restraint use in the icu - critical care...
TRANSCRIPT
RESTRAINT USE in the ICU
Louise Rose RN, MN, PhDLawrence S. Bloomberg Professor in Critical Care Nursing,
University of TorontoAdjunct Scientist, Mt Sinai Hospital and Li Ka Shing Institute,
St Michael’s HospitalDirector of Research, Provincial Centre of Weaning Excellence,
Toronto East General Hospital
Elena Luk RN, BScN, CNCC(C)PhD student
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto
DEFINITION OF RESTRAINTS
The ACCM Task force defines a restraint as:
“a treatment aimed at improving a medical condition or preventing complications by restricting a patient’s movement or access to his or her body”
Pharmacologic Restraints: medications used to control agitation or in some cases
induce coma and paralysis
Physical Restraints: mechanical devices that restrict patient’s movements
LEGISLATION, POLICIES & GUIDELINES
Criteria for restraint use:
prevent serious bodily harm
give greater freedom/greater enjoyment of life
authorized by a treatment plan (patient/SDM consent)
Concept of “least restraint”
Duty of every hospital to establish policies regarding:
staff training
monitoring
documentation
ordering (MD only; no standing orders)
Bill 85: Patient Restraints Minimization Act (2001) of Ontario
Policy direction:
Least Restraint
Least restraint = all possible alternative
interventions are exhausted before restraints used
College of Nurses of Ontario
Clinical Best Practice Guideline
February 2012
8 practice recommendations
1 educational recommendation
3 organization and policyrecommendations
Registered Nurses Association of
Ontario
PRACTICE
#3 Use clinical judgment and validated assessment tools to assess risk of restraint (IIb)
#4 Plan of care that focuses on alternatives to restraints (IIb)
#6 Multi-component strategies to prevent use of restraint (IIa)
ORGANIZATIONAL
• Establish definition of restraint
• Policy on restraint reduction/prevention
• Procedures for communication/debriefing pt/family/SDM and interprofessional team
• Evaluation program to monitor restraint use
9 recommendations for limiting physical restraint use to “clinically appropriate” situations
Key Points of Each Recommendation
1 Create least restrictive but safest environment
2 Use only in clinically appropriate situations; NOT as routine therapy
3 Evaluate if treatment of existing problem would prevent need for physical
restraint & attempt alternatives first4 Choose least invasive option
5 Document rationale for use; Orders should only be valid for max 24 hrs
6 Monitor at least every 4 hours
7 Provide ongoing education to patients/families/staff
8 Use analgesics, sedatives, and neuroleptics to minimize physical restraint use,
but do not overuse chemical restraints9 Do not use neuromuscular blocking agents as chemical restraint
2 of the 6 patient safety categories (Communication & Risk Assessment) address restraint use
1. Communication: health care team implements verification processes for high-risk activities
development of standardized protocols for restraint2. Risk Assessment: health care team identifies safety
risks inherent in client population balancing need to prevent treatment interference
in ICU and restraint use
PHYSICAL RESTRAINTS IN THE ICU
Prospective point prevalence survey
34 adult ICUs across 9 European countries
219/669 (32.7%)
Physical restraint was associated with:
mechanical ventilation (p < 0.001)
sedation (p < 0.001)
larger ICUs (p=0.005)
AND
ICUs with a lower daytime nurse-to-patient ratio (p=0.001)
All cite preventing patient-initiated treatment interference as primary reason for use
Reasons for Physical Restraint Use
Other cited reasons:
Restlessness (Benbenbishty et al., 2010; Choi & Song, 2003)
Confusion (Benbenbishty et al., 2010; Minnick et al., 2001)
Delirium
Disorientation (Benbenbishty et al., 2010)
Drowsiness
Reasons for Physical Restraint Use
Point prevalence survey of restraint use in 4 different settings in southern Ontario in 1991/1992
89% of patients restrained in the ICU
Physical Restraint Use in Canada
51 ICUs across 10 provinces
Physical restraints used during 1375/3619 (38%) patient days
FACTORS ASSOCIATED WITH/CONSEQUENCES OF
PHYSICAL RESTRAINT USE IN THE ICU
Delirium
Delirium
Smoking
Objective: to reduce need for sedatives and analgesics by oral administration of melatonin in high-risk critically patients treated with conscious sedation
Inclusion criteria age ≥18 years,
SAPSII>32 points,
expected mechanical ventilation ≥ 4 days
Access/functionality of GI tract
Double-blind RCT b/w placebo and melatonin
N = 96
in physical restraint use with melatonin group (31.1%) compared to placebo (41.8%) p<0.001
ORAL MELATONIN DECREASES NEED FOR SEDATIVES
AND ANALGESICS IN CRITICALLY ILLMistraletti et al.
ESICM abstract, Berlin 2011
Melatonin
Timing of Post-op Extubation
Mobility
Unplanned extubation: occur at rate of 0.1 to 3.6 events/100 intubation days
17 studies examined incidence of unplanned extubation in physically restrained patients % of physically restrained patients at time of UE ranged from
25% to 87% (median 67%, IQR 42%-74%)
Only one study identified use of physical restraints as associated with increased risk of unplanned extubation on multivariate analysis
(OR 3.1, 95% CI 1.71–5.7) (Chang et al. Am J Crit Care 2008;17:408–15)
Prolonged ICU Length of Stay
PTSD Symptoms
Pts with memory of restraints were more likely to develop PTSD symptoms (OR 6.0, 95% CI 2.2-16.3)
THE PATIENT PERSPECTIVE
