A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

Background Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation. Methods We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model. Results The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop. Conclusions Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger.

Bed rails in an internal medicine clinical setting: a medico-legal analysis based on a systemic review of available literature

The use of restraints and, specifically, bed rails embody a controversial topic. Bedrails are commonly considered to be a protective device; however, they may be used as a form of restraint, and they may lead to severe injuries. Often restraints are used despite the lack of indication and prescription, without complete informed consent and without adequate reporting in medical records. Due to these reasons, restraints may lead to lawsuits. We present two cases where the use of physical restraints was complicated by health consequences, leading to litigation and medico-legal evaluation of medical and/or nurse liability.

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives’/patients’ requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories ‘Restrictive’ and ‘Supportive’ devices aimed at ‘Preventing risks’ and at ‘Promoting support’, respectively, have emerged. Reasons triggering ‘restrictive devices’ involved patients’ risks, the health professionals’ and/or the relatives’ concerns. In contrast, the ‘supportive’ ones were triggered by patients’ problems/needs. ‘Restrictive’ and ‘Supportive’ devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with ‘restrictive devices’ (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.

The Impact of State Dementia Training Requirements for Nursing Homes on Resident Outcomes

Stakeholders, including policymakers, have prioritized the need to educate nursing home (NH) staff about Alzheimer’s disease and dementia. Despite this prioritization and the relationship between staff training and outcomes, dementia-specific knowledge is variable. This study examined state-level training policies between 2011-2016. During this time 12 states (regulators and payers) implemented NH dementia training requirements, creating an opportunity for a natural experiment between states with and without new requirements. We estimated difference-in-differences models to determine the effect of state requirements on outcomes. Data from Nursing Home Compare and LTCFocus.org were linked to data on state policies. Training requirements were associated with 0.39 and 0.17 percentage point reductions in antipsychotics use and restraint use, respectively, and no impact on falls or need for help with daily activities. State requirements for dementia training in NHs are associated with a small, but significant reduction in the use of antipsychotic medication and physical restraints.

Low Cognitive Performance Increases The Risk Of Hospital-Associated Complications In Older Adults

Considering the limited evidence regarding the factors that contribute to long-term consequences after hospitalization of older people, we analysed the relationship between cognitive performance and hospital-associated complications (HAC). One thousand, three hundred Individuals aged 60 and older (mean age 82.3, 53.3% female), not assigned to palliative care and admitted in medical and surgical wards from a private hospital, were followed up from admission to 30 days after discharge. HAS was evaluated using a multicomponent measure that combines 12 hospital-associated complications (delirium, functional decline, falls, pressure injuries, bronchoaspiration, non-planned ICU transfer, physical restraints, hospital stay &gt; 30 days, death, long-term care transfer, and readmission). Cognitive performance was assessed using the "10-point cognitive screener (10-CS)", which combines temporal orientation, category fluency, and word recall evaluation. Results Overall, 464 (35.7%) participants had one or more HAC during their admission. Patients with HAC showed lower 10-CS scores than those with in HAC (p &lt;0.001). Adjusting for sociodemographic data, medication, chronic diseases, delirium screening, functional performance, each 10-CS point decreased the HAC changes by 19.2% (odds ratio = 0.808; 95% CI = 0.660 – 0.990). Conclusion These findings show that low cognitive performance was significantly associated with the risk of developing HAC during hospitalization and within 30 days after discharge. That evidence forms the critical foundation for the next steps towards validating the accuracy of these models in predicting vulnerability to HAC and developing screening tools to be used at the point of care.

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.

Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial

Background Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents’ clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year. Methods In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention’s effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models. Results Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible. Conclusions As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents’ well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing. Trial registration ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542), registered on 31.08.2018.

Variation of the Occurrence of Physical Restraint Use in the Long-Term Care: A Scoping Review

Physical restraints in the long-term care setting are still commonly used in several countries with a prevalence ranging from 6% to 85%. Trying to have a broad and extensive overlook on the physical restraints use in long-term care is important to design interventions to prevent and/or reduce their use. Therefore, the aim of this scoping review was to analyze the range of occurrence of physical restraint in nursing homes, long-term care facilities, and psychogeriatric units. Pubmed, CINAHL, Ovid PsycINFO- databases were searched for studies with concepts about physical restraint use in the European long-term care setting published between 2009 and 2019, along with a hand search of the bibliographies of the included studies. Data on study design, data sources, clinical setting and sample characteristics were extracted. A total of 24 studies were included. The median occurrence of physical restraint in the European long-term care setting was still high (26.5%; IQR 16.5% to 38.5%) with a significant variability across the studies. The heterogeneity of data varied according to study design, data sources, clinical setting, physical restraint’s definition, and patient characteristics, such as ADLs dependence, presence of dementia and psychoactive drugs prescription.