RESTRAINT USE in the ICU

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1 RESTRAINT USE in the ICU Louise Rose RN, MN, PhD Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto Adjunct Scientist, Mt Sinai Hospital and Li Ka Shing Institute, St Michael s Hospital Director 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

2 DEFINITION OF RESTRAINTS

3 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

4 LEGISLATION, POLICIES & GUIDELINES

5 Bill 85: Patient Restraints Minimization Act (2001) of Ontario 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)

6 College of Nurses of Ontario Policy direction: Least Restraint Least restraint = all possible alternative interventions are exhausted before restraints used

7 Registered Nurses Association of Ontario Clinical Best Practice Guideline February practice recommendations 1 educational recommendation 3 organization and policy recommendations

8 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 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 first 4 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 restraints 9 Do not use neuromuscular blocking agents as chemical restraint

10 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 restraint 2. Risk Assessment: health care team identifies safety risks inherent in client population balancing need to prevent treatment interference in ICU and restraint use

11 PHYSICAL RESTRAINTS IN THE ICU

12 Prospective point prevalence survey 34 adult ICUs across 9 European countries 219/669 (32.7%)

13

14 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)

15 Reasons for Physical Restraint Use All cite preventing patient-initiated treatment interference as primary reason for use

16 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

17 Physical Restraint Use in Canada Point prevalence survey of restraint use in 4 different settings in southern Ontario in 1991/ % of patients restrained in the ICU 51 ICUs across 10 provinces Physical restraints used during 1375/3619 (38%) patient days

18 FACTORS ASSOCIATED WITH/ CONSEQUENCES OF PHYSICAL RESTRAINT USE IN THE ICU

19 Delirium

20 Delirium

21 Smoking

22 Melatonin ORAL MELATONIN DECREASES NEED FOR SEDATIVES AND ANALGESICS IN CRITICALLY ILL Mistraletti et al. ESICM abstract, Berlin 2011 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

23 Timing of Post-op Extubation

24 Mobility

25 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 ) (Chang et al. Am J Crit Care 2008;17:408 15)

26 Prolonged ICU Length of Stay

27 PTSD Symptoms Pts with memory of restraints were more likely to develop PTSD symptoms (OR 6.0, 95% CI )

28 THE PATIENT PERSPECTIVE

29

30

31

32 Thank you for your attention Questions?

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