What was studied in this review?
Physical restraints are devices which reduce a person's freedom to move. These can be bedrails, belts in chairs or beds, and fixed tables, which prevent people from getting out of bed or a chair, or mitts which prevent someone using their hands freely. In some countries, physical restraints are used quite commonly for older people in general hospital wards. A main reason for this is to try to prevent falls and fall-related injuries, or to prevent people from removing drips or tubes. Physical restraints are also used as a response to behaviours that make care more challenging for health care staff and may be risky, such as people behaving in an agitated or aggressive way or wandering unobserved around the ward. They are most often used in the hospital care of older people with mobility problems or cognitive impairment due to dementia or delirium.
It is not clear whether physical restraint use is effective at preventing falls or the removal of tubes, but their use may increase feelings of fear, anger and discomfort and decrease well-being. Other unintended consequences of using physical restraints include worsened mobility, increased risk of pressure ulcers and incontinence, and injuries directly related to the use of physical restraints. Therefore, physical restraints may have a negative impact on the recovery and rehabilitation of older people in hospital. Guidelines recommend that their use is reduced or stopped, and in some countries they are illegal in most circumstances. Interventions for preventing and reducing the use of physical restraints typically include education for staff and promotion of the use of other care strategies. Sometimes they may involve providing alternative devices which are thought to be less restrictive.
What did we want to find out?
We aimed to find out which interventions are most effective for preventing or reducing the use of physical restraints for older people in hospitals.
What did we do?
We searched for trials that investigated interventions intended to reduce or prevent the use of physical restraint of older people in hospital. The trials had to include a comparison group of people who did not get the intervention (a control group). We included four studies. One study was conducted in general medical wards in a hospital in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. The average age of the people in the studies was between 67 and 84 years. In all the studies, the intervention being tested was compared with treatment as usual.
Three studies tested organisational interventions intended to change policy and practice so that fewer physical restraints were used. This was done by offering education and training for nursing staff, and other strategies to support staff in avoiding physical restraints. One study tested the use of pressure sensor alarms in the beds or chairs of people at high risk of falling, which sounded an alarm if the person got up.
What did we find?
The results of the three studies that tested education together with strategies to support health care professionals avoiding physical restraints were inconsistent. In one study the number of participants with physical restraints increased during the study period in both intervention and control groups; in another study the number of participants with physical restraints decreased slightly in both groups. The third study was designed differently so that the intervention was introduced for all participants in a staggered fashion; in this study, fewer participants were physically restrained after the intervention was introduced. The use of pressure sensors in beds or chairs did not lead to a reduction of physical restraints compared with the control group.
No study looked for harmful effects, e.g. injuries as a result of the use of physical restraints.
There was no increase or reduction in the number of falls or fall-related injuries, or in the use of psychotropic medication. There was also no effect on mobility and functioning.
Our confidence in the results was limited because of the small number of studies and because the studies did not always use the most appropriate methods to carry out their investigations. For example, two studies did not assign people randomly to the study groups.
What is the conclusion?
Because of the limited amount and quality of the evidence, we are uncertain whether interventions which involve education of health care staff, together with other strategies to help them to avoid using physical restraints, can effectively reduce the physical restraint of older people in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk is probably not effective for reducing physical restraints. In order to provide care without the use of physical restraints, it is important to create care environments in general hospitals which meet the needs of older people with mobility and cognitive problems and promote safe mobility.
How up to date is this evidence?
The evidence is up-to-date to 20 April 2022.
We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.
Physical restraints, such as bedrails, belts in chairs or beds, and fixed tables, are commonly used for older people in general hospital settings. Reasons given for using physical restraints are to prevent falls and fall-related injuries, to control challenging behavior (such as agitation or wandering), and to ensure the delivery of medical treatments. Clear evidence of their effectiveness is lacking, and potential harms are recognised, including injuries associated with the use of physical restraints and a negative impact on people's well-being. There are widespread recommendations that their use should be reduced or eliminated.
To assess the best evidence for the effects and safety of interventions aimed at preventing and reducing the use of physical restraint of older people in general hospital settings.
To describe the content, components and processes of these interventions.
We searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 20 April 2022.
We included randomised controlled trials and controlled clinical trials that investigated the effects of interventions that aimed to prevent or reduce the use of physical restraints in general hospital settings. Eligible settings were acute care and rehabilitation wards. We excluded emergency departments, intensive care and psychiatric units, as well as the use of restrictive measures for penal reasons (e.g. prisoners in general medical wards). We included studies with a mean age of study participants of at least 65 years. Control groups received usual care or active control interventions that were ineligible for inclusion as experimental interventions.
Two review authors independently selected the articles for inclusion, extracted data, and assessed the risk of bias of all included studies. Data were unsuitable for meta-analysis, and we reported results narratively. We used GRADE methods to describe our certainty in the results.
We included four studies: two randomised controlled trials (one individually-randomised, parallel-group trial and one clustered, stepped-wedge trial) and two controlled clinical trials (both with a clustered design). One study was conducted in general medical wards in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. A total of 1709 participants were included in three studies; in the fourth study the number of participants was not reported. The mean age ranged from 67 years to 84 years. The duration of follow-up covered the period of patients' hospitalisation in one study (21 days average length of stay) and ranged from 4 to 11 months in the other studies. The definition of physical restraints differed slightly, and one study did not include bedrails.
Three studies investigated organisational interventions aimed at implementing a least-restraint policy to reduce physical restraints. The theoretical approach of the interventions and the content of the educational components was comparable across studies. The fourth study investigated the use of pressure sensors for participants with an increased falls risk, which gave an alarm if the participant left the bed or chair. Control groups in all studies received usual care.
Three studies were at high risk of selection bias and risk of detection bias was unclear in all studies.
Because of very low-certainty evidence, we are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on our primary efficacy outcome: the use of physical restraints in general hospital settings. One study found an increase in the number of participants with at least one physical restraint in the intervention and control groups, one study found a small reduction in both groups, and in the third study (the stepped-wedge study), the number of participants with at least one physical restraint decreased in all clusters after implementation of the intervention but no detailed information was reported. For the use of bed or chair pressure sensor alarms for people with an increased fall risk, we found moderate-certainty evidence of little to no effect of the intervention on the number of participants with at least one physical restraint compared with usual care. None of the studies systematically assessed adverse events related to use of physical restraint use, e.g. direct injuries, or reported such events.
We are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on the number of participants with at least one fall (very low-certainty evidence), and there was no evidence that organisational interventions or the use of bed or chair pressure sensor alarms for people with an increased fall risk reduce the number of falls (low-certainty evidence from one study each). None of the studies reported fall-related injuries. We found low-certainty evidence that organisational interventions may result in little to no difference in functioning (including mobility), and moderate-certainty evidence that the use of bed or chair pressure sensor alarms has little to no effect on mobility. We are uncertain about the effect of organisational interventions on the use of psychotropic medication; one study found no difference in the prescription of psychotropic medication. We are uncertain about the effect of organisational interventions on nurses' attitudes and knowledge about the use of physical restraints (very low-certainty evidence).