Standards of Medical Care Based on Consensus Rather than Evidence: The Case of Routine Bedrail Use for the Elderly

Programme d'intervention visant à réduire l'utilisation des contentions physiques dans des unités de soins de longue durée — mise en oeuvre et effets sur le personnel soignant

This study aimed at (a) developing a restraint reduction program, (b) describing its implementation in long-term care units, and (c) examining its effects on care staff's perceptions of and knowledge about the use of restraints. The program was composed of three parts: consciousness-raising meetings, staff education, and clinical follow-up. The study was a randomized, controlled clinical trial with eight intervention care units (five nursing homes) and 11 controls (five additional nursing homes). Care staff was surveyed at two time intervals over a 7-month period (pre- and post-test intervention; intervention care units: N = 171 [T0] and N = 158 [T1]; controls: N = 181 [T0] and N = 166 [T1]). The implementation of the program was successful and results showed significant changes in care staff perceptions of and knowledge about the use of restraints.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

Predisposing factors for occasional and multiple falls in older Australians who live at home

This study, which was part of a larger study on the Health Status of Older People conducted in Melbourne, Australia, aimed to identify factors that discriminate between multiple and occasional falls amongst older people living at home. It used a survey of 1000 Australians aged 65 years and over. Subjects were classified as multiple fallers (two or more falls in the past year), occasional fallers (one fall in the past year), or non-fallers. Twenty-nine percent of older people who lived at home reported falling once or more in the previous 12 months. Nearly 20% of older people fell once in the previous 12 months and just under 10% fell more than once. Occasional fallers were more likely to be women (OR 1.75, 95% CI 1.26 to 2.45), to have reported back pain (OR 1.54, 95% CI 1.10 to 2.16) and were nearly twice as likely to have more than three medical conditions compared to non-fallers (OR 1.88, 95% CI 1.22 to 2.90). Multiple fallers were also more likely to be women (OR 1.61, 95% CI 1.03 to 2.51). More multiple fallers (17%) than occasional fallers (9%) reported being very afraid of falling. Intervention strategies should take into account these differing predisposing factors for multiple and occasional falls.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.

Side rail use and bed-related fall outcomes among nursing home residents

OBJECTIVES

To analyze the effect of physical restraint reduction on nighttime side rail use and to examine the relationship between bilateral side rail use and bed-related falls/injuries among nursing home residents.

DESIGN

Secondary analysis of data collected in a longitudinal, prospective clinical trial designed to reduce restraint use.

SETTING

Three nonprofit nursing homes.

PARTICIPANTS

To examine the first question regarding the effect of physical restraint reduction on side rail usage, we included all nursing home residents who survived a 1-year data collection period (n = 463). To answer the second research question concerning the relationship between side rail status and bed-related falls, subjects' side rail status for each of the four data collection periods was compared. The sample for this analysis includes only those with consistent side rail status (n = 319) for the four observations periods: either 0/1 side rail (n = 188) or 2 (bilateral) side rails (n = 131).

MEASUREMENTS

Side rail and restraint status was directly observed by two research assistants, twice each night shift (10 p.m.-6 a.m.) for three nights at each of four data collection points. Nighttime fall-related outcome data were obtained from a review of nursing home incident reports during the entire 1-year data collection period (T1 through T4). Cognitive status was measured using the Folstein Mini-Mental State Examination. Functional and behavioral status was obtained using subscales of the Psychogeriatric Dependency Rating Scale.

RESULTS

Over a 1-year period, there was an increase in the proportion of bilateral side rail use for all three nursing homes. Based on the multiple logistic regression analysis, there was no indication of a decreased risk of falls or recurrent falls with bilateral side rail use, controlling for cognition and functional and behavioral status (adjusted odds ratio (AOR) = 1.13, 95% confidence interval (CI) = 0.45,2.03). Similarly, bilateral side rail use did not reduce the risk of recurrent falls, controlling for cognition and functional status (AOR = 1.25, 95% CI = 0.33,4.67).

CONCLUSION

Despite high usage of bilateral side rails, they do not appear to significantly reduce the likelihood of falls, recurrent falls, or serious injuries. Bed-related falls remain clinically challenging. The data from this study, coupled with increasing reports of side rail-related injuries and deaths, compel us to seek and empirically test alternative interventions to prevent bed-related falls.

Perceptions of older people who have experienced physical restraint

It is well documented that the use of physical restraints on older people has been linked to negative clinical outcomes. However, less is known about the personal perspective of those who have been restrained. This study examines the perceptions of older people who have experienced physical restraints in a rehabilitation ward. A purposive sample was used of 17 male and female patients who were restrained. The patients were interviewed using the Subjective Experience of Being Restrained instrument (Strumpf and Evans, 1988) which is a semi-structured interview schedule. The most commonly used restraint devices included side rails, screw-on tabletops and reclining chairs. The data were analysed using content analysis. The results indicate mixed feelings regarding physical restraints. Patients' impressions of physical restraints included indifference of the devices to their perceived safety value. Overall, a minority of patients (n = 4) had positive feelings about physical restraints as they provided a sense of security to them. However, the negative comments of the patients were more prevalent and their responses were categorized in terms of institutional control, ritualised care, entrapment and discomfort, and possible alternatives.

Faulty assumptions associated with the use of restraints with children

TOPIC

The use of restraints in nursing and other professions has a long and troubling history, particularly in psychiatric settings. No research evidence has demonstrated restraints to be therapeutically effective. A number of faulty assumptions appear to support the continued practice of this unproven and potentially dangerous intervention.

PURPOSE

To present and refute several faulty assumptions using the empirical literature and theory, and to discuss alternatives based on the developmental-ecological theoretical framework for responding to crises in children.

SOURCES

Extant empirical literature.

CONCLUSION

Alternatives to restraints must be investigated and developed to replace the current reactive, crisis-management orientation of practice.

Relatives' perceptions of side rail use on the older person in hospital

With an increasing emphasis on improving standards in the care of older people, the use of physical restraints has received growing attention in the nursing literature. Physical restraint use has been likened to abuse as it impedes the movement of a person, encourages dependence on staff and denies autonomy. Side rails (cot sides, bed rails) can be considered as a physical restrain device. The therapeutic use of restraint has not previously been adequately explained. Furthermore, there is a dearth of literature examining the personal experience of physical restraint use. The Family Interview Guide (Strumpf and Evans, 1988) was used to explore perceptions of nine relatives whose family had side rails used during their care in an older person ward. The findings of the study suggest that while families place value on the perceived safety function of side rails, they nonetheless have worries about their use. These pertain to the risk of patient entrapment and possible injury. Patients' relatives associated side rails with ritualized practice in gerontology and make suggestions for the re-design of side rails. The study also highlights the potential for increased family participation in the decision to use side rails.

A prolegomenon on restraint of children: implicating constitutional rights

News media and advocacy groups have brought to public attention a disturbing number of recent deaths proximal to the use of physical restraints. This paper examines the evidence indicating that use of these procedures can be dangerous to patients; explores the theoretical basis and practical application of restraints; and argues not only that their use may be unethical as a therapeutic intervention, but that it may have constitutional implications.

An analysis of falls in the hospital: can we do without bedrails?

OBJECTIVES

To determine the effects of introduction of a bedrail policy, and an educational program, on patient falls and fall-related injuries.

DESIGN

A prospective "Before and After" design.

PARTICIPANTS AND SETTING

All patients admitted during 1 calendar year in an assessment, treatment, and rehabilitation unit for older people.

INTERVENTION

A policy change for the use of bedrails (restricting their use) and an educational program about their effects.

MEASUREMENTS

Patient fall rates -- all falls and around the bed falls -- and patient and staff injuries.

RESULTS

There was a significant reduction in the number of beds with bedrails attached after the policy introduction (mean of 40/135 vs 18.5/135, respectively, P = .02), but the fall rate (either total or around the bed) did not change significantly. Serious injuries were significantly less common after the bedrail policy was introduced (P = .008), with fewer head injuries.

CONCLUSIONS

Reducing the use of bedrails did not alter patient fall rates significantly, but it was associated with a reduction in serious injuries. Unless it can be shown that bedrails are beneficial, their continued use in older patients must be seriously questioned.

Individualized assessment and intervention in bilateral siderail use

The use of bilateral siderails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. This article presents an individualized assessment for evaluating siderail use to guide nurses in managing resident characteristics for falling out of bed and intervening for high-risk residents. The individualized assessment is consistent with federal resident assessment instrument requirements and includes risk factors specific to falls from bed.

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

A restraint on restraints: the need to reconsider the use of restrictive interventions

Children with behavior problems are put in units with milieu therapy for the support and guidance of a specialized health care team, supposedly experts in the care of children with these unique and urgent needs. The reality of such units, however, is that those with the most contact with the children are often inadequately prepared, both in terms of knowledge and skills, to manage disruptive behaviors. As a result, the milieu that is supposed to provide support and structure can actually exacerbate the trauma for the vulnerable child. Preliminary data are presented from an ongoing study that is investigating the experiences and memories of formerly hospitalized children. Three types of traumatic experiences are described: vicarious trauma, alienation from staff, and direct trauma. Many of the traumatic events endured by child patients are the result of an inappropriate use by staff of power and force. There was a marked lack of understanding by the children of why given interventions were used. Although coercive interventions are sometimes necessary, ethical, legal, and other professional considerations make it clear that more work is needed. Research to identify the patterns of lack of knowledge and skills, as well as to develop appropriate interventions are recommended.

Deaths caused by bedrails

OBJECTIVES

To determine how bedrails cause death in order to suggest clinical and ergonomic changes to prevent such deaths and to promote research to improve the use and design of bed systems.

DESIGN

A review of reports of adult deaths and injuries from bedrails contained in the United States Consumer Product Safety Commission Death Certificate File and its Reported Incidents File and its National Injury Information Clearinghouse Accident Investigations from 1993 to 1996. Deaths involving the use of vest restraints were excluded. We reconstructed, reenacted, and have graphically depicted major patterns of deaths. A review of the literature to 1966 was also done.

RESULTS

The 74 deaths described are categorized into three types: (1) 70% were entrapments between the mattress and a rail so that the face was pressed against the mattress, (2) 18% were entrapment and compression of the neck within the rails, and (3) 12% were deaths caused by being trapped by the rails after sliding partially off the bed and having the neck flexed or the chest compressed.

CONCLUSIONS

Deaths from bedrails are underrecognized and preventable clinical events that can occur in any medical setting. Preventing these events will require a unified redesign of the relationships between rails, mattresses, and beds, which are now often assembled and used as separate products. Clinicians can prevent many of these deaths by using bedrails much more judiciously, confirming the proper relationships between beds, rails and mattresses, and using alarms.

Research-based practice: reducing restraints in an acute care setting--phase I

The purpose of this research utilization project was to select and implement a research-based Restraint Education Program for reducing the use of restraints in an acute care setting by changing the perception of the restraint coordinators about restraints in the direction of decreased importance. The Iowa Model, Research Based Practice to Promote Quality Care (Titler et al., 1994) was selected to guide the change process. A multidisciplinary team reviewed the restraint policy and procedure, new restraint products and alternative restraint methods. After a review of the literature on restraint education programs, the committee concluded that education was the key component in decreasing the use of physical restraints. The research-based Restraint Education Program developed by Drs. Strumpf and Evans was selected as the educational program. Education sessions were developed and a pilot study was conducted with the restraint coordinators. The Perceptions of Restraint Use Questionnaire (PRUQ) (Strumpf & Evans, 1988) was administered before and after the education sessions. The results of the t-test showed a decrease in the post-test mean scores on 7 of the 17 items indicating a less important perception by the staff about the use of restraints. Four items had an increase in mean scores on the post-test indicating the restraint coordinators increased their perception of the importance of physical restraints with these items. The restraint education program was presented to the nursing staff throughout the institution. Risk management and quality assurance will monitor patients restrained and evaluate the nursing staff with the PRUQ in 3 months.

Use of restraints and bedrails in a British hospital

OBJECTIVE

To determine the prevalence of restraint and bedrail use in a British hospital.

DESIGN

Cross-sectional observational study.

SUBJECTS

Six hundred sixty-eight patients in the acute medical, surgical, and geriatric beds of a large British teaching hospital on a single night.

MEASUREMENTS

Observed use of restraints and bedrails. Reasons for restraint use were determined by interviews with nursing staff and examination of the case notes.

RESULTS

Fifty-six (8.4%) patients had bedrails raised. No other restraints were in use. Reported indications for bedrail use were: prevention of falls (52 patients), prevention of wandering (1), and patient request (3). In stepwise logistic regression analysis, bedrail use was associated significantly with agitated confusion, age 70 years or more, and stroke, while patients on the acute geriatric wards were significantly less likely to have bedrails raised.

CONCLUSIONS

Restraint use is relatively uncommon in Britain. Nevertheless, inappropriate use of bedrails is a reason for concern.

Progress toward a restraint-free environment in a large academic nursing facility

OBJECTIVE

To review the implementation and evolution of a successful physical restraint reduction program in a large nursing facility.

INTERVENTION AND MEASUREMENTS

An initiative to reduce physical restraint began in March of 1990 with formation of a Restraint Review Committee (RRC), which developed and guided a program of inservice education, policy change, and procedural innovation. Progress was measured by monthly prevalence surveys of restraint use, both unit-specific and facility-wide.

PATIENTS AND SETTING

The study took place in an 816-bed not-for-profit nursing facility with academic affiliation and closed medical staff. Mean age of residents was 85.5; 74% were female and 26% male.

RESULTS

Physical restraint prevalence in our facility was reduced from 39% to 4% over 3 years, with marked decrease in variation among nursing units. Prevalence initially decreased to 20% after policy modifications and inservice education programs. Further innovations in procedure and policy resulted in continued reduction of physical restraint to 4%. The facility-wide rate of falls and accident-related injuries did not change over the 3-year period. Decrease in physical restraint was not accompanied by a change in the percentage of residents prescribed psychotropic medications such as benzodiazepines and neuroleptics.

CONCLUSIONS

In response to the mandate to provide a least-restrictive environment, our institution has developed a successful system resulting in a dramatic reduction in physical restraint use. Changes in institutional culture and barriers to change are discussed, as well as issues of cost and generalizability.

Use of physical restraints. 1: consequences

The use of physical restraints, e.g., cotsides, has become a routine procedure in many UK geriatric wards. However, it is associated with numerous adverse physical and/or psychological effects. Although restraints may be indicated in some cases, the nurse should be aware of the possible consequences. Ethical dilemmas may arise. This article, the first in a two-part series, discusses the consequences of restraint use, so that the nurse can balance the potential benefits and risks before deciding upon their use.

Use of siderails: rethinking a standard of practice

1. Policy and/or tradition is not adequate rationale for siderail use in light of current information indicating that siderails can be a hazard. 2. If a client is going to climb out over the siderail, the siderail increases risk for client injury. In such cases siderail use cannot be justified. 3. The nurses's goal is not to eliminate siderail use, but to individualize it--to use siderails only in cases in which they increase the safety, security, and mobility of clients.

Restraint reduction in a nursing home and its impact on employee attitudes

OBJECTIVE

To reduce physical restraint use in a nursing home and increase employee support for the restraint-reduction program.

DESIGN

A one-group pretest-posttest design with repeated measures was used to determine changes in restraint use with participants over a 14-month interval. All individuals employed at the nursing home were surveyed at two time periods to determine their opinions on restraint use.

SETTING

A 265-bed private, non-profit nursing home in Dallas, Texas.

PARTICIPANTS

A restrained cohort of 170 residents with a mean age of 84 years; 84% were female. A total of 182 employees participated in the first survey and 209 in the second.

INTERVENTION

Formation of a project team that planned and supervised restraint removal. Inservice training on restraint use was conducted for all employees.

MEASUREMENTS

Type and frequency of restraint use among the restrained cohort at four evaluation points within a 14-month interval. The frequency of restraint use in the nursing home population was also recorded. Survey measures included employee responses to a 16-item closed-end questionnaire before and after training.

RESULTS

The mean number of restraints used with each resident in the restrained cohort decreased from 1.56 to 0.67. The number of residents on restraints in the nursing home was reduced during the course of the study (67.5% vs. 36.7%, P < 0.0001). Changes in employee opinions about restraint use were found after training. On the second survey, more than twice as many employees indicated that restraints should be removed from almost all residents who have them (15.2% vs 36.3%, P < 0.0001).

CONCLUSION

A restraint-reduction program in a nursing home can produce positive results in terms of decreased restraint use and supportive employee attitudes. More practical alternatives to restraints need to be developed for application in the training of nursing home employees. Future studies on resident, employee, and family attitudes about restraint use are suggested.

Deciding to restrain medical patients

To determine when and why patients are placed in mechanical restraints, we surveyed the nurse and physician caring for each of 102 restrained patients from the general medical floors of an acute-care hospital. Ninety-three percent of the questionnaires were completed. Nursing questionnaires indicated that over half of patients were restrained during the evening shift. Nurses initiated the use of restraints in 75% of cases. Fifteen percent of the patients' physicians were unaware that the patient had been restrained. In the majority of cases, the nurse and physician believed that restraint was the best alternative for managing the patient although more physicians (11%) than nurses (2%) thought an alternative intervention would be better (P less than .02). As a group, physicians and nurses restrained patients for similar reasons, most often to prevent falls from bed (69%) or to protect medical devices (36%). However, there was poor agreement between the nurse and physician as to the reason for restraint in an individual patient (kappa statistic range from .02 to .43). These findings suggest that nurse and physician communication regarding restraint is poor. We recommend that acute-care hospitals adopt policies to promote communication between nurses and physicians concerning restraints to ensure that use of this potentially hazardous intervention is used only when necessary.

The fear of liability and the use of restraints in nursing homes

The routine use of chemical and physical restraints in nursing homes is bad care. Medical and nursing literature on the care of nursing home patients consistently criticizes the use of restraints when that use is unrelated to diagnosis and treatment considerations. Federal and state laws have included restrictions on the use of restraints for some time. The criticisms of inappropriate and indiscriminate use of chemical and physical restraints are not new. What, then, supports their continued misuse despite the ordinarily powerful combination of professional and governmental approbation?

The use of restraints responds to generally quite acceptable and desirable patient-oriented goals. Restraints are used in an attempt to protect the patient with physical or mental disabilities from avoidable injury caused by falling or wandering away from the facility. In the social context of nursing homes, restraints are also used to protect residents from injury by threatening, violent patients. When the rationale is measured against the known effects of restraints, however, the self-evident nature of the justification begins to break down.

A further exploration of the use of physical restraints in hospitalized patients

Four hundred twenty-one consecutive patients admitted to an acute general medical ward and two acute rehabilitation medical wards were studied to compare the characteristics and outcomes of physically restrained patients and unrestrained patients. Restraints were used in 35 (13%) of the general medical patients and in 49 (34%) of the rehabilitation patients. The restrained general medical patients had higher mortality and morbidity rates than their unrestrained counterparts. Restrained patients had a higher prevalence of a psychiatric diagnosis, and major tranquilizers were used more than in their unrestrained counterparts in both settings. The general medical patients tended to have more than one type of restraint at a time, whereas the rehabilitation patients were restrained for longer proportions of their hospital stay. Thirty-three percent of the restrained patients whom we were able to interview expressed negative perceptions about the presence of the physical restraints. Moreover, it was found that the presence of cognitive and physical impairments were highly predictive of restraint use in both populations.

Prediction and prevention of patient falls

Falls are a major cause of injury in hospitalized patients. To date, the focus of research has been on developing risk profiles to predict fallers and developing interventions to prevent falls. This paper presents and critiques these efforts. The authors conclude that (a) no high-risk profiles have yet been developed with adequate sensitivity and specificity to be useful as predictive instruments; (b) current fall interventions are rarely research-based; and (c) the few intervention studies conducted to date seem to reduce falls primarily through consciousness raising rather than specific changes in practice.

Tying down the elderly. A review of the literature on physical restraint

The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.

Post-stroke hip fractures

Fifty-six fractures of the proximal femur in 53 stroke survivors are described in this retrospective review. The side of fracture was found to be positively correlated with the side of hemiparesis (P less than 0.001). In all cases, the immediate proximate cause of the hip fracture was described as a fall. Falls most frequently occurred in the bathroom or during transfer activities. Though this group was largely ambulatory and living at home prior to fracture, only a minority of individuals were either ambulatory (40%) or able to return home (39%) immediately after discharge.

Incidence of physical restraints on acute general medical wards

On four acute medical wards 1292 patients were observed over 15 weeks to determine how frequently physical restraints were used. Patients were divided into age groups of less than 40 years, 40 to 55 years, 56 to 69 years, and 70 years and older. Ninety-five patients were found to be restrained giving an overall incidence of 7.4%. As expected, patients 70 years of age and older were restrained more frequently (20.3%) than younger patients, with the lowest incidence (2.9%) occurring in those 40 to 55 years of age. In each age group the patients who were restrained had a length of stay more than twice as long as their unrestrained counterparts. Twelve percent of the restrained patients died, which was nearly one-half of all the patients who died during the period of the study. The findings suggest a probable relationship between the severity of an illness and the use of physical restraints.

Prevention of patient falls through perceived control and other techniques

Every year thousands of patients suffer injury while attempting to make use of bathroom facilities. In addition to the suffering and protracted inpatient care that these incidents cause, hospitals have been faced with staggering costs in the form of increased insurance premiums arising directly out of an increased number of lawsuits. This problem has reached a proportion such that it clearly deserves careful and indepth industry study.

This article, while far from a comprehensive study, will attempt to draw certain conclusions and perhaps dispel certain myths based upon a study of 181 patient falls at a 200+-bed community hospital in the Northeastern United States.

In the not too distant past, hospitals could not generally be held legally responsible for failure to raise bedrails absent specific medical direction. Such was the case because few, if any, hospitals had guidelines or procedures for the placement of bedrails in the absence of a physician's order.

Legal and ethical implications of health care reimbursement by diagnosis related groups

The major challenge facing the American health care system today is to devise a strategy for achieving three primary objectives simultaneously: (1) high quality, or excellence in standards of care, (2) balance, or equitable access to that quality care, and (3) some reasonable semblance of cost control in providing that quality care to everyone. Following World War II, the weight of government was thrown solidly behind the access and quality portions of the equation, first with the enactment of the Hill-Burton capital financing program and its accompanying community service obligations, and accelerating in the midsixties through creation of Medicare, Medicaid, and other financing and delivery programs entitling categories of individuals to health care benefits.