Breaking Free From Restraints

Purpose:
At the inception of the open-heart surgery program at Christiana Care in 1986, restraints have been applied on 100% of patients post-operatively. This ritual has been practiced under the guise of nurse and patient safety, despite the fact that self-extubations would occur with restraints in place.

Significance:
In light of an organizational drive to minimize restraint use, this project was initiated with the goal to reduce the percentage of patients that are restrained during the recovery phase of open-heart surgery from 100% to 75%.

Strategy and Implementation:
Instituting a multi-disciplinary team approach, the Lean Process was used to determine areas for change. The process of automatic restraint application post-operatively was eliminated. Nursing comfort measures, such as pain control, family presence, use of mitts, etc., were implemented prior to seeking restraints. Respiratory therapy presence on the unit was prioritized to ensure rapid ventilator weaning and extubation. Training and reassurance was offered to nurses until comfort was achieved with the new process. The direct key measure was percent restraint use. The project yielded 3% restraint use on post-operative patients in the Cardiovascular ICU. With the reduction in restraint use, there is a projected cost savings of over $1000 per year. Other tracked measures included intubation times, medication use, and reportable events such as self-extubation. The results showed that in all these areas there was no significant change as noted from the baseline information.

Evaluation:
The goal of 75% restraint use was astoundingly exceeded (down to less than 5%) without having negative effects on other areas measured. Survey results also indicate improved nurse and patient satisfaction.

Implications for Practice:
It was accepted that patients must be restrained prior to wakening from anesthesia after open heart surgery, for both patient and nurse safety. This project has shown nursing staff that without restraints, most patients awaken calmly and cooperatively, and are easily managed by other means.