Case Study 101

Clinical Research: Patient with traumatic closed head injury

Mr. L. was a 33-year-old male who had suffered a traumatic closed head injury resulting in temporal lobe fracture, cervical injury and non-displaced fractures of several thoracic vertebrae. Lower extremity paralysis, prolonged coma, seizure disorder and ventilator dependency resulted from the initial trauma.

As the recovery process began, Mr. L remained in a semi-stuperous state and suffered from frequent episodes of intense agitation.  During these episodes, the patient thrashed about the bed throwing his head and extremities against the bed rails with such force that numerous bruises and lacerations developed.  More than once, he threw himself to the floor.

The nursing staff attempted to restrain the patient using chest and wrist restraints, which only increased his irritability and thrashing behavior.  Next, the restraints were removed and the bed rails were padded, but again the patient threw himself to the floor. The bed was kept in the lowest position at all times, but this made it difficult for the staff to carry out any procedures and several were treated for back pain after attending to Mr. L’s needs.

Mr. L’s family grew increasingly frustrated and angry about the situation. The nursing staff was frustrated as well, having exhausted all the traditional approaches to protect the patient while maintaining his dignity.

During patient rounds, the various options for the least restrictive restraints were explored. The Safe Enclosure bed was discussed as the only viable alternative to restraints for this perplexing case.  The family consented on behalf of the patient, and the attending physician wrote an order for the Safe Enclosure.

The Safe Enclosure proved to be an excellent alternative to traditional restraints.  It was implemented as the least restrictive device that would protect the patient from injury while maintaining his dignity and complying with both JCAHO Standards 1 and HFCA, HHS regulations 2.  Mr. L. was free to move about and his agitation was markedly decreased. The family stated they were very pleased because they were able to stop worrying about his safety and more easily participate in his care.

Joint Commission for the Accreditation of Health Care Organizations; TX.7.5, TX.7.5.2, TX.7.5.3, TX.7.5.4 and TX.7.5.5
2 Health Care Finance Administration, HHS, Regulations: CFR Part 483, Subpart B û Requirements for Long Term Care Facilities; 483.13, 483.15,
 Submitted by Susan Roos MS, RN