Fit to be Untied — RNs Use Alternatives to Restraints
By Terri Pauser Wolf, RN, BSN
Critical care nurse John Norris, RN, MN, experienced the disturbing realities of restraints when he became a patient after an off-roading accident resulted in a hematoma and fractured clavicle. Norris says he was restrained while he was disoriented from his head injury and was trying to get out of his ICU bed. He has limited memory of the hospitalization, but he learned how horrifying it was for his parents to watch him fighting the restraints. This 1999 event spurred Norris to research alternatives to patient restraint.
Today, Norris encourages the staff at Kaiser Permanente in Bellflower, Calif., to use alternatives to restraints, including: anticipating needs for toileting, monitoring hunger, keeping lights low, and communicating clearly to decrease anxiety. Each alternative provides a layer of care that may prevent the patient from pulling on tubes, climbing out of bed, or interfering with dressings and devices, Norris explains.
UCLA Medical Center is continually looking for ways to reduce restraints by targeting high-use areas such as the ICU. “ Alternatives are part of our value system,” comments Maureen Keckeisen, RN, MN, CCRN, clinical nurse specialist in the transplant and surgical specialty ICU. She notes that the key is identifying the need for restraint quickly and implementing the most effective, but least restrictive restraint. “We want to be as restraint-free as possible.”
Keckeisen says use of alternatives has grown at the medical center as new products have been brought in to assist with patient care. In the last two years, the hospital reviewed many vendor offerings and added several to their supply carts. Through in-services, orientation programs, and by keeping floors stocked with the products, the center has seen a reduction in restraint use and an increase in the use of alternatives. Keckeisen says nurses like using the alternatives. To increase awareness of the products, they held a “Restraint Alternatives Fair” during multiple days and shifts. A clinical nurse specialist for 15 years and a nurse for 27, Keckeisen has seen heightened demand for restraints due to the complex nature of hospitalized patients. Increased acuity, lengthier stays, multiple drug regimens, sleep deprivation, and age all affect mental status, she notes. These factors require nurses to be vigilant in keeping patients safe and to use a restraint method that is both effective and as nonrestrictive as possible.
Norris, motivated by his personal experience, worked with Anna Omery, RN, DNSc, and Candice Rogers, RN, BA, both colleagues at Kaiser Permanente, to gather data on restraint use before implementing alternative interventions. The team started the project in 2002 and recently released the results. Their study, “A Naturalistic Investigation of Alternatives to Restraint Use in an Acute Care Setting,” started with the research team reviewing existing restraint quality forms representing more than 6,000 restraint episodes for nearly 1,700 patients over a 34-month time period.
Their research revealed that of total restraint incidences, the ICU had 50%, followed by the medical-surgical/telemetry floor with 26%. The data also showed that males were more likely to be restrained than females (58.6% vs. 41.4%), and that as age increased, so did restraint usage, with patients ages 71-85 representing 42.2% of restraint incidences. When the team looked at episodes per patient, the majority of patients experienced 1-4 episodes (an episode equals 24 hours in restraints). Staff used wrist restraints most often (85.2%), followed by vests (13.5%). Norris’s study also showed that staff on the evening and night shifts had patients out of restraints more frequently and that those shifts attempted alternatives to restraints more often.
According to Norris, Kaiser Permanente audits restraint use daily, which provides the nurse researchers with important data that has been used to start the second phase of the study. A member of the regional research committee and a critical care nurse for 23 years, Norris says he undertook the research process to help nurses “maximize the use of alternatives and minimize use of restraints.” Phase two, the interventional aspect of the study that is designed to look at the use of alternatives to restraints, started in fall 2005 and will be completed in early 2007.
Revised form promotes alternatives
Norris noted that multiple alternatives were already listed in the policy and procedure manual. He reorganized the list to create a new decision-making form. By incorporating the nursing process, Norris drafted a form that starts with assessment and then provides alternatives to restraints. His process resulted in 37 alternative choices for nurses to consider before using traditional restraints. “You get to know what you may do, and get to know the patient,” he says, noting how the previous forms started with physician orders for restraints. Orders for restraints are now on the last page. To promote the alternatives, Norris gave inservices to educate staff about the phase one findings and the new form to use for phase two. Norris comments that nurses were interested and receptive to the changes because of the complexity and risks of restraint use. He asked nurses who had determined that a patient needed restraint to review the form and try alternatives first.
Norris grouped the alternatives into five categories: physical measures, psychological measures, physiological measures, environmental measures, and spiritual needs. The 24-hour form allows the nurse on each shift to review possibilities to decrease agitation and perhaps prevent the need for restraint use. Many items appear to be common sense, but may be forgotten during a busy shift. For example, the form reminds nurses to: work to promote normal sleep, coordinate activities to limit disturbances, move the patient to a room that can be observed, use music as diversion, offer frequent bathroom trips, and provide adequate pain medication. Norris’s hope is that by going through the options, the patient will not need restraints.
Keckeisen mentions that wrist restraints may increase agitation, especially in the postoperative patient. She says that UCLA Medical Center started stocking products like the elbow immobilizer to reduce restraint use. This device gives patients the ability to move their arms, wrists, and hands, but limits their ability to pull at items on their faces or torsos. She comments that patients who are at risk for pulling out a urinary catheter or arterial line can be fitted with hand control mittens.
For patients who need to keep their hands busy, UCLA Medical Center provides an activity apron that can be placed at the patient’s waist. The apron has pockets, zippers, and ties to distract the patient from reaching under the sheets and removing dressings, drains, or other medical devices. Keckeisen says the apron has proven useful for patients who have been in the ICU for a long time or patients with mild dementia.
In use at the Center as an alternative to tying a patient down is a body holder that Keckeisen describes as a long, 4-inch wide, hook-and-loop belt. Nurses place the belt under a mattress and bring it up loosely around the patient. The belt serves as a reminder to the patient to call for assistance.
Reducing restraint use may require creativity. Restraints may always be needed in some cases, but the work at a few hospitals demonstrates that looking at all available equipment and thinking creatively may be safer and less traumatizing for patients and their families. Like Kaiser, UCLA is also looking at the main reasons that patients get out of bed. Patients needing to get to the bathroom is one cause of falls. The medical center implemented an awareness campaign to increase the frequency of toileting. Bedside signs remind staff of the toileting interval for patients based on an assessment that takes into account their medications and personal habits. Taking care of patient needs beforehand decreased the need for restraints.
Norris asks nurses to think in new ways, and he has some examples. One nurse had an elderly patient who wouldn’t stop picking at her IV. Through conversation, the nurse learned that the patient was used to keeping busy and her boredom exacerbated the picking. The nurse grabbed a nasogastric tube and asked the patient to tie it in knots and then asked her to untie it. The IV stayed intact, and the patient had something to do. Norris suggests floors have activity boxes with crafts and hobby materials available. In another case, a patient wanted to make his bed, so the nurse provided him with fresh linens. Eventually he tired of the activity and stayed in bed.
Keckeisen’s goal is to look for system processes similar to the lift teams that are now used in hospitals. “Being restraint-free is a goal, but it may not be realistic.“ She says that implementation of this type of environment is a value that needs to come from hospital leadership.