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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

Thank you for your attentionQuestions?

louise.rose@utoronto.ca