Questions over influence of study linking physical restraint use and deaths

The research that likely influenced the inclusion of physical restraint as one of three quality indicators for residential aged care has been published for the first time.

A study conducted by the Victorian Institute of Forensic Medicine into deaths in residential aged care between 1 July 2000 and 30 June 2013 found that five people died as a direct result of restraints.

Researchers from the Institute, which is run out of Monash University, received funding from the University and the Commonwealth and Victorian Governments to review data relating to deaths in residential care compiled from Coroners’ reports over the 13-year period.


While findings from the study were shared with the funders in 2014, the data has not been made publicly available until now. Other findings from the study are expected to be published over the next 18 months.

The researchers found that two of the five people who died as a direct result of restraints – according to the Coroners’ reports – had slipped down in their chairs which had neck restraints in use. Two others fell out of bed and became caught in netting / webbing while the fifth person fell out of bed over the bedrail.

Of the five people who died, four had dementia, all had multiple co-morbidities, four people had impaired mobility and one person was immobile. Four had documented histories of repeated falls, which is why restraints were in use.

In three of the five cases the use of restraint had been authorised by family and or a medical practitioner. In four of the cases the restraint application was correct, while in one case the restraint had been improvised.

It was noted in two of the cases there was documented evidence of restraint-free care trials, however on review, restraint-free care was deemed high risk in both residents and restraints were reintroduced.

Inquests were held into two of the deaths – one of which did not have recorded authorisation for the restraint use – though none of the Coroners overseeing the cases made recommendations for change.

The detail of the study was published in Age and Ageing journal earlier this month, along with claims by the researchers that physical restraint-related deaths are under-reported in Australia.

“These are an underestimate of physical restraint-related deaths. Berzlanovich et al.’s study in Germany had a substantially greater number of deaths suggesting significant under-reporting in Australia,” the researchers wrote.

“Underreporting may be due to a reflexive emotional response to conceal the event or failure of providers to provide guidance on reporting requirements,” they wrote.

Despite the assertion, one of the researchers from Monash University has admitted there is no firm evidence of under-reporting.

“We can’t prove there is under-reporting, nor can we prove there isn’t [under-reporting], but we are pretty certain this is just the tip of the iceberg,” Professor Joseph Ibrahim told Inside Ageing.

“I know from personal experience that the use of physical restraint occurs more frequently than it’s reported in aged care and we have to assume that if there wasn’t a problem, there wouldn’t be a big push to make it a quality indicator,” he said.

Although the study findings were not statistically significant and the researchers noted that death from physical restraint is rare, they still recommended a “significant policy reform introducing ‘incidence of physical restraint use’ as a voluntary quality indicator for nursing homes” as well as “policy and practice reform towards a restraint free model of care.”

What is unclear is when these recommendations were made to Government and what influence this study had over the decision to include physical restraint as one of the three voluntary quality indicators for residential care.

Following a trial of the new indicators in aged care facilities between May and September 2015, KPMG carried out of a review of the indicators and found the most enquiries relating to the interpretation of the indictor definitions were about restraint.

KPMG’s report to the Department of Health in March 2016 reiterated concerns raised by participating providers about the inclusion of restraint as a quality indicator.

In its report, made publicly available by the Department in mid 2016, KPMG said a common understanding of and approach to the use of the physical restraint indicator was needed, citing frequent questions from providers relating to the use of supports and safety guards for safety purposes rather than restraint.

Professor Ibrahim said the unclear definitions around restraint remain problematic for providers trying to do the right thing.

“One of the barriers to understanding the extent to which physical restraints are used in aged care is that people view restraints differently and therefore report use inconsistently,” he said.

“The discussion about physical restraint really needs to centre around safety and intent,” Professor Ibrahim said, adding that further research is still needed to identify effective alternatives to restraint and to examine the reporting system around physical restraint-related deaths.

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