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GUEST EDITORIAL |
Division of Geriatric Medicine, Saint Louis University School of Medicine, and GRECC, VA Medical Center, St. Louis, Missouri.
THE letter by Woo and others (1) highlights an enduring challenge for health care professionals who care for older persons: the use of restraints. The letter by deVries and others (2), however, is an excellent stepping stone towards a goal that is obtainable: restraint-free hospitals and nursing facilities. The fact that it is done in some European hospitals as reported by deVries, in some U.S. hospitals, even among delirious patients (3), and some nursing facilities (4,5,6) should be evidence enough that it can be done elsewhere. It is fortuitous that the deVries study was done by geriatricians who were participants of the European Academy of Medicine of Ageing (EAMA). One of the aims of the EAMA is "to harmonize the attitudes and goals of future opinion leaders in geriatric medicine throughout Europe" (7). As leaders, it may not be enough to "encourage" health care professionals not to use physical restraints. Rather, a restraint-free environment should be held up as the standard of care, and anything less is substandard. As has been previously argued in the Journal, it is the responsibility of geriatricians to argue for enhanced quality of care for our vulnerable patients (8–10).
The most common arguments against achieving this standard are either related to nursing issues (financial or workforce) or related to a system that is too difficult to change. On the contrary, we would argue that the stumbling blocks to achieving the standard are related to misperception, misplaced priorities, and misleading data.
Too often, restraint use is blamed on the perception that more nursing staff are needed. While there is some validity to the argument that patient-to-nurse ratios are important (3,11), this is not the most important part of the restraint-free equation. Woo and others found that low staff numbers were not a significant factor associated with restraint use (1). A study by Castle and others (4), based on over 15,000 nursing homes, showed that facilities that were restraint free compared with nonrestraint-free facilities did not differ in the total number of staff per resident. On the other hand, they did find that restraint-free facilities were more likely to use more full-time equivalent (FTE) registered nurses per resident, but fewer FTE nurse aides and licensed practical nurses per resident. Psychoactive drug use rates did not differ between the types of homes (4). Be careful, however, because another study found that initiation of restraint use was associated with a higher rate of licensed nursing personnel (12).
No matter how small a part of the equation the patient-to-nurse ratio is, because of the prevailing perception that it is a major part, we still need to deal with this issue in the fight against restraints. As advocates for older patients, priorities must be put in perspective, and pushing for "high-touch" in addition to high-tech is an integral part of this role. Of note, high-touch should not be equated with a settling of worse outcomes at the expense of comfort. On the contrary, high-touch has the power to save lives also! Compare mortality rates of high-tech heart care with that of simply increasing patient-to-nurse ratios.
Three systematic reviews comparing percutaneous coronary intervention (PCI) (angioplasty) to thrombolytic therapy indicate that for every 1000 cases of ST-segment elevation myocardial infarction, PCI could result in approximately 20 to 30 fewer deaths (13–15).
According to a study to determine the association between patient-to-nurse ratios and patient mortality among surgical patients, Aiken and others calculated that if staffing ratios were 6 patients per nurse rather than 8 patients per nurse, there would be approximately 12 fewer hospital deaths per 1000 patients. If the ratios were 4 instead of 8, the number of prevented deaths would be 23 (11).
The cost differential for an angioplasty compared to thrombolysis is in the thousands per patient (16), while the cost differential to go from 8 nurses per patient to 4 nurses per patients is approximately (US) $450 per patient. [Calculation: 1000 patients x average length of stay of 6 days = 6000 patient days; 6000 patient days divided by 8 patients/nurse = 750 nurses; 750 nurses x 24 hours x $25/hour = $450,000; 6000 patient days divided by 4 patients/nurse = 1500 nurses; 1500 nurses x 24 hours x $25/hour = $900,000; $900,000–$450,000 = $450,000; $450,000 divided by 1000 patients = $450/patient.]
Although many would say that it is impossible to emphasize high-touch and not to move forward with technological advances, two major studies out of Europe are going to create great pressure on hospitals to decide where they will put their emphasis and, consequently, their health care money. One study in the Czech Republic and another in Denmark showed that long distance transport for primary angioplasty was superior to local thrombolysis (17,18). Ironically, the Czech Republic was one of four countries in central Europe (Slovenia, Hungary, and Slovakia were the other three) reported to still have a serious problem with physical restraints for their mentally ill patients (19). Can geriatricians in Europe, as well as the United States, China, and other countries, stand up for the needs of their older patients against a culture that favors costly high-tech interventions? The time for leadership and speaking out is now.
Another example of potential for misplaced priorities and misleading data is the preferential pharmacological approach instead of the nonpharmacological approach to patients with dementia who are at high risk for being restrained (1). The not-so-new drug, memantine, when added to donepezil for patients with Mini-Mental State Examination scores of 5 to 14, has been shown to improve scores on various cognitive, functional, and global outcome research instruments (20). How will this affect what happens in nursing homes? Although payment for medications and nursing salaries come from different sources, imagine a 30-bed Alzheimer's unit staffed by 1 registered nurse and 2 nursing assistants. If 20 of the patients get put on memantine, the cost of this drug (for 20 patients) for 1 month (approximately $85/month x 20 patients = $1700/month) would cover the cost of 1 more certified nursing assistant for 40 hours/week. The Journal has previously highlighted the importance of high-touch care in the management of persons with dementia (21–24). Although many would argue that we should not have to choose between the two, the reality is, as long as health care is perceived as a pie, with an infinite number of slices (instead of a garden, which, if properly cared for, will grow and prosper), perhaps it is time to either do the randomized controlled trials, which ethically would be difficult, or to ask families and nursing staff their preference.
In the end, it is a matter of priorities and data, and although we agree with deVries and others (2) that it would be helpful to have further studies in this area, it is time to use what we have and to say: It is clear that not only is restraint reduction safe and effective, in hospitals (25) and nursing homes (26–28), but care that is completely free of physical restraints is possible (2–6) and should be the standard of care for all older persons.
Received April 12, 2004
Accepted April 12, 2004
References
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