States tighten grip on ICU’s patient restraints
Creating protective care plan can meet compliance
While the use of physical restraints in the ICU has been an accepted practice at most hospitals, critical care nurses are being cautioned about a growing trend. States are taking a firmer stand in discouraging the application of wrist and leg restraints, regardless of safety concerns for patients.
"Critical care units have not been exempted from the laws," warns Vanessa Alvarado-Greer, RN, MSN, CCRN, an adult nurse practitioner at the Veterans Affairs Central California Healthcare System in Fresno, CA. Regulatory agencies are asking for more proof that the use of restraints was warranted, she says. Nurse managers will have to supply that proof when it’s requested.
The heightened demand is resulting in additional documentation and proof of proper authorization for every incident of restraint use. Nurses are also required to maintain constant checks on patients to re-evaluate the situation hourly or at shorter intervals. (For suggested regulatory compliance guidelines, see chart above.)
Providers have to prove threat of self-injury
In California and several other states, extended care facilities are barred from physically strapping down patients to a chair. But acute-care hospitals are permitted to use restraints to prevent agitated patients from injuring themselves under certain conditions.
However, providers will have to prove there was a threat of self-injury, and a written physician’s order explicitly stating the reasons for the restraints must be available in the medical record, Alvarado-Greer says.
Restraining an agitated patient to a bed has never been standard practice, even for critical care, she says. Alvarado-Greer has taught courses on patient protective care for hospital personnel.
In the ICU, extremely agitated patients may have their wrists and sometimes their ankles tied to bed frames with foam or leather ties when they have attempted to extubate themselves or tamper with cables or tubing.
But nothing in the literature shows that the use of physical restraints increases patient safety in the ICU, Alvarado-Greer says.
"Because there is no evidence in the research, we don’t have any jump-off point, except to say that we’ve all been using them," she adds.
Patients who suffer extreme anxiety or pain in the ICU are most likely to be restrained. Use of restraints may actually exacerbate these conditions and result in increased heart rate, respiration, arrhythmia, and oxygen consumption. Nearly 90% of ICU patients experience anxiety or agitation.
Instead of implementing physical or pharmacologic interventions, clinicians should determine why the patient is anxious or agitated and take appropriate steps to remedy the problem, Alvarado-Greer observes.
If restraints are warranted, a standard protective care plan form should be used by nurses that encompasses 12 to 24 hours of monitoring and covers the following:
• A clear description of the patient’s observable problems.
• Objective of the physical restraint intervention.
• A patient assessment. Is the patient confused, anxious, agitated, combative, etc.? Assess pain or agitation on a scale of 1 to 4. Record time of each assessment.
• Explanation of possible reasons for the agitation or pain. Is there hypoxemia due to a low hemoglobin or hematocrit? What is the oxygen saturation? Are there possible metabolic reasons for the agitation, such as an electrolyte imbalance?
• Patient/family response to restraint use. Does the patient understand the potential for self-injury? Is family support available?
• Description of results of initial or primary intervention. Are tubes or lines moved out of reach? Was comfort therapy applied, i.e., pillows, reduced noise, relaxation exercises, music therapy, frequent repositioning, family visits?
• Assessment of primary intervention. Was intervention successful? If not, why?
• Medication interventions. Were medications administered? Did physician order it? When? What types of medications? Was medication effective? Respond on a sedation scale of 1 to 5. The time and date of this intervention must be recorded.
• Physical or secondary interventions. What type of restraint was used, i.e., left or right wrist, left or right ankle? What time were they applied?
• Protective care maintenance log. What time interval was used for each visual check of patient? The patient should be visually checked every 15 minutes, and physical needs met every two hours such as water, bathroom visits, and skin integrity.
Finally, a patient must only be secured to a bed or chair that has wheels for fire safety reasons, Alvarado-Greer says. When securing a restraint to a bed or chair, the knot must be an easy-release hitch that can be undone by the pull of one tie. Leather belts with metal buckles are not to be used, she adds.
"Vendors are developing new and better products for physical restraints such as Gore-Tex materials and elbow restraints that free the patient’s wrists while restricting their reach," Alvarado-Greer says. "These are helping to reduce the added anxiety caused by the restraints."
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