Talking Points for the Safe Enclosure

In general, approximately 12% of patients admitted to acute care facilities nationwide will need some form of restraint or behavior management during their hospital stay. Both HCFA (US Government Health Care Financing Administration) and JCAHO (Joint Commission on Accreditation of HealthCare Organizations) approve the use of restraints “for medical care to ensure a patient’s safety and only after less restrictive interventions have been found ineffective”. The definition of
the Safe Enclosure by both these organizations is “technically, a bed enclosure is neither purely a restraint nor seclusion….and as such would fall somewhere between a restraint and seclusion”. This is because it allows a patient freedom to move within the bed, have access to one’s own body and interact with the environmental factors around them.

Traditional restraints have shown that “hospitalized patients who are restrained have twice the length of institutional stay, are more likely to be transferred to nursing homes for care, and are at higher risk of early death than non-restrained persons”. There is potentially large cost savings for hospitals and at a broader level for the whole health care system if agitated or confused patients could be taken care of with a relatively inexpensive, clinically-effective, and ethically acceptable system.

The best way to describe the Safe Enclosure is that it is the adult equivalent of a crib or playpen for a child.  It creates a safe and secure environment in which the patient has a maximum of physical freedom while the caregiver has the peace of mind knowing the patients can not harm or injure themselves.  The Safe Enclosure has dark nylon netting on all four sides and on top so the patient has complete surrounding visibility similar to looking through a window screen.  Yet the strong nylon construction and teal coloration provide a pleasing injury free atmosphere for the patient.

While the Safe Enclosure has broad application for behavior management, it does have its limitations and is not applicable to all circumstances.  Patients who constantly want to pull out IV’s or other tubing or exhibit highly aggressive behavior are inappropriate for the Safe Enclosure.  Furthermore, the Safe Enclosure should never be used for non-medical purposes.

The best way to evaluate the Safe Enclosure is by comparison to other commonly used methods of behavior management and restraint.

Medications

Various drugs such as Ativan, Haldol and Respiradol are used to calm and alleviate symptoms from substance withdrawal, delirium and other psychological conditions. Invariably when medication is used, the patient loses some degree of physical and/or
mental functionality.  If the loss of mental acuity is slight, then the patient is at risk of getting out of bed and wandering or falling.  Wandering and falling are among the leading causes
of patient injury in medical institutions.  To address this, some form of restraint is necessary.  In addition, the patient is denied the mental alertness and functionality they would otherwise have.  If the medication is such that the patient lacks ambulation, recovery can be substantially lengthened and complications from immobility such as skin breakdown, urinary infections, pneumonia and so on can become compromising issues. Use of the Safe Enclosure can avoid these complications, require less nursing administration of medication, and allow more time to provide adequate nutrition, hydration and toileting.

Physical Restraints

Physical restraints come in many forms, the most common being tie down straps for arms and legs and posey vests.  The major issue with physical restraints when used alone is that the patient can and usually does become extremely agitated from the severe limitation of movement.  Consequently, the patient struggles to get out of the restraints and causes physical harm to themselves.  This can be in the form of skin abrasions to hyperventilation to cardiac arrest.  Provided the patient is not already extremely violent, the Safe Enclosure allows complete movement and freedom thereby defusing agitation caused by active restraints.  If the patient does vent frustration or has seizures, they are in totally safe surroundings. Most RNs feel that this is a more humane treatment of individuals than traditional four point restraints.

Isolation and Seclusion

Particularly in psychiatric hospitals, abusive patient behavior is often addressed using isolation rooms.  Isolation cuts the patient off from all outside influences and can be very detrimental to the recovery or psychological condition of the patient.  The Safe Enclosure performs the same function of controlling the patients’ abusive behavior, but allows the patient to interact with their environment, be it other people, television or radio.  This interaction can be healthy for the patient, assist in their recovery, and certainly prevent their condition from getting worse.

Sitters

Many hospitals use sitters to prevent patients from getting out of bed and falling or wandering.  Sitters also prevent patients from pulling tubes and IV’s or doing physical harm to themselves.  However, sitters are very expensive and in the final analysis, if a patient is a real behavioral problem, must border on getting combative in order to prevent or correct actions detrimental to the patient’s health.  The Safe Enclosure can not address the issue of patients removing tubes.  In these cases, sitters, active restraints or sedation may be necessary.  If however, sitters are being used to prevent patients from falls, wandering or other behaviors detrimental to their health, the Safe Enclosure is a far more cost efficient and clinically effective means of managing that behavior.

Bed Monitors

Monitors are plagued with false alarms.  In many instances, the alarm can not be responded to fast enough to prevent the patient from getting out of bed and falling.  Responding to all of the alarms can use up much of the staffs time depriving other patients of needed care and raising overall costs.  With the Safe Enclosure, patients can be observed and attended to on normal rounds
without interruptions.

Doctors, nurses and other caregivers sometimes have adverse and negative reactions when first introduced to the Safe Enclosure.  Among the most common reactions is that it is too claustrophobic, too much like a prison, not very compassionate, provides too much separation between the caregiver and the patient and is not in keeping with environment of care being promoted.  Let’s look at each of these complaints individually.
 

1.      Too Claustrophobic and like a Prison: The Safe Enclosure has been designed specifically to be as invisible as possible and give the patient an unrestricted feeling.  The amount of netting has been maximized, the size of the mesh has been optimized and the dark coloration has been adopted for minimal visual impedance.  To the contrary, the
Safe Enclosure gives a patient a sense of oneness with the room they are in.  Furthermore, is providing for a patient’s safety in a Safe Enclosure more claustrophobic or imprisoning than medication that limits their mental faculties or active restraints that bind them down or isolation that cuts them off from the world or getting into a combative situation with a sitter?
 

2.      Not Very Compassionate: The Safe Enclosure was design and intended to address the very issue of compassion.  It was conceived because the existing methods of behavioral control were not very compassionate.  How can strapping a patient down or isolating them be considered compassionate?  The Safe Enclosure maximizes the degree of freedom while encouraging them to interact with their environment.
 

3.      Provides Too Much Separation: Clearly as previously described, the whole intention of the Safe Enclosure is to do all possible to minimize the separation between the caregiver, the surroundings and the patient.  However, when direct access to the patient is necessary, unzipping the canopy drapes on either side or end can attain access simply and quickly.  There is 360 degrees of access to the patient.
 

4.      Not in Keeping with the Environment of Care: This is a subjective evaluation that can only be made in the context of the other methods of behavior management and restraint.  Is it more humane to medicate a patient to where they have a loss of their mental faculties or even to the point of loss of conciseness?  What kind of environment is it when a patient is physically restrained or isolated? How compassionate is it when a sitter has to get combative with a patient or the patient falls and is injured?  How much attention can the medical staff pay to needed patient care when they are constantly responding to false bed alarms? In traditional restraint situations, patients describe feelings ranging from anger to demoralization and fear, as well as increased agitation when being tied down. Patients
who have been placed in the Safe Enclosure have even requested to return to the “special bed” during the weaning process when they felt themselves becoming upset. Family members have accepted the Safe Enclosure with a minimum of hesitation and even readily approve when the reasons for it were carefully explained and have preferred it to “tying down” the patient. I do not think anyone can make a legitimate case that the alternatives provide a better environment of care!