Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit

12 Pages·2003·0.12 MB·English

Special Articles
Clinical practice guidelines for the maintenance of patient physical
safety in the intensive care unit: Use of restraining therapies—
American College of Critical Care Medicine Task Force 2001–2002
Gerald A. Maccioli, MD, FCCM; Todd Dorman, MD, FCCM; Brent R. Brown, MD;
John E. Mazuski, MD, PhD, FCCM; Barbara A. McLean, MN, CCRN, CCNS-NP, FCCM;
Joanne M. Kuszaj, MSN, RN, CCRN; Stanley H. Rosenbaum, MD, FCCM; Lorry R. Frankel, MD, FCCM;
John W. Devlin, PharmD, BCPS, FCCM; Joseph A. Govert, MD; Brian Smith, RCP, RRT;
William T. Peruzzi, MD, FCCM
Objective:Todevelopclinicalpracticeguidelinesfortheuseof weight of scientific information within the literature and expert
restraining therapies to maintain physical and psychological opinion.Draftdocumentswerecomposedbyataskforcesteering
safety of adult and pediatric patients in the intensive care unit. committeeanddebatedbythetaskforcemembersuntilconsen-
Participants: A multidisciplinary, multispecialty task force of suswasreachedbynominalgroupprocess.Thetaskforcedraft
expertsincriticalcarepracticewasconvenedfromthemember- thenwasreviewed,assessed,andeditedbytheBoardofRegents
shipoftheAmericanCollegeofCriticalCareMedicine(ACCM),the of the ACCM. After steering committee approval, the draft docu-
Society of Critical Care Medicine (SCCM), and the American As- ment was reviewed and approved by the SCCM Council.
sociation of Critical Care Nurses (AACN). Conclusions:Thetaskforcedevelopedninerecommendations
Evidence:Thetaskforcemembersreviewedthepublishedliter- with regard to the use of physical restraints and pharmacologic
ature(MEDLINEarticles,textbooks,etc.)andprovidedexpertopinion therapiestomaintainpatientsafetyintheintensivecareunit.(Crit
fromwhichconsensuswasderived.Relevantpublishedarticleswere Care Med 2003; 31:2665–2676)
reviewed individually for validity using the Cochrane methodology KEY WORDS: agitation; analgesia; chemical; delirium; ethical;
(http://hiru.mcmaster.ca/cochrane/orwww.cochrane.org). evidence-basedmedicine;guidelines;intensivecareunitpsycho-
Consensus Process: The task force met as a group and by sis;monitoring;moral;nursingassessment;pain;pharmacologic
teleconferencetoidentifythepertinentliteratureandderivecon- therapy; physical; restraints
sensus recommendations. Consideration was given to both the
RECOMMENDATION 1—LEVEL RECOMMENDATION 2—LEVEL RECOMMENDATION 3—LEVEL
OF EVIDENCE C OF EVIDENCE C OF EVIDENCE C
Patients must always be evaluated to
Institutions and practitioners should Restraining therapies should be used
determinewhethertreatmentofanexist-
strive to create the least restrictive but only in clinically appropriate situations
ing problem would obviate the need for
safestenvironmentforpatientsinregard and not as a routine component of ther-
restraint use. Alternatives to restraining
to restraint use. This is in keeping with apy.Whenrestraintsareused,theriskof
therapies should be considered to mini-
the goals of maintaining the dignity and untoward treatment interference events
mizetheneedforandextentoftheiruse.
comfort of our patients while providing must outweigh the physical, psychologi-
excellence in medical care. cal, and ethical risks of their use.
RECOMMENDATION 4—LEVEL
OF EVIDENCE C
The choice of restraining therapy
FromCriticalHealthSystems(GAM),RaleighPrac- Hospital(BLS),Chicago,IL;andSectionofCriticalCare should be the least invasive option capa-
ticeCenter,Raleigh,NC;DepartmentsofAnesthesiol- Medicine(WTP). bleofoptimizingpatientsafety,comfort,
ogy/Critical Care Medicine, Medicine, Surgery, and Thesepracticeguidelineshavebeendevelopedby and dignity.
Nursing(TD),JohnsHopkinsHospital,Baltimore,MD; a task force assembled by the American College of
Internal Medicine Program (BRB), University of Okla- Critical Care Medicine of the Society of Critical Care
homa College of Medicine; Washington University Medicine and have been reviewed by the Society’s RECOMMENDATION 5—LEVEL
SchoolofMedicine(JEM),AtlantaMedicalCenter(BM), Council.Theseguidelinesreflecttheofficialopinionof OF EVIDENCE C
Atlanta, GA; Medical Surgical Intensive Care Unit theSocietyofCriticalCareMedicineandshouldnotbe
(JMK), Rex Healthcare, Raleigh, NC; Department of construedtoreflecttheviewsofthespecialtyboards Therationaleforrestraintusemustbe
Anesthesiology(SHR),YaleUniversitySchoolofMedi-
oranyotherprofessionalmedicalorganization. documented in the medical record. Or-
cine; Stanford University (LRF); Tufts-New England
MedicalCenter(JD),Boston,MA;DukeUniversityMed- Copyright©2003byLippincottWilliams&Wilkins ders for restraining therapy should be
icalCenter(JAG),Durham,NC;NorthwesternMemorial DOI:10.1097/01.CCM.0000095463.72353.AD limited in duration to a 24-hr period.
CritCareMed2003Vol.31,No.11 2665
Newordersshouldbewrittenafter24hrs ICU (4–6). Many critical care providers surrogate’sdecisions.Anadditionalprob-
if restraining therapies are to be contin- believe that opponents of restraint use lemisthattheincompetentpatientrarely
ued. The potential to discontinue or re- have not satisfactorily considered the hasacontinuouslyavailablesurrogateto
duce restraining therapy should be con- unique needs of and therapies for the determine minute-to-minute issues.
sidered at least every 8 hrs. criticallyillpatientthatmandatethecau- The ethical-legal system recognizes
tioususeofrestraintsinappropriateclin- thatwhenconsentcannotbeprovidedby
RECOMMENDATION 6—LEVEL ical situations. the patient or a surrogate, the “reason-
OF EVIDENCE C In view of this ongoing controversy, able person” rule applies. A critically ill
the American College of Critical Care patientbroughtintothehospitalmaybe
Patients should be monitored for the Medicine of the Society of Critical Care subjected to emergent procedures with-
development of complications from re- Medicine assembled a task force of ex- out formal informed consent based on
straining therapies at least every 4 hrs, perts to evaluate the use of restraints in theideathata“reasonableperson”would
more frequently if the patient is agitated the ICU and to develop practice guide- have consented to these procedures. The
or if otherwise clinically indicated. Each lines for the appropriate use of such re- “reasonable person” rule is itself ambig-
assessment for complications should be straints for both adult and pediatric pa- uous and may at times unintentionally
documented in the medical record. tients. It is anticipated that the violate the rights of individuals (e.g., Je-
implementation of these guidelines will hovah’s Witnesses, Christian Scientists)
RECOMMENDATION 7—LEVEL decrease the inappropriate use of re- to decline standard medical care. Never-
OF EVIDENCE C straints.Thesepracticeguidelinesshould theless, it is reasonable to assume that
serve as a benchmark for regulatory implied consent exists when a person
Patients and their significant others
agenciesinassessingtheappropriateuse seekstreatmentandthatcliniciansmight
should receive ongoing education as to
of restraining interventions in the ICU. institute restraining therapies in appro-
the need for and nature of restraining
priate situations when a patient or pa-
therapies.
ETHICAL CONSIDERATIONS tient’ssurrogateisunabletoprovidecon-
sent.
RECOMMENDATION 8—LEVEL
Restraints are used in ICUs to main- The paradigm that most medical pro-
OF EVIDENCE C tainongoinginvasivetherapieswhenpa- fessionalsadheretoisthatofbeneficence
tientsareunabletounderstandtheneed or doing good, nonmalfeasance or doing
Analgesics,sedatives,andneuroleptics
forsuchtherapies.Cliniciansshouldlook no harm, and respect for the patient’s
usedforthetreatmentofpain,anxiety,or
for alternatives to restraints when possi- autonomy. Consensus regarding major
psychiatric disturbance of the intensive
ble, knowing the ethical questions that medicaldecisionsisreachedbetweenthe
careunitpatientshouldbeusedasagents
ariseoncetheydecidetoapplyrestraints. medical team and the patient as the ill-
tomitigatetheneedforrestrainingther-
Theclinician’suseofrestraintsshould ness evolves. Usually this produces little
apies and not overused as a method of
not be derived from a purely utilitarian disagreement between medical profes-
chemical restraint.
perspective. Such interventions require sionalsandtheirpatientsorbetweenthe
ethicaljustification.Thereispotentialfor multiple medical professionals them-
RECOMMENDATION 9—LEVEL
conflict between the medical team’s per- selves.Butthedecisiontoimplementre-
OF EVIDENCE C
ception of the patient’s best interest, straints rarely is regarded as a major
Patients who receive neuromuscular whattheteamhasbeenexplicitlyautho- medical decision. Furthermore, the pa-
blocking agents must have adequate se- rized to do by the patient or patient’s tients in question usually are unable to
dation, amnesia, and analgesia. The use legalguardian,andthepatient’slegaland provide consent, and their surrogates of-
ofneuromuscularblockingagentsneces- socially accepted rights. ten are not immediately available. Thus,
sitates frequent neuromuscular blockade Over the past few decades, medical the“reasonableperson”rulefrequentlyis
assessment to minimize the serious se- careintheUnitedStateshaspassedfrom appliedinmakingthedecisiontorestrain
quelae associated with long-term paraly- an era when paternalistic physicians de- critically ill patients to prevent patients
sis. Neuromuscular blocking agents cided “what was best” into an era where from harming themselves.
shouldnotbeusedaschemicalrestraints patient autonomy supersedes most other The result is a tension between the
when not otherwise indicated by the pa- issues. Mentally competent patients are medical team’s desire to further the best
tient’s condition. notforcedtoaccepttreatmentevenwhen interests of the patient and the patient’s
the decision results in a hastening of own rights as an autonomous being.
Restraints are widely used in the in- death. Patient autonomy is widely ac- An additional ethical concern is the
tensive care unit (ICU) to facilitate pa- ceptedandrarelyopposedbythemedical needtoprotectthemedicalteamandthe
tient tolerance of invasive therapies and establishment. patient’s significant others from injuri-
to avoid potentially life-threatening con- Autonomy presupposes a competent ous acts that a delirious patient might
sequencesassociatedwiththeabruptdis- patient or an available surrogate to rep- unknowingly commit. Although the pa-
continuationofsuchinterventions(1–2). resent the patient’s best interests. The tienthastherighttoautonomyandqual-
The use of restraints recently has come determinationofcompetencyisoftendif- ityhealthcare,themembersofthemed-
under increased scrutiny from institu- ficult. Language and cultural barriers, ical team also have the right to a safe
tions,externalregulatorybodies,andthe emotional distress, the presence of delir- working environment. Mitigating the
public (3). Some observers perceive that ium, and the need for sensorium cloud- reason for the patient’s agitation (e.g.,
there is pervasive and inappropriate use ingmedicationsareamongthemanyfac- pain control) should be attempted first.
ofphysicalandchemicalrestraintsinthe torsthatmayimpairapatientorapatient However, in some situations, restraining
2666 CritCareMed2003Vol.31,No.11
therapies may be required to protect consensus was reached. The specific rec- Agitation can have deleterious conse-
caregivers and visitors alike. ommendations were assigned a “grade” quences,includinginterferencewithme-
Another concern is that the delirious (Table2)basedontheweightofscientific chanical ventilation, acute myocardial
but conscious patient will be aware of evidence on which the recommendation stress, and cerebral ischemia (12, 13).
restraints and find them uncomfortable. was based. Agitation makes diagnostic evaluations
Thedilemmathenarisesofbalancingdis- moredifficultandmayinterferewiththe
comfort vs. medical necessity. The pro- BACKGROUND performance of procedures. The self-
viders involved may determine that pa- removalordisruptionofdevicesusedfor
tientautonomymustbeoverruledforthe Although numerous publications re- diagnosis, treatment, or physiologic
sake of safety for the patient and others. gardingtheuseofrestraintswereidenti- monitoringofthepatientmayhavedisas-
This often presents a situation that is fied,manydidnotspecificallyaddressthe trous sequelae (14–17). Each such event
both ethically difficult as well as psycho- use of restraints in ICU patients. Most may require redundant intervention and
logically unpleasant for the medical studies made general statements regard- increase costs significantly (17). Patient
team. ing the use of restraints in all hospital- agitation frequently contributes to the
There are many situations where pa- ized patients or in patients treated out- stressoffamilyandfriendsandmayeffect
tients can, and do, injure themselves if side the acute care setting. Although theirsatisfactionwithhealthcaredelivery
not restrained. Most patients and their some issues regarding the use of re- (10, 18).
significant others expect the medical straints may be relevant to all clinical Patient-Initiated Treatment Interfer-
team to protect patients from their own settings, such as the role of restraints in ence. The best studied type of patient-
delirious behavior and would regard the preventing patient falls, many issues re- initiated treatment interference in the
failure to do so as negligence. latedtotheuseofrestraintsareuniqueto ICU is agitation-related tracheal self-
critical care practice. extubation. The reported incidence of
METHODS The severity of illness manifested by self-extubation varies widely, ranging
patients in the ICU and the need for in- from 2% to 17% of intubated patients
The task force members individually vasive devices and therapies account for (19). The impact of this complication on
and collectively undertook a systematic many of the unique issues related to the mortalityandmorbidityratehasnotbeen
search of published literature pertaining useofrestraintsystemsintheICU.These well delineated. The literature contains
to the use of restraints in the ICU using invasive therapies are often uncomfort- multiple reports of fatal self-extubations;
MEDLINE, CINAHL, and the Cochrane ablebutmayleadtopatientmorbidityor however, well-designed studies to estab-
Library. In addition, the reference lists death if interrupted in an uncontrolled lish the mortality rate of self-extubation
for each identified article were reviewed manner. Traditional ICU practice has as- are lacking. The determination of mor-
for additional published works. Key sumed that restraints enhance patient bidityrelatedtopatientself-extubationis
words used in these searches included safetyinthesettingofhigh-riskinterven- even more poorly defined. The incidence
restraints, intensive care unit, self- tions and severe physiologic distur- of significant complications directly re-
extubation, physical, chemical, moral, bances.Unfortunately,theliteraturethat lated to self-extubation and reintubation
ethical, sedation, pain, patient monitor- has evaluated the risk-to-benefit ratio of (e.g.,aspirationpneumonia)hasnotbeen
ing, and nursing assessment. Searches restraining interventions is methodolog- specifically evaluated in a prospective
wererestrictedtoEnglishlanguagepub- ically weak (i.e., poorly controlled, small fashion. Adding to the confusion on the
lications and primarily to citations pub- samplesizes).Theneedforwell-designed, morbidity of self-extubation has been
lished since 1990. The publications be- adequately powered, multiple-center, some authors’ categorization of self-
lievedtobemostpertinenttothisreview prospectiveevaluationsisgreat,butwith- extubation as a morbid event in and of
were identified by group consensus. To out federal sponsorship and funding, itself. However, between 63% and 89%
establishtherelativescientificvalidityof such studies of restraining therapies are (20, 21) of patients who extubate them-
these references, each publication was unlikely to be performed. selves do not require reintubation, cast-
categorized according to the Cochrane Agitation in the ICU. A major factor ing doubt as to whether self-extubation
methodology described in Table 1. Two drivingtheuseofrestraintsintheICUis itself should be regarded as a morbid
members of the task force (GM, TD) in- the underlying confusion and agitation event.Thesedataalsosuggestthatmany
dependently reviewed and graded the lit- experienced by many critically ill pa- patientsshouldbeconsideredforextuba-
eraturewithathirdmember(BB)acting tients. More than 70% of ICU patients tionearlierinthecourseoftheirillness.
as arbitrator where disagreement oc- may experience some degree of agitation Prospectivetrialshaveshownthatproto-
curred. A summary of the literature se- duringtheirICUstay(7,8).Mentalstatus cols to facilitate weaning are valuable in
lected is included in the reference list. changes often make ICU patients unable decreasing the duration of mechanical
Basedonthisliteraturereviewandthe tocomprehendthepurposeofthethera- ventilation. It is plausible that the need
expertise of the individual members, the pies that are a part of their care. The for restraining therapies could be signif-
taskforcemetasagroupandbytelecon- causesofagitationintheICUarenumer- icantly reduced merely through the use
ferencetodevelopconsensusrecommen- ous. Some medical conditions like sepsis of protocols designed to facilitate timely
dations. Consideration was given to the may directly cause patient confusion. extubation.
weight of scientific evidence in the liter- Other factors resulting in agitation in- Although some cohort analyses have
atureaswellastoindividualexpertopin- cludediscomfortassociatedwithendotra- identified the failure to use restraints as
ion.Draftdocumentswerecomposedbya cheal intubation, surgical and diagnostic an important contributor to self-extuba-
task force steering committee and de- procedures(9,10),anxiety,andsleepde- tion(16,20,22,23),theroleofrestrain-
bated by the task force members until privation (7, 11). ingtherapyinpreventingself-extubation
CritCareMed2003Vol.31,No.11 2667
Table1.Cochranemethodology:Levelsofevidenceandgradesofrecommendations,November23,1999
Gradeof Levelof Therapy/Prevention,
Recommendation Evidence Etiology/Harm Prognosis Diagnosis
A 1a SR(withhomogeneitya)ofRCTs SR(withhomogeneity)ofinception SR(withhomogeneity)oflevel1diagnostic
cohortstudiesoraCPGb studiesoraCPGvalidatedonatestset.
validatedonatestset.
1b IndividualRCT(withnarrow Individualinceptioncohortstudy Independentblindcomparisonofanappropriate
confidenceintervalc) with(cid:1)80%follow-up spectrumofconsecutivepatients,allofwhom
haveundergoneboththediagnostictestand
thereferencestandard.
1c Allornoned Allornonecase-seriese AbsoluteSpPinsandSnNoutsf
B 2a SR(withhomogeneity)ofcohort SR(withhomogeneity)ofeither SR(withhomogeneity)oflevel(cid:1)2diagnostic
studies retrospectivecohortstudiesor studies
untreatedcontrolgroupsinRCTs
2b Individualcohortstudy Retrospectivecohortstudyor Anyof:
(includinglow-qualityRCT; follow-upofuntreatedcontrol 1. Independentblindorobjectivecomparison
e.g.,(cid:1)80%follow-up) patientsinanRCTorCPGnot 2. Studyperformedinasetofnonconsecutive
validatedinatestset. patientsorconfinedtoanarrowspectrum
ofstudyindividuals(orboth),allofwhom
haveundergoneboththediagnostictest
andthereferencestandard
3. AdiagnosticCPGnotvalidatedinatestset
2c “Outcomes”research “Outcomes”research
3a SR(withhomogeneity)ofcase-
controlstudies
3b Individualcase-controlstudy Independentblindcomparisonofanappropriate
spectrum,butthereferencestandardwasnot
appliedtoallstudypatients.
C 4 Case-series(andpoorquality Case-series(andpoorquality Anyof:
cohortandcase-control prognosticcohortstudiesh) ● Referencestandardwasnotobjective,
studiesg) unblinded,ornotindependent
● Positiveandnegativetestswereverified
usingseparatereferencestandards
● Studywasperformedinaninappropriate
spectrum**ofpatients
D 5 Expertopinionwithoutexplicit Expertopinionwithoutexplicit Expertopinionwithoutexplicitcriticalappraisal,
criticalappraisal,orbasedon criticalappraisal,orbasedon orbasedonphysiology,benchresearch,or
physiology,benchresearch,or physiology,benchresearch,or “firstprinciples”
“firstprinciples” “firstprinciples”
SR,systemsresearch;CPG;RCT,randomized,controlledtrial.
aByhomogeneitywemeanasystematicreviewthatisfreeofworrisomevariations(heterogeneity)inthedirectionsanddegreesofresultsbetween
individualstudies.Notallsystematicreviewswithstatisticallysignificantheterogeneityneedbeworrisome,andnotallworrisomeheterogeneityneedbe
statisticallysignificant.Asnoted,studiesdisplayingworrisomeheterogeneityshouldbetaggedwitha“(cid:2)”attheendoftheirdesignatedlevel;bClinical
PredictionGuide;cseenote2foradviceonhowtounderstand,rate,andusetrialsorotherstudieswithwideconfidenceintervals;dmetwhenallpatients
diedbeforetheprescriptionbecameavailable,butsomenowsurviveonit;orwhensomepatientsdiedbeforetheprescriptionbecameavailable,butnone
nowdieonit;emetwhentherearenoreportsofanyonewiththisconditioneveravoiding(all)orsufferingfrom(none)aparticularoutcome(suchasdeath);
fanAbsoluteSpPinisadiagnosticfindingwhosespecificityissohighthatapositiveresultrulesinthediagnosis.AnAbsoluteSnNoutisadiagnosticfinding
whosesensitivityissohighthatanegativeresultrulesoutthediagnosis;gbypoorqualitycohortstudywemeanonethatfailedtoclearlydefinecomparison
groupsorfailedtomeasureexposuresandoutcomesinthesame(preferablyblinded),objectivewayinbothexposedandnonexposedindividualsorfailed
to identify or appropriately control known confounders or failed to carry out a sufficiently long and complete follow-up of patients. By poor quality
case-controlstudy,wemeanonethatfailedtoclearlydefinecomparisongroupsorfailedtomeasureexposuresandoutcomesinthesameblinded,objective
wayinbothcasesandcontrolsorfailedtoidentifyorappropriatelycontrolknownconfounders;hbypoorqualityprognosticcohortstudy,wemeanone
inwhichsamplingwasbiasedinfavorofpatientswhoalreadyhadthetargetoutcome,orthemeasurementofoutcomeswasaccomplishedin(cid:1)80%of
studypatients,oroutcomesweredeterminedinanunblinded,nonobjectiveway,ortherewasnocorrectionforconfoundingfactors.
has not been prospectively evaluated in selves using facial and lingual maneu- capability for decreasing the frequency
a randomized, controlled trial. Other vers while their arms were restrained of this event remains ill-defined.
authors have noted that physical re- (20, 24). The use of physical restraints Severalcohortanalyseshaveidentified
straintsmayfailtopreventthiscompli- actually may increase patient agitation inadequatesedationandanalgesiaasim-
cation. Reports exist of securely re- and increase the incidence of self- portant risk factors for self-extubation
strained patients who successfully extubation (20). The literature reflects (15, 24, 25). A prospective trial of a pro-
managed to remove endotracheal tubes that physical restraints themselves are tocol to promote effective sedation per-
with their hands, and of other patients not uniformly successful in preventing formed by Brook et al. (26) showed a
who succeeded in extubating them- self-extubation, and that their overall decrease in the duration of mechanical
2668 CritCareMed2003Vol.31,No.11
Table2.Comparisonofstudiesconcerningrestrainingtherapiesandtheirabilitytolimitpatientinterferenceeventsforself-extubationincriticalcare
ClinicalStudy ResearchQuestion NatureofComparison Setting Results
Anidetal.(30) Self-extubation:what Evaluatepotentialfactors ICU/CCU Restless,sedated,butuncontrolled
istheproblem? forself-extubation patientsandpatientsintubated
(cid:1)24hrsareatgreaterriskfor
self-extubation
Kapadiaetal.(31) Airwayaccidentsin Assesstherateof GeneraladultICU Airwayaccidentsoccurredatlow
intubatedICU occurrenceandnature levels,withthemostfrequent
patients ofairwayaccidents beingself-extubationofan
endotrachealtube
Happ(32)(surveyeduseof Preventingtreatment Describetheprocesses Medicalandintermediate Inadditiontoverbalstrategiesand
restraintsandreasonsin interference:the usedbycriticalcare medicalICU othernoninvasivetechniques,
differentpartsofhospital, nurse’srolein nursestoprevent nursesuseassessment-driven
includingcriticalcare maintaining treatmentinterference physicalandchemicalrestraining
units) technologicdevices therapiestopreventtreatment
interference
Carrionetal.(16) Accidentalremovalof Characterizetheratesof Medical/surgicalICU Limitingupperextremityaccessto
endotrachealtubes accidentalremovalof within20cmfromthe
endotrachealtubesand endotrachealtubesignificantly
assessefficiencyof reducedpatient-relatedremoval
correctivemeasures oftubes.
aimedatreducing
accidentalremovalof
endotrachealtubes.
Chevron(25) Unplannedextubation: Nursestaffinglevelsand Medical/surgicalICU Agitatedpatientswhoreceived
Riskfactorsof levelofpatient insufficientsedationandwere
developmentand agitation orallyintubatedpresentedthe
predictivecriteria highestriskforunplanned
forreintubation extubation
Baer(20) Isthereananswerto Editorialcommentson ICU Delaysintheweaningprocessmay
preventing unplannedextubation contributetounplanned
unplanned extubation
extubation?
Winslow(21) Dorestraintsreally Reviewofmultiplestudies ICU Confinetheuseofrestraintsto
protectintubated involvingunplanned intubatedpatientsinthehigh-
patients? extubations riskcategorywhoaredeliriousor
agitatedandarereceivinghigh
levelsofoxygenormechanical
ventilation
Tominagaetal.(22) Decreasingunplanned Methodofendotracheal SurgicalICU Restricteduseofhandrestraints
(Interventionstodecrease extubationsinthe tubefixation,useof wasassociatedwithasignificant
unplannedextubations, surgicalICU chemicalrestraints,use increaseinunplanned
suggestedthatrestricting ofhandrestraints. extubations.Endotrachealtubes
useofrestraints securedwithwaterprooftape
contributedtoincreased significantlyreducedaccidental
riskofunplanned extubation
extubation.Prospective,
observationaldata)
SesslerandListello(33) Preventionof Literaturereviewand ICU Identityofpatientsatriskofan
unplanned editorialcomments adverseoutcomeifunplanned
extubation extubationoccurs.Secure
endotrachealtubefirmly,
maximizepatientacceptanceof
theendotrachealtube,control
agitation,useeffectiverestraints
whennecessary,performtimely
extubation,andoptimizepatient
surveillance
ICU,intensivecareunit;CCU,criticalcareunit.
ventilation in the group sedated by pro- be used judiciously, as the excessive use been shown to avoid this complication
tocol.Prospective,randomizedtrialscon- ofsedationinventilatedICUpatientsmay (28). Further discussion of sedation is
firmingsuchadecreaseinself-extubation increase duration of mechanical ventila- outside the scope of this practice guide-
bytheuseofsedationprotocolshavenot tion (27). Protocols for the periodic in- line.Formoreinformation,thereaderis
been performed. Sedation therapy must terruption of intravenous sedation have referred to the Clinical Practice Guide-
CritCareMed2003Vol.31,No.11 2669
lines for Sustained Use of Sedatives and cludedpharmacologicagentstotreatthe modalitieshasresultedinadecreaseduse
Analgesics (29). patient’sagitation.Anadditionalstrategy of physical restraints, generally without
Patient discontinuation of other de- is the identification of problems causing an increase in morbidity from falls or
vices and therapies in the ICU has not patientdiscomfortandagitationthatcan other adverse events (36, 39–41). Given
been as well studied as self-extubation, be easily corrected. Urinary retention, the paucity of data documenting the
but it is likely that many of the same malpositionofanendotrachealtube,and safety and efficacy of these alternatives
considerations apply (30, 31). Carrion et discomfort related to body position all comparedwithtraditionalrestrainttech-
al. (16) studied patient removal of naso- can be remedied, decreasing agitation. niques, there is no assurance that alter-
gastrictubes,arterialcatheters,andcen- Another strategy is the use of diversion- native strategies would be embraced by
tralvenouscathetersandconcludedthat aryactivitiesthatmayreducethelevelof critical care practitioners (2). However,
restraints substantially decreased the re- agitation.Music,providingscheduledac- criticalcareprovidersshouldinitiatetri-
movalofsuchdevices.However,thecom- tivities,allowingthefamilygreateraccess alscomparingthesealternativestrategies
plications of the restraining therapies to the patient, frequent reorienting, and totraditionalrestrainttechniquestopro-
usedwerenotclearlydescribed,sothata personalattentiontothepatientbycare- vide better evidence for the development
risk to benefit assessment for the use of givershavebeensuggestedasmethodsto of future guidelines.
restraints was difficult to make for these lessen the use of restraints. Other inter- Psychological Aspects of Restraint
clinical scenarios. ventions have included altering the ICU Use. Caregiver attitudinal factors may
No studies have been designed to environment to decrease agitation- drive the use of restraints in the ICU as
study patients at high risk for morbidity producing stimuli and using alternative identifiedinastudybyHapp(32)onthe
or death in the event of abrupt loss of methodsforsecuringendotrachealtubes. attitudes of ICU nurses toward the pre-
their airway or other therapies. It is in High noise levels in the ICU disrupt ventionofpatienttreatmentinterference.
suchhigh-riskpatientsthatrestraintuse sleepandcontributetopatientagitation. The need to prevent life-threatening
is most likely to prove beneficial. High Environmental modifications to reduce events was perceived as the justification
riskshouldincludepatientswithdifficult noise levels and alterations of ICU rou- for the use of restraints, but nurses ex-
airways,facialedema,cervicalspineinju- tines to facilitate more normal sleep- pressedambivalenceastotheuseofthese
ries, and halos, as well as the hemody- wake cycles may reduce the need for re- devices. In this study, ICU nurses pre-
namically unstable, the hypoxemic, and straining therapies. The use of bed exit ferredtheuseofsedativeandotherphar-
those experiencing myocardial ischemia. alarms,relocatingpatientsclosertocen- macologic therapies in lieu of physical
The fact that most studies have included tral monitoring areas, and increasing in- restraints for most of their patients (32).
patientsatlowriskforserioussequelaeif patient observation (i.e., video cameras) Littleinformationhasbeenpublishedre-
important therapies were suddenly dis- may permit early identification of in- garding the attitudes of ICU physicians
continuedmayhaveledauthorstoincor- creasing agitation, allowing intervention towardtheuseofrestrainingtherapies.It
rectly conclude that restraint therapies before critical events occur. The use of might be expected that there would be
were of no benefit in preventing harm family members or friends as “sitters” differences between nurses and physi-
(Table 2). alsomayfacilitatecloserobservationand ciansintheperceivedneedforrestraints,
A number of well-designed, prospec- provide a calming influence on the pa- but no studies exist evaluating such dif-
tive trials regarding the use of pharma- tient. ferences. Perhaps the most important
cologic therapies to treat ICU patients’ Finally, evolving techniques and de- perceptions to consider are those of re-
pain and anxiety have been performed. vicesmaydecreasethepatient’sabilityto strained patients. Leith (38) noted the
Thesestudiessuggestthattheuseofan- interfere with treatment. Improved negativeattitudesofhospitalizedpatients
algesic, sedative, and neuroleptic agents methods of securing endotracheal tubes toward being restrained, but the percep-
to treat pain, anxiety, and delirium is maylessentheirchanceofbeinginadver- tions of ICU patients who have been re-
associatedwithnumerousbenefits.These tently removed. The use of a stockinet strainedhavenotbeenwelldocumented.
trials usually have not assessed the im- overthesiteofanintravenouscatheteror Minnicketal.(2)describedtheresultsof
pact of sedation therapy on the use of bulky dressings covering devices to re- interviews with 15 ICU patients about
restraints in the ICU. Rather, the use of duce access to gastrostomy tubes may their perceptions of restraints after they
sedation and analgesia therapy to de- decrease inadvertent dislodgment of weredischargedfromtheICU.Only40%
crease the use of restraints has been in- these devices (32–36). of the patients remembered being physi-
ferredbytheefficacyofthesetherapiesin Some authors have suggested that cally restrained, and these patients did
reducing patient agitation, pain, anxiety, lowercaregiver-to-patientratiosincrease not report undue distress related to the
or psychiatric disturbance. theuseofrestraintsandrelatedtherapies process. Much of the distress of these
AlternativestotheUseofPhysicalRe- includingheavysedation(19,27,37,38). patients related to the discomfort of in-
straints. Although a number of alterna- Some self-extubation studies have ob- tubation and to their hallucinations. Al-
tives to physical restraints in the ICU servedincreasedself-extubationsinasso- though the applicability of this small
have been proposed, the efficacy and ciation with decreased nurse staffing ra- study to the general ICU population is
safety of these interventions have not tios (25). The value of alternatives to uncertain,theseresultsprovidesomeev-
been prospectively evaluated. Unfortu- physical restraints in the ICU principally idencethatphysicalrestraintsintheICU
nately, most of these studies have been has been derived from testimonial data do not commonly produce patient psy-
conducted outside the ICU setting, and andhasreceivedlittleprospectiveassess- chological distress.
the applicability of these alternatives to ment. In other healthcare settings, par- Posttraumatic stress disorder (PTSD)
restraints for critically ill patients re- ticularlyinnursinghomes,caregivered- occurs in many ICU patients (42). PTSD
mains unproven. Alternatives have in- ucation in the use of alternative results from an exposure to a traumatic
2670 CritCareMed2003Vol.31,No.11
eventandevokesintensefear,horror,and Such therapies may be physical or phar- restraints,upperbody-vests,two-tofive-
a feeling of helplessness. The aftermath macologic. Physical restraints are me- point leather restraints, No-No arm
may affect patients’ ability to cope with chanical devices that restrict patients’ boards when tied to the bed or crib (in
dailylife.InstudiesofICUpatients,PTSD movements. Many devices commonly pediatric patients), and body webs.
hasbeenrecognizedasafrequentsequela used in the intensive care unit could in- Pharmacologic restraints are medica-
of a prolonged ICU stay. Symptoms of correctly be considered physical re- tionsusedtocontrolagitationorinsome
PTSD include anxiety attacks, hypervigi- straints. These include medical protec- casesinducecomaandparalysis(e.g.,for
lance, nightmares, insomnia, intrusive tive devices, which protect the patient extracorporeal treatment of severe respi-
thoughts,flashbacks,anddepressionthat fromfurtherexacerbatingtheunderlying ratory failure). Under this definition, a
may manifest during ICU care. Intensive illness or injury. An example is a splint numberofcommonlyusedpharmaceuti-
care professionals must recognize the applied to a fractured extremity. Such a cal agents could be included. Among
symptomsofPTSDandminimizepatient device is standard medical therapy and them are analgesics, particularly opioid
stressors. The role that restraints play in doesnotconstitutearestrainingtherapy analgesics, benzodiazepines and other
the development of PTSD-related disor- although it restricts the patient’s free sedative agents, major tranquilizers, dis-
ders is unknown, but there is an associ- movement. Although these devices are sociative agents, and neuromuscular
ation between the use of sedatives and not considered further in these guide- blockingagents.Anextensivedescription
neuromuscular blocking agents and the lines,theirusemaynecessitatemonitor- of the use of analgesics, sedatives, and
development of this disorder (42). ingforthedevelopmentofcomplications neuroleptic agents is available in the re-
Whetherthisreflectscausationorsimply similar to those that may develop with vised clinical practice guidelines for the
theidentificationofthemostseriouslyill physical restraints. sustained use of sedatives and analgesics
patientsisunclearbutpointstotheneed Another form of restraint used in the in the critically ill adult (29). Practice
for careful consideration of the potential ICU is medical immobilization, defined guidelinesfortheappropriateuseofneu-
sequelae of such therapies. as a temporary immobilization for the romuscular blocking agents in the ICU
performanceofandrecoveryfromamed- also have been developed by the ACCM
THE OBJECTIVES OF ical or surgical treatment (e.g., surgical (43), and these currently are undergoing
RESTRAINING THERAPIES positioning,intravenousarmboards,pro- revision.
tection of surgical treatment sites by What Are the Indications for the Use
The objective of restraining therapies bulky dressings in pediatric patients). ofRestrainingTherapiesintheICU?The
in the ICU is to provide optimal patient These restraints both facilitate perfor- primary goal for the use of restraining
safetywhilemaintainingcomfortandin- manceoftheprocedureandpreventcom- therapies in the ICU is to ensure patient
dividualdignityasmuchaspossible.The plicationsthatmightoccurduringrecov- safety.Themostcommonindicationisto
subsequent discussion focused on this ery. The use of restraints in these decreasetheriskofdeliberateorinadver-
overall objective by addressing several circumstancesisgenerallyoflimiteddu- tent removal of an essential medical de-
questionsrelatedtotheuseofthesemo- ration.Aswiththeuseofmedicalprotec- vice. This includes circulatory assist de-
dalities: tive devices, this form of immobilization vices, endotracheal tubes, tracheotomy
should not be considered a restraining tubes, intracranial catheters, nasogastric
Whatdefinesrestrainingtherapyinthe
therapy. Nevertheless, precautions must ororogastrictubes,enteralfeedingtubes,
ICU?
be made to prevent patient injury when central venous catheters, arterial cathe-
Whataretheindicationsfortheuseof medical immobilization is used. ters,chesttubes,surgicaldrains,intrave-
restraining therapies in the ICU? Occasionally, physical restraints are nous lines, and urinary catheters. Re-
How do we determine which patients appliedtopatientswhohavebeenlegally strainingtherapiesalsomaybenecessary
need restraining therapies? detained. The use of restraints under tolimitthepatient’smovementsifmove-
these circumstances is considered foren- ment might lead to a new or exacerbate
What alternatives to restraining ther-
sic restraint. This use of forensic re- anexistinginjury.Anexampleisapatient
apy should be considered?
straints is outside the purview of this withaspinalfracturewhomightsuffera
How should restraining therapies be
document. However, the clinician must spinal cord injury by moving before sta-
initiated?
monitor these patients for complications bilization of the spine has been estab-
How frequently should patients be re- related to the use of such restraints. Al- lished.
assessed with regard to their need for thoughlawenforcementofficialsneedto Restraining therapies also may facili-
restraining therapies? maintain careful surveillance of the in- tate the performance of bedside proce-
How frequently should monitoring for carcerated patient, medical care of the dures in patients who cannot cooperate.
complicationsbeperformedinpatients patientmustnotbecompromisedbythe For instance, such therapies might be
subjected to restraining therapies? use of forensic restraints. used during the insertion of an arterial
The restraining therapies relevant to catheter in a delirious patient, both to
How should restraint use be docu-
these guidelines are the mechanical and allow placement of the device and to en-
mented in the medical record?
pharmacologicmechanismstolimitorin surethatthepatientisnotinjuredduring
What Defines Restraining Therapy in some cases totally prevent patient move- its placement.
theICU?Arestrainingtherapyisatreat- ment where patient interference with Anotheruseofrestrainingtherapiesin
mentaimedatimprovingamedicalcon- treatment could have life-threatening the ICU is for patients with primary be-
dition (e.g., hypoxemia) or preventing consequences. Typical physical restrain- havioral or psychiatric disorders. Occa-
complications by restricting a patient’s ing devices used in the ICU include, but sionally such patients may be housed in
movement or access to his or her body. are not limited to, soft wrist and ankle anICUbecauseitistheonlysettingavail-
CritCareMed2003Vol.31,No.11 2671
able where the patient can be closely of prolonged intubation and may elimi- activitiesduringwakinghourssothepa-
monitored.Moreoftenthesepatientsare natethesourceofthepatient’sagitation. tient attains a more normal sleep-wake
admitted to the ICU because of an acute The patient also should be evaluated cycle. Increased vigilance of the patient
medical condition, such as a drug over- withregardtotheconsequencesoftreat- mayallowfortheeliminationofphysical
dose or suicide attempt. On improve- ment interference events and therefore restraints. Using family members and
ment, these patients may remain in the the risk of withholding restraining ther- other healthcare personnel (“sitters”)
ICU awaiting transfer to an appropriate apies. A patient whose only invasive de- mayallowreductionofrestraints.Nonre-
psychiatric facility. Because of their un- vice is an intravenous catheter is at far straining techniques that interfere with
derlying psychopathology, these patients less risk from treatment interference the patient’s ability to remove a device
havethepotentialtoinjurethemselvesor thanthepatientonextracorporealmem- may reduce the need for full physical
others. Under such circumstances re- braneoxygenation.Becauseofthecritical restraints. Methods to better secure en-
strainingtherapiesmaybeindicated,but nature of the latter patient’s therapies, dotrachealtubesareincludedinthiscat-
their use should be in accordance with the preemptive institution of restraining egory,asarebulkydressingsthatmakeit
local institutional ICU policy and con- therapies is more compelling than in lesslikelythatthepatientwillnoticeand
temporary standards of psychiatric care. most situations. remove the device. The removal of de-
How Do We Determine Which Pa- What Alternatives to Restraining vicesfromtheoropharynxandnasophar-
Therapies Should Be Considered? The ynxmaylessenpatientdiscomfort.Thus,
tients Need Restraining Therapies? Re-
most important alternative therapies are if a patient is likely to require long-term
straining therapies should be used only
pharmacologic agents used to treat the ventilatory or nutritional support, tra-
when they have been deemed a clinical
patient’s agitation (Table 3). Sedatives cheostomyorgastrostomymaylessenpa-
necessity and when alternative measures
and analgesics are commonly used to tient discomfort.
havebeenunsuccessfulorcannotbeem-
treatpainandanxietyintheICUpatient. Ifalternativesfail,restraintsthenmay
ployed without jeopardizing patient
Neuroleptic agents such as haloperidol be necessary. Determination of restraint
safety or care. Several factors should be
also should be considered since they re- typemustincludeanevaluationofpoten-
considered in determining the patient’s
lieve agitation and distressing hallucina- tialforrestraint-inducedinjury.Theleast
need for restraining therapies. Careful
tions. Neuromuscular blockers should restrictive restraint should be used for
patient examination may reveal a cause
not be considered as alternatives to re- the shortest duration necessary.
for agitation that is remediable without
straining therapies. These agents may be HowShouldRestrainingTherapiesBe
restraining therapy.
necessaryinpatientswithsevererespira- Initiated?Thephysician,nurse,andother
The possibility of hypoxemia, hyper-
tory dysfunction to optimize mechanical membersofthecriticalcareteamshould
capnia,electrolyteimbalances,andunto-
ventilation, use extracorporeal tech- concuronthepatient’sneedforrestrain-
ward effects of medications should be
niques, and reduce patient oxygen con- ing therapy before its initiation and on
considered in any agitated patient. Mal-
sumption. However, when their primary the form of restraining therapy to use
function of mechanical devices, such as
purpose is to prevent movement of a pa- (Tables 3 and 5). The initial physician
endotrachealtubes,urinarycatheters,in-
tient,theyshouldbeconsideredchemical ordermaybeaverbalorderbasedonthe
travenous infusion pumps, or epidural
restraints. Their use as restraining ther- assessment of the patient by a registered
catheters may create discomfort or stop
apy should be as a last resort when all nursethathasbeencommunicatedtothe
ongoing analgesia leading to agitation.
other methods have proven unsuccessful physician.Theverbalordershouldbefol-
Patients should be evaluated for un-
or not feasible. Neuromuscular blockade lowed by a bedside assessment by the
treatedpain,anxiety,ordeliriumandap-
mustalwaysbeaccompaniedbyadequate physician as soon as possible (Table 6).
propriate therapy instituted if needed.
sedative and analgesic medications. When restraints are initiated for marked
Toxicity from medications or illicit sub-
Nonpharmacologic methods are also agitation or violence, the physician
stances may manifest itself by altered
available as alternatives to the use of re- shouldbenotifiedofrestraintusewithin
mental status. Acute withdrawal from
straints (Table 4). These include diver- 1 hr of restraint application, and physi-
ethanol or other addictive substances
sionary tactics to calm the agitated pa- ciansshouldpersonallyexaminesuchpa-
should always be considered. tientortoredirectthepatient’sattention tientswithin4hrs.Patientsrestrainedto
The ventilator settings of agitated pa- away from a medical device producing prevent treatment interference alone
tients should be reassessed and con- distress. Altering the local environment should have their physician notified
firmed to be appropriate to ensure that to decrease sensory stimuli may be use- within12hrsandshouldbeexaminedby
patient-ventilator dyssynchrony is not ful. This could include limiting noise the physician within 24 hrs of restraint
the cause of the patient’s distress. Pa- from alarms, avoiding unnecessary application.
tients undergoing “noninvasive” ventila- arousal of the patient, and scheduling When physical restraints are applied,
tion should be evaluated to optimize
maskfitandpaddingtoensurethisisnot
asourceofagitation.Inpatientswhoare Table3.Pharmacologicalalternativestophysicalrestraints
intubated,theliteratureclearlyidentifies
● Analgesics
ongoingintubationofthe“weanable”pa- ● Sedatives
tient as a perturbation with a high like- ● Majortranquilizers(neurolepticagents)
lihoodoftreatmentinterference.Patients ● Dissociativeagents
should be frequently reassessed for their ● Other
RevisedClinicalPracticeGuidelinesfortheSustainedUseofSedativesandAnalgesicsinthe
suitability for extubation, as the timely
CriticallyIllAdult(29)
extubationofthepatientavoidstherisks
2672 CritCareMed2003Vol.31,No.11
Table4.Alternativestorestrainingtherapies
Environmental Therapy Communication
Alterenvironmentalstimuli Managepainandhypoxemia,evaluateventilator Maximizecommunication
settings
Keepobjectsnecessaryfordailylivingcloseat Maximizeactivitiesofdailyliving Providecommunicationaids
hand
Usesupportdevicesthatarenotsorestrictive Eliminatebothersometreatmentsassoonas Providerealitylinksandreorientationcues
possible
Decreasebedrailuseifpatientisclimbingover Beginoralfeedingsassoonaspossible Involvepatientincareplanningifpossible
them
Usemorefrequentorconstantsupervision Removecathetersassoonaspossible Useanxietyreductiontechniques
Increasethecaregiversupervisionratio Reviewmedicationsforanypossiblecontributors Involvefamilyandothersincareplanning
todeliriumoranxiety
Useone-to-onesupervision Encouragephysicalexertion,exercise,mobility
ModifiedfromFletcher(36).
Table5.Categoriesofphysicalrestrainingtherapies How Frequently Should Monitoring
for Complications Be Performed in Pa-
Most
tients Subjected to Restraining Thera-
TypesofRestraints Restrictive 3 LeastRestrictive
pies? Restraining therapies themselves
Chest/body can pose a threat in the form of compli-
Limbplusvest * cations. Complications may occur not
Papooseboard * only in a physical sense but also from a
Poseyvest *
psychological perspective. Not only does
Extremities
4-point(felt) * the patient need to be monitored for
2-pointsoftwrist * complications from the restraints, but
2-pointdiagonalsoft * the patient’s care needs also must be ad-
Elbow(restraints) *
dressed (Table 6). A restrained patient
Mittens *
Environment cannolongerprovideforhisorherbasic
Seclusion * needs of turning, eating, drinking, and
Highclimber * toileting. The staff caring for the patient
Siderails *
must be skilled in providing for these
VailbedorCraigbed *
Gerichair * needswhileatthesametimemonitoring
for complications from the restraining
therapies in use. The frequency of moni-
toringshouldbedeterminedbytheclin-
anRNorLV(P)Nmustdosoorsupervise Restraining Therapies? Reassessment of
icalconditionofthepatient.Ingeneral,a
application by other qualified staff. The the need for the therapy to continue
calm patient receiving restraining thera-
application of the device should be done should be based on the same principles
piesmustbemonitoredforcomplications
in such a way that upholds the patient’s used in the determination to initiate re-
at least every 4 hrs. Agitated patients
rights and dignity. The patient and sig- straining therapy. Since the goal is to
need more frequent monitoring, and re-
nificantothersmustbegivenappropriate only use such therapy when there is no
information regarding the need for the suitablealternative,thecriticalcareteam evaluation every 15 mins is recom-
restraining therapy. Restraining thera- shouldassessreadinessofthepatientfor mended until the patient becomes calm.
piesmustbeeasytoremoveincaseofan restraint reduction or removal at least How Should Restraint Use Be Docu-
emergency. every 8 hrs (Table 6) The frequency of mented in the Medical Record? Docu-
To ensure that patient care staff un- reassessments should be based on the mentation in the medical record should
derstand the use of alternative therapies clinical circumstances of the patient and include the assessment of the need for
and safe application of the restraining the predetermined plan of care. restraints, what alternatives to restraints
devices,trainingprogramsmustbecom- Thebedsidenursemustconstantlybe were unsuccessfully used, and the find-
pleted with initial employment and an aware of the possibility that the patient ingsofongoingmonitoringofthepatient
annual competency review should be re- may have recovered from the clinical for complications (Table 6). How re-
quired of staff thereafter. conditions that necessitated the use of strainingtherapyfitsintotheplanofcare
Each healthcare organization should restraints in the first place. The critical shouldbeincludedintheprogressnotes.
develop internal monitoring or quality care team should reassess the patient at Education of the patient and significant
assurance programs to ensure that the least every 24 hrs to determine whether othersaboutrestraintusemustbedocu-
staffiscompliantwiththeprinciplesand the order for restraints should remain mented.
policies surrounding the appropriate use active. At each institution, a quality assur-
of restraining devices. During reassessment, the nurse ance system should review medical
How Frequently Should Patients Be should continue to attempt use of the recordspertainingtotheuseofrestraints
ReassessedWithRegardtoTheirNeedfor alternativestorestraintslistedinTable4. to develop quality improvement strate-
CritCareMed2003Vol.31,No.11 2673
Table6.Recommendationsfortheinitiation,monitoring,anddocumentationofphysicalrestraints
EmergentBehavioralIndication NonemergentMedicalIndication
Justification:Patientexhibitsviolentbehavior. Justification:Limitmobilitytoprovidesafecare
RestraintInitiation RestraintInitiation
1. Physiciannotificationwithin1hrofapplicationforverbalorder 1. Physiciannotifiedwithin12hrsforverbalorder
2. MustbeseenbyphysicianorLIPwithin4hrsofapplication 2. PatientmustbeseenbyphysicianorLIPwithin24hrsof
3. Orderscovera24-hrperiod restraintapplication
4. Dailyentriesjustifyingrestraintmustbeenteredintomedical 3. Orderscovera24-hrperiod
record 4. Dailyentriesjustifyingrestraintmustbeenteredintothe
Reorder medicalrecord
Mustberedocumentedevery24hrs Reorder
BedsideMonitoring Mustberedocumentedevery24hrs
Whenpatientisagitated:every15mins BedsideMonitoring
1. Chestskincolor,capillaryrefill,pulseofrestrainedextremities Whenpatientisagitated:every15mins
2. Checkforextremitymovementandsensation 1. Checkskincolor,capillaryrefill,pulseofrestrainedextremities
3. Properbodyalignment Whenpatientiscalm:atleastevery4hrs
4. Documentinrecord 1. Checkskincolor,capillaryrefill,pulseoneachrestrained
Whenpatientisagitated:every2hrs extremity
1. Evaluationofpharmacotherapeuticsusedtocontrolpain,anxiety, 2. Checkforextremitymovementandsensation
agitation,anddelirium 3. Properbodyalignment,reposition
2. Offertoiletingorassesseliminationneedsatleastevery2hrs 4. Documentinrecord
3. Offerfoodandfluidsforthosewhocantakeoralnutritionat Whenpatientiscalm:every2hrs
leastevery2hrs 1. CheckLOC,vitalsigns,ventilatorindicators(ifapplicable)
4. Ifpatientisunabletohaveoralnutrition,assessadequate 2. Monitorthepatencyand/ormechanicalfunctionofdrainage
hydrationandnutrition tubes,positionofendotrachealtubes
5. Extremityrelease/ROM 3. Evaluatepharmacotherapeuticsusedtocontrolpain,anxiety,
Assessreadinessforrestraintreductionorremovalatleastevery8hrs agitation,anddelirium
4. Effectofadjunctivetherapies(e.g.,musictherapy,dimlights,
familypresent)
5. Extremityrelease/ROM
Assessreadinessforrestraintreductionorremovalatleastevery8hrs
LIP,licensedindependentpractitioner;ROM,rangeofmotion;LOC,levelofcomfort.
gies.Reviewofthefollowingcomponents 2. Trialsofreleaseofrestrainingther- With pediatric patients, the critical
ofmonitoringanddocumentationshould apies. careteamshouldbeparticularlyattentive
be a part of the quality review and im- to maintaining proper body alignment
provement program: If a death occurs while a patient is in and correct device positioning when
physical restraints, the death should un- physical restraints are used. The re-
1. Therecordshouldcontainadequate dergo institutional review. strainedchildshouldbemonitoredevery
documentation in the nursing and Leather restraints occasionally are 30 mins for evidence of respiratory dis-
physicianprogressnotesoftheneed used in the ICU for patients who are se- tress. The nursing staff should evaluate
to initiate restraints. verely agitated or suffer from behavioral thechild’slevelofconsciousnessandas-
2. Ifrestraintswereappliedbynursing disorders.Whentheserestraintsareused, sess restrained extremities for pressure-
personnel under the institution’s more frequent monitoring is required. related injury or impaired circulation at
prorenataurgentrestraintusepol- Based on the patient’s level of agitation least every 2 hrs. Physical restraints
icy,therecordshouldreflectawrit- andclinicalcondition,assessmentsofthe shouldberemovedforextremityrangeof
tenorverbalorderfortherestraints patient’s condition and safety should be motion, patient repositioning, the offer-
usedfromaphysicianincludingthe performed every 15–30 mins. As with ing of food/fluids, and patient hygiene
date and time of the order. other restraints, the patient’s condition every 4 hrs or more frequently if clini-
shouldbereevaluatedseveraltimesaday cally indicated.
3. Documentation should be made of
and less dangerous and restrictive re-
ongoing assessments and monitor-
ing for complications during each straints substituted when the patient’s CONCLUSIONS
condition permits such a change.
restraint use episode.
Assessment of Pediatric Patients. Pe- Despite the numerous questions that
In addition, the following policies are diatric patients in restraint by seclusion exist about the risks, benefits, and prac-
recommended for patients restrained by ormechanicaldevicesshouldbeobserved ticaluseofrestrainingtherapiesincriti-
physical restraints: at intervals of (cid:2)15 mins. Written orders cally ill people, there is currently little
for physical restraints or seclusion for prospective information in the literature
1. Theprovisionofongoingpsychologi- behavioralhealthpatientsshouldbelim- that can be used for development of evi-
calandspiritualsupportforboththe itedto2hrsforchildrenages9–17and1 dence-based guidelines to promote the
patientandsignificantothers. hr for patients (cid:1)9 yrs. scientific application of these modalities.
2674 CritCareMed2003Vol.31,No.11