Adopt Least Restraint Principles

Coroner committee investigated accidental hanging in hospital

Following the accidental hanging of an elderly patient in a hospital’s continuing complex care unit, health care teams are urged to familiarize themselves with Ontario legislation about using physical restraints and adopt least-restraint principles to avoid accidental asphyxia.

The recommendation comes in the wake of an investigation conducted by a committee of the Ontario Coroner’s office, following the death of a patient restrained in a “tilt-in-space positioning chair” in his private room. The chair is intended to prevent skin breakdown.

The patient was secured in the chair using a thigh belt restraint. When his family came to visit, they immediately called for nursing assistance when they found he had slid to the floor from the reclining chair with the thigh belt around his neck. Family and staff removed the belt and lowered him to the floor. He was noted to be without a pulse or respirations, and later pronounced dead by the emergency physician on duty.

The Geriatric and Long-Term Care Review Committee indicated the death highlights several factors in geriatric medicine and Ontario law. The deceased was an elderly patient with cognitive impairment, admitted to a 20-bed acute care hospital and then complex continuing care, who was put on multiple (and increasing) psychotropic medications. He was placed in a reclining “tilt-in-space” chair with physical restraints (i.e., a thigh belt) in an unsupervised environment. He later died of asphyxia when he slid down the chair and his neck became entrapped in the belt.

The hospital, which was part of a larger health care alliance, did not provide a copy of their restraint policy or guidelines for the use of reclining chairs for review, nor was there evidence to suggest staff were trained on the use of the chair. The hospital and health alliance did not appear to have related policies or guidelines, which must be publicly available.

Significantly, there was also no recorded physician order for the use of restraints, and no record of the need for restraint or reassessment of the need for restraint.

In the hospital setting, the Patient Restraint Minimization Act of 2001 regulates the use of restraints. The law emphasizes the use of the least restraint (or application of monitoring devices) and always the use of non-restraint alternative methods, if possible. Restraint is allowed if it is necessary to prevent harm to the person or others, allows the person “greater freedom,” or is authorized by a plan to which the patient or substitute decision maker (SDM) has consented.

The following is a summary of the relevant sections of the law as it pertains to this case:

• Section 7 (1) every hospital must have a restraint policy, (2) policy encourages alternative methods of safety, (4) policy must be available to the public for inspection.
• Section 8 hospital has duty to monitor patient and reassess.
• Section 9 (1) staff must have training of specific device and alternatives, (3) hospital must keep records on restraining patient.
• Section 10 only physician (and other providers mentioned in the act) may write restraint orders.

There were no Health Canada recalls or safety alerts relating to this chair. The thigh belt (used on patient) and a chest belt (not used on patient) were available after-market. The operating manual and instructions recommended restraint belts only be used when documented in a care plan and only be prescribed by a qualified practitioner (i.e., physician, physiotherapist or nurse practitioner). The thigh belt was to be used for safe positioning and not if less restrictive methods were available. The manual indicated the patient must never be left unattended by staff and the device should not be used with patients who may become aggressive, combative, agitated or suicidal. The instructions suggested training, documentation of safety checks and frequent reassessment of the need for restraint.

Death by strangulation or asphyxia secondary to lap belt use has been recognized and studied in many countries. A recent Forensic Medicine review from Germany indicated between 1997-2010, in a catchment area of 7.5 million people, there were 22 deaths directly related to physical restraints by belts. Of the 22 cases, the mean age was 75 years. Also of note, in 19 of the 22 cases, restraints were not applied correctly.

The Committee indicated a hopeful development in recent years is an intervention program that showed a 65 percent reduction in nursing home restraint use sustained over 24 months (from 13 percent in the control group to 3 percent in the intervention group). The EXBELT program is an education and culture shift methodology pioneered by Gulpers et al., which consists of a policy change, educational program, consultation service and availability of alternative interventions. The Committee said such a program may be considered in hospitals and nursing homes to reduce restraint-use and potential deaths related to restraint-use.

“Deaths related to the application of restraints are preventable, even in our challenging work environment and limited human resources,” said Dr. Anil Chopra, emergency physician and CPSO medical advisor. “The judicial use of restraints, when non-restraint alternatives have been unsuccessful, in the most limited way possible, for the shortest duration possible, with frequent reassessments of the patient is the standard of care.”

The Coroner’s Committee set out a number of recommendations to the hospital and several organizations, including CPSO and the College of Nurses of Ontario, about physical restraint education. It also included a recommendation that the regulatory bodies issue a reminder to its members that in the event of non-natural or sudden and unexpected deaths in which medical care may be a contributing factor in the death, the body and death scene must not be altered pending direction from the Coroner.