Implementation of an Evidence Based Nursing Practice Guideline on Physical Restraints

Purpose:
This presentation will describe a process used to implement a nursing practice guideline on restraint use in an acute care setting and associated monitoring of restraint utilization.

Significance:
Restraint utilization continues in acute care, despite safety warnings in the 1990's from the ANA, FDA, CMS, and The Joint Commission on the risks of restraining patients. NDNQI benchmarks for restraint prevalence in acute care ranges from 0.34% in pediatrics to 20.11% in adult critical care.

Strategy and Implementation:
After approval of the evidenced based nursing practice guideline on restraints, education sessions were set up to inform staff of the guidelines. Knowing education alone is inadequate to change unit culture, a second phase of implementation began. During this phase, meetings were arranged with unit leaders to review the guideline, review data and determine a plan for unit specific implementation. The units worked through their collaborative governance structure (Unit Councils) to review unit specific data and determine an action plan. Each unit then set specific goals related to restraint prevalence or utilization. After implementation of innovative strategies to reduce restraint use, the unit councils were given data monthly to monitor progress and identify changes needed for the plan. Examples of innovative changes included changing unit stock, identifying criteria to remove restraints earlier, and notification of nursing unit leadership.

Evaluation:
Success of the implementation was measured using NDNQI data on restraint prevalence. Restraint documentation data was utilized to measure number of restraint hours, type of restraint, use of alternatives to restraints and restraint patient days as well as personal safety attendant requests.

Implications for Practice:
Sustained changes in practice require changes in unit culture by continually reviewing process and outcome indicators. Keys to success included unit based champions who regularly review the data at unit meetings and continue to identify ways to improve identified metrics.