Loosening Our Grip on Restraints in the Intensive Care Unit

Purpose:
The MICU nurses determined that use of soft wrist restraints (SWR) was above the NDNQI benchmark. They determined that the parctice of placing SWR on the majority of patients was inappropriate. They decided to implement three changes; proper sedation,restraint alternatives, and early mobilization.

Significance:
Evidence based practice over the last few years has shown the importance of creating a restraint free environment. Restraints restrict a patients freedom of movement and can actually lead to complications due to decreased ability of patients to move and shift in the bed.

Strategy and Implementation:
Staff nurses were educated on the benefits of early mobilization, assessing patients for appropriate use of sedation medications, use of alternatives to restraints and decreased SWR usage. Patients were evaluated based on their tolerance for activity and then placed into a mobilization plan. This categories depended on the patients hemodynamic stability and ranged from limited turning, passive range of motion, active range of motion, weight bearing and ambulation. Ventilation status did not impact mobility and the project caused nurses to get their patients out of bed even while intubated. This plan pushed nurses to assure appropriate sedation so that patients were more involved in thier activity plan. Restraints were replaced with mitts to allow for better movement and interaction. Daily rounds were conducted to evaluate sedation, restraints, moblization and skin condition. During the rounds the nurses were re-educated on the importance of all processes involved in the research.

Evaluation:
Restrant prevalence decreased from 21.98 to 6.67. Patient and family satisfaction increased as well as family involvement. Pressure ulcer occurence decreased. Restraints continue to decrease and goal is to be restraint-free. There was no increase noted in unplanned extubations with reintubation

Implications for Practice:
This study had a cultural impact in the MICU. Nurses are more comfortable using alternatives such as mitts. They no longer apply restraints just because it was always done that way. Nurses are working hard to decrease sedation and increase mobility in all patients including those that are intubated.