Using Restraint When Using Restraints

Purpose:
Decrease restraint utilization a minimum 25% in the SICU while demonstrating that patient safety and staffing adequacy were not compromised. Maintain the rights of the patient without any statistically significant concomitant increase in patient self-extubations or harm.

Relevance/Significance:
Use of physical restraints in acute care has come under scrutiny and has been the subject of ongoing state and federal review. Accounts of patient harm while in restraints prompted changes in federal regulation and accrediting bodies have developed standards to which organizations are held accountable. Our professional commitment to the patient rights and our core value of compassion were noted to be in direct opposition to the practice of utilizing anticipatory restraints in the SICU.

Strategy and Implementation:
Executive sponsorship was provided by the Director of Regulatory Affairs. A nursing centric task force promoted rapid cycle change using a multimodal approach; policy and process revision, clinical practice change, education of stakeholders to include patient and family and development of a monitoring plan. Process changes included development of standardized order sets and assessment forms to hardwire compliance with regulatory and policy guidelines. The use of mittens as an alternative to physical restraint when appropriate was initiated in the SICU. An interdisciplinary Restraint SWAT Team was used to prospectively monitor restraint episodes, audit process reliability, serve as a resource and to provide staff with direct feedback and coaching. Clinical staff became engaged in the initiative and fostered a cultural change where restraint use was no longer considered a routine aspect of post-op care. Outcome measures are restraint utilization, unplanned extubation and inpatient falls.

Evaluation:
Pre-intervention, the SICU averaged 1.9 restraints per day and 2.3 unplanned extubations per 100 ventilator days. There has been a steady decline in restraint utilization and no falls reported. Post-intervention, total patient days have remained stable, while ventilator days have increased 28.9%. The unit averaged 0.07 restraints per day and 0.64 unplanned extubations per 100 ventilator days.

Implications for Practice:
Reduction in restraints has been achieved without affecting patient outcomes. Promoting a culture where patient dignity and rights were a shared goal allowed for spread to all ICUs. The balancing measure, a slight increase in 1:1 hours in the SICU will be the focus of the next intervention cycle.