Reducing Physical Restraints in the ICU

1. Reducing Physical Restraints in the ICU Faculty Advisor: Jackie Lamb, MS, RN Tyler Estes Mandy Johnson Heather Spears Melissa Wilson

2. In adult ICU patients 18 years through end of life, is sitter presence better than chemical restraints when used to decrease physical restraint use? PICO Question

3. Physical Restraint- Any manual method or physical or mechanical device that restricts freedom of movement and normal access to one�s body that the patient cannot easily remove. (Bray, 2004) Key Terms (Bray, 2004)(Bray, 2004)

4. Chemical Restraint- A drug that is used to control behavior or restrict the patient�s freedom of movement, and is not the standard treatment for the patient�s medical or psychiatric condition. (Bray, 2004) Key Terms Continued (Bray, 2004) *For the purpose of our PICO question and study, our chemical restraints are limited to: - sedative/hypnotics - anxiolytics - neuromuscular blocking agents(Bray, 2004) *For the purpose of our PICO question and study, our chemical restraints are limited to: - sedative/hypnotics - anxiolytics - neuromuscular blocking agents

5. Sitter � a person employed to provide direct observation of patients for the purpose of providing a safer environment. Key Terms Continued Sitters in hospitals can be hired from within the facility or outside the facility. Sitters in hospitals can be hired from within the facility or outside the facility.

6. ICU Nurse at a Local Hospital Lack of sufficient resources Lack of alternative options Discrepancies in procedure and protocol Identification of the Problem Where did the question come from? (A nurse in a local ICU) Lack of resources- Where do nurses go for information? How were policies and procedures developed if there is a lack of sufficient research? How much education do nurses receive for restraints (chemical, physical and alternative therapies)? Lack of options- Nurses believe this is the standard practice and that it is widely accepted. Discrepancies- In the Rutledge study, between 60% and 70% of nurses reported that chemical and physical restraints are a source of disagreement between hospital staff and families. 78% agreed or strongly agreed that caregivers try all alternatives before restraining patients on their units (Rutledge, 2003).Where did the question come from? (A nurse in a local ICU) Lack of resources- Where do nurses go for information? How were policies and procedures developed if there is a lack of sufficient research? How much education do nurses receive for restraints (chemical, physical and alternative therapies)? Lack of options- Nurses believe this is the standard practice and that it is widely accepted. Discrepancies- In the Rutledge study, between 60% and 70% of nurses reported that chemical and physical restraints are a source of disagreement between hospital staff and families. 78% agreed or strongly agreed that caregivers try all alternatives before restraining patients on their units (Rutledge, 2003).

7. 59%- PR use in adult ICU patients 58%- PR use in adult ICU patients > 65 51%-PR use in ventilated ICU patients (Minnick, 2007) 53% of nurses believe restraints reduce falls 45% report the risk of complications from restraints is low Extent of the Problem Majority of restraint related deaths occurred when restraints were properly applied. Patients in ICU, those over 65 years of age, and those with confusion, poor judgment or behavioral problems combined with physical impairments are the most likely to receive restraints while in acute care�are these patients the ones that need it the most? And it is fair for us to lump these very different patients together? Patients usually view this treatment as negative Nurses waiver between not wanting to �tie down� a patient and needing the patient and others around him or her to be safe. Nurses also cite fears of legal actions if a patient is harmed and restraints were not applied. There is little evidence supporting the concern that unrestrained patients fall or injure themselves more often than patients who are restrained.Majority of restraint related deaths occurred when restraints were properly applied. Patients in ICU, those over 65 years of age, and those with confusion, poor judgment or behavioral problems combined with physical impairments are the most likely to receive restraints while in acute care�are these patients the ones that need it the most? And it is fair for us to lump these very different patients together? Patients usually view this treatment as negative Nurses waiver between not wanting to �tie down� a patient and needing the patient and others around him or her to be safe. Nurses also cite fears of legal actions if a patient is harmed and restraints were not applied. There is little evidence supporting the concern that unrestrained patients fall or injure themselves more often than patients who are restrained.

8. Systematic Review Observational Studies Perspective Follow-Up Studies Descriptive Studies Descriptive Study w/Cluster Analysis Review of the Literature There were several different types of research used for this subject including: (name bullet points).There were several different types of research used for this subject including: (name bullet points).

9. Prevention of harm to self and others Safe work environment Decrease falls Preventing interference with devices Physical Restraint- Pros None of these have been proven, these are the perceptions of nurses and health care workers. *Restraints are considered appropriate in acute care settings when used for behavioral reasons (such as an aggressive or violent patient at risk for harming himself or others) and to prevent patient behavior that may interfere with treatment (such as pulling out a nasogastric tube or intravenous line). Restraint standards for medical or surgical purposes apply when the primary reason for use directly supports medical healing (JCAHO, 2004)None of these have been proven, these are the perceptions of nurses and health care workers. *Restraints are considered appropriate in acute care settings when used for behavioral reasons (such as an aggressive or violent patient at risk for harming himself or others) and to prevent patient behavior that may interfere with treatment (such as pulling out a nasogastric tube or intravenous line). Restraint standards for medical or surgical purposes apply when the primary reason for use directly supports medical healing (JCAHO, 2004)

10. Lack of Documentation Patient Agitation & Confusion Psychological Effects Sentinel Events Nosocomial Events Time Spent re-evaluating situation Physical Restraint- Cons Nurses are not honest or thorough enough with their PR assessments and do not re-evaluate. An important finding is that once a patient has been restrained, nurses will tend to re-strain again rather than re-assess. Physical restraints can increase the amount of agitation and confusion for the patient. Patients feel as though they lose their dignity, freedom and autonomy while restrained. *INTERESTING NOTE* It is illegal to restrain any patient with a history of physical or sexual abuse. It has been reported that up to 100 deaths occur annually as a result of improper use of restraints. The use of physical restraints can lead to: skin trauma, pressure sores/ulcers, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, and a decline in functional and cognitive state. The nurses have to check on the restraint at least every two hours, usually every hour, re-adjust and re-evaluate whether or not the restraints are needed. (in most hospitals) The doctor must write an order for PR and they have to be re-written every 24 hours. Also, if PR are not ordered but the nurse feels as though they are necessary, they can apply the restraints but the doctor has to see the patient within an hour.Nurses are not honest or thorough enough with their PR assessments and do not re-evaluate. An important finding is that once a patient has been restrained, nurses will tend to re-strain again rather than re-assess. Physical restraints can increase the amount of agitation and confusion for the patient. Patients feel as though they lose their dignity, freedom and autonomy while restrained. *INTERESTING NOTE* It is illegal to restrain any patient with a history of physical or sexual abuse. It has been reported that up to 100 deaths occur annually as a result of improper use of restraints. The use of physical restraints can lead to: skin trauma, pressure sores/ulcers, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, and a decline in functional and cognitive state. The nurses have to check on the restraint at least every two hours, usually every hour, re-adjust and re-evaluate whether or not the restraints are needed. (in most hospitals) The doctor must write an order for PR and they have to be re-written every 24 hours. Also, if PR are not ordered but the nurse feels as though they are necessary, they can apply the restraints but the doctor has to see the patient within an hour.

11. 1:1 Ratio Peace of mind for family Quick Intervention Alleviate the demand on nurse�s time Sitters- Pros Someone is with the patient 24/7. If the patient tries to get up or pull at a device, someone is already in the room ready to intervene. Families tend to feel relieved knowing that someone is always there reducing the loneliness of the patient. Sitters can be taught to be aware of any slight changes in a patient�s condition (for example, mental changes, extreme heart rate, blood pressure or pulse oxygenation changes if constantly monitored), they can engage awake patient�s in conversation, and they can readjust devices such as SCD�s. If there is a change in a patient�s condition or something needs to be addressed that the sitter is not able to do, they can inform the nurse, cutting down on the nurse�s time. Someone is with the patient 24/7. If the patient tries to get up or pull at a device, someone is already in the room ready to intervene. Families tend to feel relieved knowing that someone is always there reducing the loneliness of the patient. Sitters can be taught to be aware of any slight changes in a patient�s condition (for example, mental changes, extreme heart rate, blood pressure or pulse oxygenation changes if constantly monitored), they can engage awake patient�s in conversation, and they can readjust devices such as SCD�s. If there is a change in a patient�s condition or something needs to be addressed that the sitter is not able to do, they can inform the nurse, cutting down on the nurse�s time.

12. Lack of Education Lack of Research Findings Costs Sitters- Cons An interview with Andrew Harding revealed that his institution only spent 30 minutes educating their sitters. Their education included: having full attention on the patient at all times, legality and policy issues, including proper documentation and attire, basic first aid, crash cart location, use and purpose of call light, barriers and limit setting involving conversations with patients, signs of agitation and confusion, how to make the room safe, how to take and give report, and relevant medical findings (for example, the nurse informing the sitter that the patient�s blood glucose level can affect a patient�s confusion state). The effectiveness of the use of sitters in preventing falls has been recognized by hospital administrators, but whether they decrease inpatient fall rates is still uncertain. A study conducted by Huey-Ming Tzeng estimated the cost of a sitter was around $160 per shift. The cumulative effect of the sitters on falls and patient satisfaction was a revenue enhancement of $3.76 per sitter shift; therefore, the net expense of a sitter shift was $156.24. In other words, using sitters was not cost effective for decreasing patients falls because the gains did not offset the direct expense related to the sitter program. An interview with Andrew Harding revealed that his institution only spent 30 minutes educating their sitters. Their education included: having full attention on the patient at all times, legality and policy issues, including proper documentation and attire, basic first aid, crash cart location, use and purpose of call light, barriers and limit setting involving conversations with patients, signs of agitation and confusion, how to make the room safe, how to take and give report, and relevant medical findings (for example, the nurse informing the sitter that the patient�s blood glucose level can affect a patient�s confusion state). The effectiveness of the use of sitters in preventing falls has been recognized by hospital administrators, but whether they decrease inpatient fall rates is still uncertain. A study conducted by Huey-Ming Tzeng estimated the cost of a sitter was around $160 per shift. The cumulative effect of the sitters on falls and patient satisfaction was a revenue enhancement of $3.76 per sitter shift; therefore, the net expense of a sitter shift was $156.24. In other words, using sitters was not cost effective for decreasing patients falls because the gains did not offset the direct expense related to the sitter program.

13. Reduced Duration of Mechanical Ventilation Daily sedation breaks Individualize Care Promotion of Patient Safety Safe Work Environment Decrease Falls Preventing Interference with Devices Chemical Restraint- Pros Reduced time being mechanically ventilated usually involved daily sedation breaks. The doctors and nurses can collaborate to determine what level is best for each patient individually. Usually doctor�s leave levels of sedation up to the nurse�s discretion and will allow for daily sedation breaks. They do have to evaluate and re-evaluate like they do for physical restraints, but it takes less time and there is a standing order in place, versus physical restraints, where the doctor usually has to rewrite an order after 24 hours. This seems to be a false sense of security like the physical restraints. However, reaching a therapeutic level of sedation, in theory, would most likely reduce the chances of a patient getting up and falling or pulling at devices versus using physical restraints. Reduced time being mechanically ventilated usually involved daily sedation breaks. The doctors and nurses can collaborate to determine what level is best for each patient individually. Usually doctor�s leave levels of sedation up to the nurse�s discretion and will allow for daily sedation breaks. They do have to evaluate and re-evaluate like they do for physical restraints, but it takes less time and there is a standing order in place, versus physical restraints, where the doctor usually has to rewrite an order after 24 hours. This seems to be a false sense of security like the physical restraints. However, reaching a therapeutic level of sedation, in theory, would most likely reduce the chances of a patient getting up and falling or pulling at devices versus using physical restraints.

14. Psychological Effects Pre-Existing Conditions Complexity of Care Overuse, over-sedation Chemical Restraint- Cons Psychological effects can be numerous and there is a lack of research on this subject. Patients have reported a feeling of confusion, doom and anxiousness if doctors and nurses have discussed a patient�s state at the bedside and heard negative words about their condition. Alcoholics and drug addicts are much harder to sedate due to a high tolerance and if they are going through withdrawal. Also, increased metabolic states increase tolerance. There are many factors in chemical sedation such as pre-existing conditions, body weight, sex, age, polypharmacy, and perceived danger to health care team. Unwanted side effects from chemical sedation include: hypotension, REM sleep reduction, constipation, and accumulation of drugs leading to delayed weaning and increased length of ICU stays. When discussing restraint in general, the health care team may consider the need to obtain consent for physical restraint, yet if a decision is made to administer chemical restraint for critically ill patients consent is rarely sought. An important finding is that once a patient has been restrained, nurses will tend to re-strain again rather than re-assess again. Psychological effects can be numerous and there is a lack of research on this subject. Patients have reported a feeling of confusion, doom and anxiousness if doctors and nurses have discussed a patient�s state at the bedside and heard negative words about their condition. Alcoholics and drug addicts are much harder to sedate due to a high tolerance and if they are going through withdrawal. Also, increased metabolic states increase tolerance. There are many factors in chemical sedation such as pre-existing conditions, body weight, sex, age, polypharmacy, and perceived danger to health care team. Unwanted side effects from chemical sedation include: hypotension, REM sleep reduction, constipation, and accumulation of drugs leading to delayed weaning and increased length of ICU stays. When discussing restraint in general, the health care team may consider the need to obtain consent for physical restraint, yet if a decision is made to administer chemical restraint for critically ill patients consent is rarely sought. An important finding is that once a patient has been restrained, nurses will tend to re-strain again rather than re-assess again.

15. In adult ICU patients 18 years through end of life, chemical restraints were proven to be more beneficial than sitter presence when used to decrease physical restraint use. Conclusion However, this recommendation does NOT stand alone.However, this recommendation does NOT stand alone.

16. Chemical Restraint Use/Sedation Alternatives: Therapeutic Massage Music Therapy Expressive Touch Communication Relative/Friend Presence Acupuncture Recommendations Factors that MUST be considered when using chemical restraints: Protocol must be in place Only 32.6% of adult ICUs in the United States indicated using written protocols (Arabi, 2007). A sedation goal or endpoint should be established for each individual patient, along with regular assessment of the sedation level using a validated sedation scale and the patient�s response to therapy should be regularly documented. We recommend a daily sedation break since studies have shown this method shortens the patient�s time spent mechanically ventilated and the length of the ICU stay. Prepare and implement a multifaceted multidisciplinary education program including point of use reminders, directed educational efforts, and opinion leaders. All of these alternative methods have been shown to reduce anxiety and pain, and to promote relaxation. The alternative methods should be used if they are thought to be beneficial for the individual patient. Again, research varies widely and there needs to more conducted. Most research tends to focus on specific conditions. If alternative methods are to be used, we recommend: collating the evidence base with regard to safety and efficacy, obtaining consent from the patient, considering appropriateness of the therapy, developing and utilizing protocols, use of qualified therapists, educating and training staff, and audits.Factors that MUST be considered when using chemical restraints: Protocol must be in place Only 32.6% of adult ICUs in the United States indicated using written protocols (Arabi, 2007). A sedation goal or endpoint should be established for each individual patient, along with regular assessment of the sedation level using a validated sedation scale and the patient�s response to therapy should be regularly documented. We recommend a daily sedation break since studies have shown this method shortens the patient�s time spent mechanically ventilated and the length of the ICU stay. Prepare and implement a multifaceted multidisciplinary education program including point of use reminders, directed educational efforts, and opinion leaders. All of these alternative methods have been shown to reduce anxiety and pain, and to promote relaxation. The alternative methods should be used if they are thought to be beneficial for the individual patient. Again, research varies widely and there needs to more conducted. Most research tends to focus on specific conditions. If alternative methods are to be used, we recommend: collating the evidence base with regard to safety and efficacy, obtaining consent from the patient, considering appropriateness of the therapy, developing and utilizing protocols, use of qualified therapists, educating and training staff, and audits.

17. Monitoring of Use: Prevalence Documentation/Chart Review Evaluate Patient Outcomes Evaluate Patient and Staff Satisfaction Evaluate Cost Effectiveness Evaluation Methods This comes with proper and honest documentation and the manager and/or health care team regularly checking documentation. Patient outcomes-specific complications and adverse drug effects, surveys on what the patient thought of their experience Satisfaction-new procedure and outcomes, what do they think? Was it effective? What else do you suggest? STAFF BY IN- EVERYONE ON BOARD Cost effectiveness-implementation and maintenance of new protocol, time and money training staff, patient outcomes and decreased vs. increased length of stayThis comes with proper and honest documentation and the manager and/or health care team regularly checking documentation. Patient outcomes-specific complications and adverse drug effects, surveys on what the patient thought of their experience Satisfaction-new procedure and outcomes, what do they think? Was it effective? What else do you suggest? STAFF BY IN- EVERYONE ON BOARD Cost effectiveness-implementation and maintenance of new protocol, time and money training staff, patient outcomes and decreased vs. increased length of stay

18. Comparative studies Patient response Sitters Psychological effects of chemical and physical restraints on patients Long term effects Presence of pre-existing conditions on outcomes Alternative therapies Suggestions for Further Study �Litigation from restraints has been for their misuse, not their non-use.� (Hurlock-Chorostecki, 2006)�Litigation from restraints has been for their misuse, not their non-use.� (Hurlock-Chorostecki, 2006)

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