Monitoring, training reduce restraint use in the ICU

ICU. Image: Norbert Kaiser

A VA medical center found that it was possible to reduce the use of restraints in intensive care units (ICUs) through a change of hospital culture. Use of restraints may not always be necessary and may cause harm, according to participants in a 2-year pilot program.

The use of restraints in the ICU has been linked to numerous adverse outcomes, including urinary incontinence, impaired circulation, loss of muscle mass and flexibility, falls, edema, and even death. During the course of a 29-month pilot project, Salem Veterans Affairs Medical Center in Virginia reached its goal of significantly reducing its use of restraints on patients in all three of its ICUs through a change in hospital culture. The surgical ICU underwent the most pronounced reduction in use.

The interdisciplinary program included review and adoption of best practices, staff education, monitoring, the addition of alternative equipment, and daily rounds, according to Mary Y. Wright, RN, MS, who was a member of a team composed of physicians, nurses, and hospital management. The goal was to reduce the use of restraints by 50% in three months and 90% within a year. Data on the methods and outcome of the program were presented at the Society of Critical Care Medicine’s 37th Critical Care Congress.

The team collected data on how many patients during the study period were put in restraints and the total hours of restraint use. They tracked restraint use in three different wards:

• ICU 1 -- an eight-bed step-down unit
• ICU 2 -- a six-bed cardiac care and pulmonary unit
• ICU 3 -- an eight-bed surgical ICU.

In ICUs 1 and 2, the total number of patients in restraints declined by 49%, and in ICU 3 the total number declined by 75%. The hours of restraint use were reduced by 88% in ICU 3 and by 53% in the other units. There was no evidence of an increase in unplanned extubations, the researchers noted.

A specific example of when a restraint may be unnecessary and potentially risky is when an elderly patient reacts with agitation and confusion after surgery. “If such a patient were noted to have a change in behavior, staff should consider the possibility that the patient could be experiencing hypoxia,” said Ms. Wright. “Assessing the patient’s need for oxygen through a blood gas measurement or through pulse oximetry may lead to avoidance of the use of a restraint. Placing a patient in restraints to treat the agitation or confusion caused by lack of oxygen could produce a negative outcome.”

Ms. Wright believes the Salem facility’s success was due in large part to two major components: the monitoring of restraint use and recommending and purchasing equipment for alternatives to restraints. Once the facility met its goal through the pilot project, it became the responsibility of the nurse managers to continue the program, she said.

“Our facility continues to monitor restraint hours on a monthly basis. We continue to look at current research and expand our list of alternatives to provide a safe and comfortable environment for our patients. Our policy is to utilize restraints as the last resort, once other contributing medical factors are assessed and alternatives fail.”

Recommendations for alternatives to restraint were sought from occupational, physical, and music therapists, as well as pharmacologists. Based on these recommendations, adult busy aprons (with buttons and zippers that provide comfort through touch), music, movies, books, and handheld games were purchased or received through donation.

Ms. Wright’s team also adopted a “Restraint Decision Wheel” -- developed by a British cardiac surgery recovery unit at London Health Sciences Centre University Hospital, that offers medical staff a quick visual cue for when to use restraints, alternatives, or no restraints. In the broadest terms, restraints should be used only when the patient’s behavior is a threat to his or her life-saving treatment.

This article originally appeared in Pulmonary Reviews.