The Absence of Restraint Is Liberty: Sustaining the Efforts of a Restraint-Free Environment

Purpose:
Several years ago, the RNs of this unit set out to reduce overall restraint usage. Restraint usage, particularly on ventilated patients, had become "routine" practice, with little assessment for whether they were really needed.

Relevance/Significance:
Ethical and legal implications of restraint usage in ICU patients is well-documented in literature. Restraining patients without consent can violate a patient's autonomy, and can take away from a patient's dignity, even though restraining may contribute to patient safety. Legally, we are bound to utilize the least-restrictive means when applying restraints, otherwise, principles of justice and nonmaleficence are violated.

Strategy and Implementation:
Originally, a "process improvement" project was implemented to reduce post-operative restraints on open-heart patients in a 26-bed cardiac medical and surgical ICU. However, it was realized that the process could easily be applied to all patients in the unit, not just post-op patients. The multidisplinary team set out, utilizing the PDCA model, to reduce retraints throughout the unit. Alternative interventions were implemented, such as re-orienting and re-directing patients, establishing better methods of communication, and addressing discomfort in patients. The need for restraints was addressed in multidisciplinary rounds by the entire team.

Evaluation:
Since project implementation in 2011, restraint usage in this unit has averaged significantly below the NDNQI mean for mixed acuity units, and has reached near 0. With the reduction in restraint usage, it was noted that less sedating medications were used, incidence of delirium were reduced, and ICU length of stay was reduced.

Implications for Practice:
Restraints are not necessary to implement routinely in an ICU setting. In fact, doing so violates ethical principles of patient care, and can actually interfere with patient recovery.