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Guidelines Promote “Least Restrictive” Care

Restraints should be used only to maintain patient safety in the ICU.

Monday January 1, 2007
(Photo by Joseph Cyganowski.)
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Doris Tavares, RN, remembers how the use of restraints was more a given than an option to nurses in the intensive care unit. Now, the 35-year nurse and co-nurse manager of the medical ICU for Georgetown University Hospital, Washington, D.C., says that nurses’ first thoughts are whether a patient needs to be restrained — and what alternatives are available.

“And the moment that we do put someone in restraints, we’re already thinking about how to get them out,” Tavares adds.

Guidelines for the use of restraints

Critical care nursing practice is trending toward using restraints only to prevent patient harm and to maintain therapeutic regimes. Clinicians should use the least restrictive mechanism of restraint only after ruling out other alternatives.

The American Association of Critical Care Nurses (AACN) joined with the American College of Critical Care Medicine and the Society of Critical Care Medicine to review the literature about the use of restraints.

The resulting clinical practice guidelines for patient safety in the ICU, published in 2003, offer nine major recommendations. (See sidebar.) The AACN’s work supplements legal regulations and standards regarding the use of restraints from the Joint Commission on the Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration, or HCFA).

“In general, restraints in the ICU remain a fact of life in certain instances because, sometimes, they have to be used to prevent potentially life-threatening consequences,” says Janice Weber, RN, MSN, AACN public policy specialist.” The guidelines say that restraints shouldn’t be used as routine components of ICU care. The main recommendation that came out of that is that they should only be used in clinically appropriate situations to maintain patient safety in the ICU.”

While these guidelines might prompt a shift in thinking for seasoned nurses, less experienced nurses are aware that alternatives should be considered first, according to Janie Heath, RN, PhD, APRN-BC, ANP, ACNP, assistant professor, Georgetown University School of Nursing and Health Studies, Washington, D.C. Heath, an AACN board member, says nursing faculty are focusing on evidence-based practice and teaching students about national guidelines and the leading authorities that make the recommendations.

“As educators we know that our students have to be aware of quality issues. And restraints are at the top of the list,” Heath explains.

Providing information

Georgetown University Hospital has hospitalwide restraint guidelines, which assist nurses in choosing options and closely monitoring patients who are restrained. The choice to use restraints is a multidisciplinary decision-making process, according to Mary Herold, RN, Tavares’s co-nurse manager and a nurse for 23 years. It involves physicians, nurses, and family members — and sometimes the patients themselves.

Georgetown’s multipronged approach also includes providing a list of least restrictive measures to staff and an information sheet about the use of restraints to family members.

The list of least restrictive measures includes —
    • Verbal deescalation strategies, including talking with patients in a slow, nonthreatening manner and using relaxation techniques
    • Participation from family members and others in care strategies
    • Modification of the environment by making it safer, reducing stimuli, decreasing light, and offering the patient warm beverages
    • Supervised physical activities to divert patients’ attention, for example, providing patients with an activity that occupies their hands

Tavares and Herold have noticed a positive difference in the use of restraints on the MICU since employing these techniques.

Alternatives at work

The critical care unit at the University of California San Francisco Medical Center (UCFS) demonstrated the ability to reduce restraint use, according to Hildy Schell, RN, MS, CCRN, clinical nurse specialist for adult critical care at UCFS. The staff conducted the performance-improvement study with the goal of ensuring both appropriate use and reduced use of restraints. In the sample of about 60 patients, restraint use decreased from 40% in December 2000 to 29% in May 2001.

“It was a big change in critical care to say that every intubated patient does not need to be restrained because they have a tube in their trachea. Prior to two or three years ago, that was the [norm] in many ICUs,” says Schell.

The UCFS nursing staff learned to assess individual patients, including patient behaviors and conditions. For example, Schell says some patients will suffer potentially life-threatening situations if they pull out their tubes, while others will not. The study helped staff to capture the nursing interventions that they were using, including distractions and diversions, she adds. For example, disoriented patients are given gadgets, little balls, and wash clothes to occupy their hands. They are also provided with drains and apron devices they can tie or play with to divert attention away from the real IV tubes.

“We try to camouflage any tubes that we do not want them to pull [putting tubes out of easy reach rather than on the patient’s chest],” she says. “We also make sure patients are comfortable [in positions].” Reorienting patients is also important. For example, nurses place pictures of family members in the room and frequently reorient patients to time and place.

Personal touch takes time

Monitoring patients and discontinuing the use of restraints in a timely manner is imperative and demands frequent evaluation by nurses and physicians, which can be time-consuming. And according to Schell, restraints require a physician’s order every 24 hours for the medical/surgical restraints, which are the most common — behavioral restraints are rarely used.

Weber agrees that time can be a factor. “The typical case of where restraints are used, or should not be used, is when there isn’t enough staff and nurses feel they will not be available to monitor their patients appropriately or adequately,” says Weber. “The nurses apply the restraints with the intent of protecting the patient, rather than solving the problem of why they can’t directly address the patient’s agitation or confusion or other reasons for using restraints.”

Because patients who are provided alternatives rather than restraints also need attention, nurse managers and leaders should address time constraints placed on staff when alternative options are used. Schell tries to adjust staffing when a nurse has an agitated or extremely difficult patient so that the nurse has one patient, rather than two, for example.

“We restrain when we need to, but this is an assessment process, and if patients are restrained, they need to be constantly reassessed,” Schell explains, adding that the challenge to nursing is also to reassess and change the culture regarding the use of restraints.

Lisette Hilton is a freelance health care reporter.

Clinical Practice Guidelines for the Use of Restraints

The following recommendations regarding restraint use in ICU patients are provided by the American Association of Critical Care Nurses, the American College of Critical Care Medicine, and the Society of Critical Care Medicine.

Recommendation 1. Institutions and practitioners should strive to create the least restrictive but safest environment for patients in regard to restraint use. This is in keeping with the goals of maintaining the dignity and comfort of our patients while providing excellence in medical care.

Recommendation 2. Restraining therapies should be used only in clinically appropriate situations and not as a routine component of therapy. When restraints are used, the risk of untoward treatment interference events must outweigh the physical, psychological, and ethical risks of their use.

Recommendation 3. Patients must always be evaluated to determine whether treatment of an existing problem would obviate the need for restraint use. Alternatives to restraining therapies should be considered to minimize the need for and extent of their use.

Recommendation 4. The choice of restraining therapy should be the least invasive option capable of optimizing patient safety, comfort, and dignity.

Recommendation 5. The rationale for restraint use must be documented in the medical record. Orders for restraining therapy should be limited in duration to a 24-hour period. New orders should be written after 24 hours if restraining therapies are to be continued. The potential to discontinue or reduce restraining therapy should be considered at least every eight hours.

Recommendation 6. Patients should be monitored for the development of complications from restraining therapies at least every four hours, more frequently if the patient is agitated or if otherwise clinically indicated. Each assessment for complications should be documented in the medical record.

Recommendation 7. Patients and their significant others should receive ongoing education as to the need for and nature of restraining therapies.

Recommendation 8. Analgesics, sedatives, and neuroleptics used for the treatment of pain, anxiety, or psychiatric disturbance of the intensive care unit patient should be used as agents to mitigate the need for restraining therapies and not overused as a method of chemical restraint.

Recommendation 9. Patients who receive neuromuscular blocking agents must have adequate sedation, amnesia, and analgesia. The use of neuromuscular blocking agents necessitates frequent neuromuscular blockade assessment to minimize the serious sequelae associated with long-term paralysis. Neuromuscular blocking agents should not be used as chemical restraints when not otherwise indicated by the patient’s condition.

Source: Maccioli GA, Dorman T, Brown BR, et al. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies. American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med. 2003;31(11):2665-2676.