. His wife also reports that WP sometimes complains of pain in his legs and back after being in the wheelchair throughout the day. She is also concerned about WP wanting to get out of the wheelchair to get to the toilet. After reviewing all of the risks and benefits, WP's wife decides, for quality of life reasons, that staff should not use a wheelchair seatbelt. Even though she has made this decision, she is concerned about her husband's overall safety from sliding. Together, the OT and WP's wife come up with restraint alternatives that can be trialed. Knowing that feedback from the rest of the staff is also very important, the occupational therapist calls an interdisciplinary team meeting to discuss alternatives to restraints and the SDM's informed decision to not use a wheelchair restraint. Restraint alternatives for WP The alternatives to restraints on WP's care plan, which staff andWP's wife agree should be trialed, are as follows: • Ensure wheelchair is tilted (and change the degree of tilt throughout the day). Gravity of tilt will prevent WP from sliding forward and prevent skin breakdown. • Trial a lighter-weight tilt wheelchair that has a low seat-to-floor height so that WP can independently foot propel. • Trial different cushions (e.g., an air/foam combination) to accommodate foot propulsion and prevent sliding. • Trial different backrests to limit back pain. • Change the seatbelt from a two-point to four-point belt to ensure proper pelvic positioning and help to prevent sliding. • Consider a chair-check alarm-belt that would notify staff when WP attempts to unbuckle or slide out of the wheelchair. • Move WP to different locations to allow for changes of scenery. Move him closer to common areas, when possible, so that staff can easily observe him. • Engage WP in unit activities to monitor him and to keep him occupied. • Provide one to two rest periods in bed daily to minimize WP's back and leg pain. • Liaise with WP's physician about his pain and the agitation that occasionally occurs in the wheelchair and examine the potential need for medication. • Toilet WP after all meals so that he does not feel any urgency to get out of the wheelchair and visit the bathroom. • Educate staff regarding the SDM's informed decision to not use a seatbelt. • Reinforce the need for all interdisciplinary team members to document any observations regarding WP's wheelchair seating and safety concerns. Outcome WP remains restraint free and has had no documented falls or near misses since the alternatives to restraints were implemented. Furthermore, WP's wife feels that her husband is more content and comfortable in his wheelchair, resulting in improved quality of life. Staff are able to care for WP without incident or imminent concern for his safety. A key to the success of WP's care plan, which outlined alternatives to wheelchair restraints, was its collaborative development. Restraint reduction and prevention is only effective if all team members are involved, decisions are based on staff resources and limitations and the resident's needs and concerns are considered. Legal responsibilities and the ethical importance of involving the resident and/or SDM in making decisions must also be taken into account. Eliana Caranci is an occupational therapist at St. Joseph's Health Care, London ( Parkwood Hospital ). She currently works in the Veterans' Dementia Care Program. Jennifer Allen is an occupational therapy/physiotherapy assistant in the Veterans' Dementia Care Program. |