The National Aged Care Quality Indicator Program commenced as a voluntary program in January 2016. The following module was produced at that time and will be updated to reflect the now mandatory status of the program.
Welcome to the Department’s online information session for QI 2 – Physical Restraint for the National Quality Indicators Program in residential aged care services.
This information session builds on the National Aged Care Quality Indicator Program Webinar, and is a deeper dive into quality indicator (QI) 2 physical restraint. During this session we will discuss the why, what, and the how of collecting and reporting physical restraint. We will touch on how the QI results will be displayed and how the QIs complement the existing accreditation standards. To finish this session we have developed a quick quiz to allow you to reflect on your understanding of the information.
As you know from the quality indicators webinar, the voluntary national quality indicator program has commenced with an initial suite of 3 indicators for residential aged care services, which includes the QI 2 – physical restraint.
So why is monitoring physical restraint so important?
Restraint is an aversive practice, device or action that interferes with a resident’s ability to make a decision, or which restricts their free movement. A restraint-free environment is the recommended standard of care. It may not be something you always achieve but should be something you strive towards over time as part of your quality improvement program.
Physical restraint can cause negative physical and psychological outcomes. And there are adverse events or harm associated with the use of physical restraint, such as death, pain, decreased cognitive function, infection, pressure injury development and falls, to name a few.
Evidence for the prevalence of physical restraint suggests that physical restraint is used in some form for between twelve to forty-nine percent of residents in residential aged care.
Family members or legal representatives do not have the legal right to request that a resident be restrained.
The evidence actually indicates that restraint does not prevent falls or falls-related injuries and is actually likely to exacerbate behaviours.
To review the supporting evidence you can hover you mouse over the dots points now.
The supporting evidence is also available in appendix 5 of the resource manual.
When you are ready click ‘next’ to continue
Slide 3 – Definitions
So what are we measuring?
Definitions are very important when it comes to collecting good comparable quality indicator data.
Everyone collecting data must be on the same page about how to recognise and count physical restraint for both measures one and two. Data collectors should be well trained in the program definitions, and have access to support to help them make consistent data collection decisions.
The use of physical restraint indicator is collected and reported using two measures counting every resident every quarter:
- Measure one - intent to restrain, and
- Measure two - use of devices commonly associated with physical restraint.
Measure one is defined as the intentional restriction of a resident’s voluntary movement or behaviour by the use of a device, or removal of mobility aids, or physical force for behavioural purposes.
This measure requires observation and recording of any instance where any restraint equipment or action is in place to intentionally restrain a resident using devices or actions contained in the definitions A, B and C.
Measure two is about counting all devices in use at the time of the audit for any reason in accordance with definition B - a commonly associated device with physical restraint. These are to be counted whether they are being used to intentionally restrain a resident or not.
Three definitions are used for this indicator.
Definition A is “Intent to restrain”, which is intentional restriction of a residents’ voluntary movement or behaviour by the use of a device, or removal of mobility aids, or physical force.
Definition B is “devices commonly associated with physical restraint”. The devices included under the definition are:
- chairs with locked tables,
- seatbelts other than those used in active transport,
- manacles and,
- safety vests.
You should note for measure two, only physical restraint devices explicitly listed under definition B are included. The devices listed under definition B have been expertly reviewed and will be periodically reviewed by the program’s technical advisory panel.
Definitions A and B do not list all possible physical restraints. Definition C makes sure that the observation process considers the placement of furniture, use of concave mattresses, lap rugs with ties, intentionally locking a bedroom door and any other devices in use with the intent to restrict free movement. These should be included in measure 1.
You can review the QI Program definitions now, by hovering over the different sections for more information. If you would like to refer to the program definitions, they are available in the Quality Indicator Resource Manual.
To get the most accurate information possible, it is important that everyone collecting the data is clear on the data rules for each indicator.
The rules are designed to help organisations collect information that gives them a clear picture of their risks and issues for each quality indicator.
The direct observation survey method is used to collect data for this indicator, with nine observations made across three observation days each quarter. At the start of each quarter, you should select three observation days for the quarter. Approximately one per month. On each of these days, conduct three observations of each resident: one in the morning, one in the afternoon and one at night.
The key data rules for the use of physical restraint indicator are:
- All observations should be unannounced
- Use restraint definitions A, B and C for measure one; and for measure two only count physical restraint devices listed under definition B
- Record on the data-recording sheet with comments. Comments allow you to provide context to your QI results. An example of this for measure one is “one resident is restrained using a water chair due to safety concerns, a restraint plan is in place and is reviewed on a monthly basis.”
- Exclude secure areas, locked wards and perimeter alarms
- All residents should be observed, including all respite residents.
Data collectors should refer to the resource manual for further guidance on how to count Measures 1 and 2.
For more information on each of the points, please mouse over them now for more information.
Slide 5 – Scenarios of QIs
The next part of this information session is a mock data collection. The mock data collection will work through the three observations across one of the three observation days for a reporting cycle. It will cover recording the results on the data collection sheet, before preparing the data for upload into the QI system within the My Aged Care Provider Portal.
As your facility is new to the program, you have decided that you will do the morning session and Harry will do the evening observation. You have also decided that to keep the observations consistent you will complete the afternoon observation together, allowing you to discuss and compare consistency of application of the definitions.
You start your morning observation. The first resident you note is Mr Smith coming past you strapped to his wheel chair with a seat belt in transit for his morning shower.
Pop up example recording sheet
Using the program definitions although he is restrained, he has only been restrained during transit to and from the shower. The program definitions exclude seat belt use for this purpose.
Highlight scenario 2
You continue your observations. While observing Mrs Chopra eating her breakfast in her room you notice that the chair she is sitting in has the table locked across it. You investigate why she is using a chair with a locked table and confirm that there is no intention to restrain her. The table was just the closest one available when she asked to have her breakfast served in her room.
Show Pop up recording sheet 2.
As there was no intent to restrain her, this has been recorded as 0 for measure 1. For measure 2, as a locked table is listed under definition B and is functioning as a physical restraint device regardless of the intent. You place a comment on the recording sheet to note that there was no intent to restrain and the device used was a locked table.
Highlight scenario 3
You now move to the common rooms where you find Mrs Farooque watching morning TV, she is by herself in the room and you note that she has a locked table across her lap restraining her.
On investigation of the restraint, you note that one of the team locked the table across her lap because she was sitting by herself, and they were worried that she would fall out of her chair.
Show Pop up recording sheet 2.
As the restraint was intentional, you record this as 1 for Measure 1, and as a locked table is listed as a physical restraint device under definition B you count this as 1 for Measure 2.
Highlight scenario 4
You complete the morning observation, noting 6 beds with rails, 2 safety vests and 2 chairs with locked tables, all of them were not in use.
Pop up recording sheet.
Although all of the devices are listed under definition B, none of the devices are in use at the time of observation. As such, for both measure one and measure two they are not counted under the program definitions.
For the afternoon, you have decided to complete this observation with Harry to give you a chance to compare your understanding of the definitions to make sure there is consistency across all three observations.
Highlight scenario 5
You start the afternoon observations, observing all residents. The first resident you come across is Mr Adama. Mr Adama is strapped to his chair with a seat belt during his shower so he would not fall out of his chair.
Pop up – recording sheet
Unlike Mr Smith, he was not in transit at the time of the observation, as such not excluded under the definitions. Doing a bit of further investigation, you find that the family requested that he is strapped into his chair for his own safety during his daily showers. Regardless of the reason behind the restraint, this is still counted as intentional restraint under the program definitions and counts as 1 for Measure 1.
As he is strapped in his chair with a seat belt, which is listed under definition B, this would count as 1 for Measure 2 – use of physical restraint devices. You note in the comments that the restraint was used at family’s request.
Highlight scenario 6
You see Mr Smith. He is in a water chair, as he is immobile and can no longer walk; this was done to prevent him falling out of his chair. You note that the water chair does not restrict his freedom of movement in any way.
Pop up recording sheet
As his freedom of movement has not been restricted in any way under the definitions for measure 1, this does not count under “intent to restrain”. Although the water chair can be used as a physical restraint device, it is not listed under definition B for measure 2.
Highlight scenario 7
In the next room you come to you observe, Ms Ngo has been locked in her room, after she had become agitated with another resident.
Pop up recording sheet
As Ms Ngo has been intentionally locked in her room, this shows intent to restraint and as a locked room is counted as a physical restraint device under definition C, you record this as one for measure 1.
For measure 2 although the locked door is used as a physical restraint device, it is not listed under definition B and as such not counted for this measure. You record this on your data-recording sheet, and add comments for future reference.
Highlight scenario 8
You move on to the common rooms where you find Mrs Farooque again happily watching TV, you note that she has a locked table across her lap again restraining her from getting up. Once more, you note that one of the team has locked the table across her lap because she was sitting by herself and they were worried she may fall out of her chair while no one was in there with her.
Show Pop up recording sheet 2.
Although Mrs Farooque is restrained in the same way in both the morning and afternoon observations, you still count this a second time under the program definitions. As the restraint was again intentional, you record this again as 1 for Measure 1, and as the locked table is listed as a physical restraint device under definition B this would count as 1 for Measure 2.
There was nothing else of note for the rest of the observations. This completes the afternoon observations.
Highlight scenario 9
Harry starts the Night observations, the first room he comes to he observes that Mr Giordano has both bedrails pulled up. On investigation, he finds that Mr Giordano has pulled them up himself so that he feels safer. However, Harry notes that due to the design of the bedrails he cannot put them back down without assistance.
Pop up recording sheet.
Harry counts this as 1 for Measure 1- “intent to restrain”. Although it was Mr Giordano has intentionally restrained himself, Harry knows that the negative consequences of them being restrained do not disappear, just because residents have requested to be or have restrained themself. As such, Harry counts this in line with the program definitions for “Intent to restrain”
For Measure 2 under the program definitions although there are 2 bedrails in use, it is counted as 1 under the definitions.
The reason for this counting method under program definitions for bedrails is, they need to be used in conjunction with a secondary device to physically restrain a resident. Bedrails are commonly used with either a second bedrail or a wall to form the restraint. In this case the bedrails are used in conjunction with each other to form the single restraint device. If the case also included Mr Giordano being strapped to his bed with a seat belt as well as the bedrails this would be counted as 2 under the Program definitions.
Highlight Scenario 10
Harry next observes Mrs Esposito who feels safer having her bed pushed up against the wall.
Pop up recording sheet
As Mrs Esposito can get out of the other side of her bed her freedom of movement is not impacted in anyway, as she isn’t restrained this is not counted for measure 1, or for measure 2.
Highlight scenario 11
Harry continues his observation and comes across Ms Zhào’s room. Ms Zhào has one bed railing pulled up on her bed. Harry knows that Ms Zhào has this pulled up during the day to assist with her mobility around the room.
Pop up recording sheet 4>
For Measure 1, although one bed railing is in use, it is in place to assist with her mobility and not for restraint; as such, it is not included under the Program definitions.
For Measure 2, although bedrails are identified under definition B as a physical restraint device, in this case only 1 bedrail is in use, and as Ms Zhào can still get out of bed from the other side, it is not being used as a physical restraint device. As such, this is not included under the Program definitions for measure 2.
Highlight scenario 12
The next room Harry comes to he notices the door is locked and Ms Ngo is fast asleep in her bed. Harry Investigates and finds Ms Ngo frequently gets up in the middle of the night. When she does, she often wanders the facility becoming dis-orientated and upset. While dis-orientated she often walks into other residents rooms waking them.
Pop up recording sheet
As Ms Ngo has been intentionally locked in her room, and a locked door is included as a physical restraint device for measure 1 under definition C. Harry records this on the data-recording sheet, and adds a comment for future reference.
For measure 2 although the locked door is used as a physical restraint device, it is not listed under definition B and not counted for this measure.
Harry finishes his observations for the night but does not observe any other noteworthy situations for the night. Thus ends the 1st day of observations days.
You can review the final sheet by hovering over the button in the bottom right. Click next when you are ready to review the summary data sheet.
Over the rest of the reporting period, you complete the final six observations across the last two observation days. The final step before submission of your QI data is to summarise the results of all nine observations onto a single data summary sheet.
Preparation of this summary data sheet ready for submission into the QI system, will simplify the upload process for your My Aged Care Outlet Administrator. While summarising the data collected, you will need to make sure you remove all personally identifiable data such as names and room numbers from the comments ready for uploading. Once ready, you will need to send your summary data sheet to your My Aged Care Outlet Administrator for submission.
You can review the summary data sheet now. When ready click next to view the data submission page in the My Aged Care provider portal.
The My Aged Care Outlet Administrator will enter and submit the QI results via the My Aged Care provider portal. As you can see the fields on the data summary sheet directly map across to the My Aged Care submission screen.
If you would like to find out more about how to set up and use QI within the My Aged Care system, please refer to the quick reference guides or tutorial video available on the quality indicators webpage. If you are new to using My Aged Care Provider Portal you will also need to set up an AUSKey before you can access it. The last page of this information module has links to the quick reference guides and how to set up an AUSKey.
The intention for the National Quality Indicator Program is to assist you in continuous quality improvement and provide consumers with transparent, comparable information about the quality of service in your facility.
The department is looking at providing the results through two separate channels; one provider focused information through the My Aged Care Service Provider portal, and the second through the service finder in My Aged Care.
The first provides four reports, which will become available 7 days after the end of the submission period for that quarter. Any staff member or team lead can run the QI reports, once their My Aged Care Outlet Administrator has enabled their QI role. The available reports will expand overtime as additional quality indicators are added to the suite and will be enhanced based on feedback from sector consultation over time.
The second channel of publication will be through the My Aged Care Service Finder and will focus on consumer choice. Twenty four hours after you have submitted your QI data for a period, a participation icon will appear on your facility’s service finder page identifying your participation in the voluntary program. This indicator will disappear if you do not submit QI data for two consecutive quarters.
In the future quality information based on program results will be published. Before this publication occurs, the department will be undertaking a full analysis and validation of QI results utilising a minimum of 12 months of data. The results of this analysis will undergo a further consultation with the sector as to what should be published.
Please hover over the sections provided to get more information and definition of QI result calculations, when you are ready click next to progress to the next page.
So how does this QI complement the accreditation standards?
The National Quality Indicator Program is a voluntary program and is not a requirement of the accreditation process. The quality indicator program is a free tool made available to assist you identifying areas of improvement in your organisation, allowing you to put improvement strategies in place and tracking how effective these strategies are.
If you are involved in the program, we encourage you to discuss the results as part of your accreditation process as they do assist in demonstrating continuous quality improvement. We have mapped the accreditation standards against QI 2 – physical restraint. You can review these now or for further information please refer to the resource manual
Slide 13-20 Quiz
Now it’s time to take the quiz and find out what you’ve learned in the information session.
Congratulations on completing the Quality Indicator 2 – Physical restraint Indicator information session!
We hope it’s successfully introduced you to this indicator if you’re new to it. Or if you’re a current user, that it’s updated and refreshed your knowledge.
More information can be found in the Department’s quality indicator resource materials.
It’s a good idea to visit these for further guidance and more detail on data collection and reporting and use of the data.
For your convenience we have pulled together some handy links to help you find program related information, please click next to view them. When you are finished you can close the session by closing your web browser.