Frances Healey on the use of restraint vests and why the UK is lucky to have avoided introducing them.
This article is in response to Nursin’ USA - Why do UK nurses consider restraints unacceptable?
The consequences of a fall in hospital can be severe, and the risk of falls and injury are a great cause of anxiety to nurses who want to keep their patients safe. But advocating that nurses in the UK should copy their American counterparts by tying patients to their beds or chairs with restraining vests is not the way forward. The Royal College of Nursing in their guidance on restraint (RCN, 2008) state that “Vest, belt or cuff devices specifically designed to stop people getting out of beds or chairs are in relatively common use in hospital and care home settings in many countries outside the UK, including in Europe, the USA and Australia. These devices are not acceptable in the UK.”
Undoubtedly there are situations where nurses have a duty to intervene to keep patients without capacity safe, even if this involves restraining them - we would and should try to stop a delirious patient walking out of hospital – and the RCN guidance gives good advice on difficult situations where restraint as a last resort may or may not be appropriate. But there are very sound reasons why their guidance outlaws vest, belt and cuff devices. Firstly, these devices have been associated with a series of deaths from asphyxiation – a patient struggling to escape the vest may tighten it around their chest or neck (Capezuti, 2004). Patients tied to their beds or chairs with these devices have much greater likelihood of developing pressure ulcers and thromboses, and are more likely to die in hospital (Evans et al, 2003). Incontinence becomes almost inevitable, and patients already disorientated by a hospital admission will only become more distraught if they find themselves tied to their bed; the recollections of patients restrained in this way make harrowing reading (Mion et al, 1996).
And in addition to the direct harm they can cause, they do not reduce the risk of falls. In the short term, an agitated patient may still fall, but with their chair or wheelchair landing on top of them. In the longer term, even one or two days tied to their bed or chair will affect the strength and balance of a frail older person, so unless you plan to tie them down for the rest of their life, their time in the restraining vest will have left them weakened and even more vulnerable to falls (Mahoney, 1998). This may be why countries where their use is permitted have falls rates greater than (Schwendimann et al, 2006)or equal to (Krauss et al. 2007)rates from England and Wales (National Patient Safety Agency, 2010), and why organisations that stop using these devices find that fewer falls occur (Evans, 2002).
And we have a legal system that rightly protects vulnerable adults from unjustified deprivation of liberty (Mental Capacity Act, 2005). The responses to Sara’s opinion piece shows just how much we need this, as some suggest these vests should be used not only for falls prevention but to ensure patients with dementia can’t annoy other patients. And whilst Sara’s comparison of older patients with toddlers is one that makes me uncomfortable, it is worth reflecting that strapping toddlers into their highchairs for days at a time is also unacceptable, however ‘safe’ that might make them.
Far from being accepted as good practice in the rest of the world, most other countries are making dedicated efforts to eliminate or drastically curtail the use of these devices (Australian Commission for Safety and Quality in Healthcare, 2009). They would see the UK as lucky for having avoided introducing them. This is not to say we should be complacent; the use of medication to control behaviour – chemical restraint – also causes serious harm. But substituting restraining vests for chemical restraint is not the answer either; there are a range of far more positive steps that Sara and all other nurses who care about preventing falls can take, and many resources that are available to help them (Patient Safety First, 2009) including at patientsafetyfirst.nhs.uk, profane.eu.org,www.scie.org.uk/socialcaretv/ and institute.nhs.uk.
About the author
Frances Healey is head of patient safety at the National Patient Safety Agency