JAMDA xxx (2016) 1
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Letter to the Editor
Response to Letter to the Editor “A Quality Improvement Project to Improve and Reduce the Use of Hand Mitt Restraints in Nursing Home Residents” To the Editor: While we applaud the team that recently investigated the frequent use of hand mitt restraints in the New Territories West Cluster region of Hong Kong,1 we are shocked at the high rate of use before and even after the implementation of the quality improvement project. According to the Letter to the Editor, the justiﬁcation for using hand mitt restraints was threefold: (1) “risk of behavioral problems ., (2) risk of disrupting health care treatments ., and (3) both reasons.” Our response to this rationale isdwhat is the risk? How is that determined? Are mitts used even if no behavioral problem existsdjust out of concern that it may occur? And, if a person does remove clothing or scratch his/her skin, does a mitt remove the discomfort? Regarding the disruption of health care treatments, perhaps the person does not want a feeding tube, a catheter, or other uncomfortable treatment that is being imposed on him/her. If the intrusive tube or device is causing pain, general discomfort, or other negative outcomes, who are we to make the patient even more frustrated, fearful, or angry by imposing additional burdens on him or her? In the United States, Hong Kong, and many other nations, nursing homes face similar challenges related to stafﬁngdlow wages, long hours, and emotional stress leading to stafﬁng shortages.2 These conditions will have an impact on optimal care, but this cannot be the excuse for allowing poor quality of life. After 30 years advocating for the elimination of physical restraints across the US and abroad, and more than 20 years assisting Pennsylvania nursing homes speciﬁcally (Pennsylvania Restraint Reduction Initiative or PARRI), we know that the nonuse of physical restraints improves each person’s lifedoverall physical function, cognitive function, and emotional well-being. Each care recipient needs to be considered on an individual basis. And, it is our
http://dx.doi.org/10.1016/j.jamda.2016.04.010 1525-8610/Ó 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
contention that simply tying a person or putting a mitt on his/her hands does not address the root cause of the behaviors. A conclusion reached by the Hong Kong quality improvement initiative was that “Multicomponent interventions by a multidisciplinary team can improve restraint application and reduce its use.” The multidisciplinary team’s focus (and we would state that it needs to be an interdisciplinary team working together and not “multidisciplinary” with each discipline operating in a silo), needs to be on the underlying meaning of the behavior and focusing on interventions that remove the source of discomfort rather than “improving the proper application.”1 The letter concluded with, “Continuous quality improvement programs can improve the quality of care in nursing home residents.” We would argue that quality improvement programs such as this will never improve outcomes for people in their care. They need to be person-centered with comprehensive assessments and targeted interventions that meet each individual’s personal needs. Unless the New Territories West Cluster region of Hong Kong can signiﬁcantly reduce physical restraint use now, it is likely that many more older people will be restrained in their care facilities in the future. References 1. Shum CK, Wai M, Chan YW, et al. A quality improvement project to improve and reduce the use of hand mitt restraints in nursing home residents. J Am Med Dir Assoc 2016;17:272e273. 2. KPMG International. An Uncertain Age: Reimagining long-term care in the 21st century, KPMG International commissioned by the Lien Foundation, Publication number: 121549, April 2013. Available at: https://www.kpmg.com/TW/zh/ IssuesAndInsights/Articles-and-Publications/Documents/2013-kpmgbiotech-tl/anuncertain-age-2013.pdf. Accessed April 7, 2016.
Beryl D. Goldman, PhD Neil D. Beresin, MEd Ruth L. Bish, MSN Janet L. Davis, BA Linda L. Hnatow, MS Diane E. Massey, MS Karen Russell, RN Kendal Outreach/Pennsylvania Restraint Reduction Initiative Team Kendal Outreach Kennett Square, Pennsylvania