New Guidelines for Restraint Use in ICU
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Release Date: December 12, 2003;
Valid for credit through December 12, 2004
Dec. 12, 2003 — The American College of Critical Care Medicine (ACCM) has developed guidelines for the use of restraints in the intensive care unit (ICU), which are published in the November issue of Critical Care Medicine. They made nine recommendations for implementation and proposed three recommendations for further study with randomized trials.
, 百拇医药
"Restraints are used in ICUs to maintain ongoing invasive therapies when patients are unable to understand the need for such therapies," write Gerald A. Maccioli, MD, FCCM, from Critical Health Systems at Raleigh Practice Center in North Carolina, and colleagues. "Clinicians should look for alternatives to restraints when possible, knowing the ethical questions that arise once they decide to apply restraints."
Members of the ACCM, the Society of Critical Care Medicine, and the American Association of Critical Care Nurses took part in a multidisciplinary, multispecialty task force to review pertinent published literature and provide expert consensus opinion. The Cochrane methodology determined the validity of individual published studies.
, 百拇医药
Based on the weight of published scientific information and expert opinion, the task force developed nine recommendations regarding the use of physical restraints and pharmacologic therapies to maintain patient safety in the ICU. These nine recommendations were all supported by grade C evidence.
To allow patient dignity and comfort without sacrificing medical care, institutions and physicians should aim for the least restrictive but safest patient environment. Restraints should not be used routinely, but only when clinically appropriate. Alternatives to restraining therapies should be considered, especially the treatment of an existing problem that would obviate the need for restraint use.
, http://www.100md.com
The least invasive restraining therapy that is still effective should be chosen; the rationale for its use should be documented; and restraining orders should be limited to 24 hours in duration. Patients should be monitored for complications, and their significant others should be educated concerning restraint use.
Although analgesics, sedatives, and neuroleptics can reduce the need for restraining therapies, they should not be overused as chemical restraints. Patients receiving neuromuscular blocking agents must also have adequate sedation, amnesia, and analgesia.
, 百拇医药
"Restraining therapies in the ICU are used primarily to maintain patient safety," the authors write. "The principal concern of care providers is the inadvertent discontinuation of life support therapy or invasive monitoring devices and the prevention of injury from falls
Crit Care Med. 2003;31:2665-2676
Learning Objectives
1. Upon completion of this activity, participants will be able to:
, 百拇医药
Describe the nine recommended practice guidelines for the use of restraints in critically ill patients in the ICU.
2. Define the purposes of restraining therapies in the ICU.
Clinical Context
The ACCM, the SCCM, and the AACN convened a task force to examine evidence for the use of restraints for maintenance of adult and pediatric patient safety in the ICU. Evidence was systematically reviewed after a search of the MEDLINE and CINAHL databases and the Cochrane Library for English publications from 1990 to 2001. Selection of studies was based on consensus discussion and classification of evidence into levels and grades of recommendation. All nine resulting recommendations are of the grade C or level 4 evidence (based on case series, poor-quality cohort, and case control studies). The literature evaluating the risk-to-benefit ratio of restraining interventions is methodologically weak, and the authors recommend future randomized controlled trials to examine the efficacy of various restraining therapies; to assess optimal methods for safety weaning or discontinuing restraints; and to address the hypothesis that staffing patterns influence the use of restraints.
, 百拇医药
Objectives of restraining therapies in ICU include restricting patient movement or access to his or her body to preserve treatment (such as a catheter or splints); preventing the removal of life-saving devices (such as endotracheal tubes); and facilitating the performance of bedside procedures in patients who cannot cooperate (for example, the insertion of a catheter in a delirious patient).
Study Highlights
Practice Guidelines:
, 百拇医药
1.The least restrictive but safest environment should be created when restraints are used. Alternatives to physicial restraints to reduce patient agitation should be considered, including pharmacologic agents such as sedatives, analgesics, and neuroleptic agents. Other alternatives include more frequent supervision, avoiding unnecessary arousal, and use of caregivers as "sitters."
2 .Restraining therapies should be used only when clinically appropriate, when the risk of untoward treatment interference by the patient outweighs the physical, psychological, and ethical risks of their use.
, 百拇医药
3. Evaluation should always be undertaken to identify and manage a problem that would obviate the need for restraints. These problems include agitation (treatment of its underlying cause is recommended), pain, hypoxemia, hypercapnia, and other organic conditions.
4. The type of restraint used should be the least invasive, optimizing patient safety, comfort, and dignity. Neuromuscular blockade should always be accompanied by adequate analgesic, amnestic, and sedative medications.
, 百拇医药
5. The rationale for restraint must be documented in the medical record and the order should be limited to a 24-hour period, to be rewritten if restraints are to be continued. Documentation should include the unsuccessful use of alternatives to restraining therapy. The potential to discontinue restraining therapies should be considered at least every 8 hours. The initial decision should be made by a team consisting of the treating physician, nurse, and other critical caregivers. An initial verbal order by a physician should be followed by a bedside assessment by the physician as soon as possible. Physicians should be notified of restraint application within one hour, and physicians should examine the patient within 4 hours. Patients restrained to prevent treatment interference should have their physician notified within 12 hours and should be examined by a physician within 24 hours of application of restraint.
, http://www.100md.com
6. A calm patient should be monitored for complications at least every 4 hours, while an agitated patient should be monitored at least every 15 minutes until the patient becomes calm. Each assessment for complications should be documented. The patient should be evaluated by the critical care team at least every 24 hours.
7. Patients and their significant others should receive ongoing education on the need for and the nature of restraining therapies. Although in one study reviewed by the task force only 40% of discharged ICU patients recalled being restrained and did not report undue distress related to the restraining therapy, the effect of restraining therapies on subsequent posttraumatic stress disorder has not been studied. Ongoing psychological and spiritual support is recommended for patients and their families.
, 百拇医药
8. Analgesics, neuroleptics, and sedatives should be used only for specific treatment of pain and anxiety of psychiatric disturbance and should not be overused as a method of chemical restraint.
9. Patients receiving neuromuscular blockade require frequent assessment to minimize the serious sequelae associated with long-term paralysis.
Recommendations for Study:
1. With pediatric patients, the team should be attentive to maintaining body alignment and correct device positioning when restraints are used, and nursing evaluation of consciousness, extremities, and circulation should occur every 2 hours.
2. Staff training and quality assurance for proper application of restraints and annual retraining and competency review is recommended.
3. If death occurs while a patient is in physical restraints, an institutional review should be conducted., 百拇医药
CME Author: Désirée Lie, MD, MSEd
Release Date: December 12, 2003;
Valid for credit through December 12, 2004
Dec. 12, 2003 — The American College of Critical Care Medicine (ACCM) has developed guidelines for the use of restraints in the intensive care unit (ICU), which are published in the November issue of Critical Care Medicine. They made nine recommendations for implementation and proposed three recommendations for further study with randomized trials.
, 百拇医药
"Restraints are used in ICUs to maintain ongoing invasive therapies when patients are unable to understand the need for such therapies," write Gerald A. Maccioli, MD, FCCM, from Critical Health Systems at Raleigh Practice Center in North Carolina, and colleagues. "Clinicians should look for alternatives to restraints when possible, knowing the ethical questions that arise once they decide to apply restraints."
Members of the ACCM, the Society of Critical Care Medicine, and the American Association of Critical Care Nurses took part in a multidisciplinary, multispecialty task force to review pertinent published literature and provide expert consensus opinion. The Cochrane methodology determined the validity of individual published studies.
, 百拇医药
Based on the weight of published scientific information and expert opinion, the task force developed nine recommendations regarding the use of physical restraints and pharmacologic therapies to maintain patient safety in the ICU. These nine recommendations were all supported by grade C evidence.
To allow patient dignity and comfort without sacrificing medical care, institutions and physicians should aim for the least restrictive but safest patient environment. Restraints should not be used routinely, but only when clinically appropriate. Alternatives to restraining therapies should be considered, especially the treatment of an existing problem that would obviate the need for restraint use.
, http://www.100md.com
The least invasive restraining therapy that is still effective should be chosen; the rationale for its use should be documented; and restraining orders should be limited to 24 hours in duration. Patients should be monitored for complications, and their significant others should be educated concerning restraint use.
Although analgesics, sedatives, and neuroleptics can reduce the need for restraining therapies, they should not be overused as chemical restraints. Patients receiving neuromuscular blocking agents must also have adequate sedation, amnesia, and analgesia.
, 百拇医药
"Restraining therapies in the ICU are used primarily to maintain patient safety," the authors write. "The principal concern of care providers is the inadvertent discontinuation of life support therapy or invasive monitoring devices and the prevention of injury from falls
Crit Care Med. 2003;31:2665-2676
Learning Objectives
1. Upon completion of this activity, participants will be able to:
, 百拇医药
Describe the nine recommended practice guidelines for the use of restraints in critically ill patients in the ICU.
2. Define the purposes of restraining therapies in the ICU.
Clinical Context
The ACCM, the SCCM, and the AACN convened a task force to examine evidence for the use of restraints for maintenance of adult and pediatric patient safety in the ICU. Evidence was systematically reviewed after a search of the MEDLINE and CINAHL databases and the Cochrane Library for English publications from 1990 to 2001. Selection of studies was based on consensus discussion and classification of evidence into levels and grades of recommendation. All nine resulting recommendations are of the grade C or level 4 evidence (based on case series, poor-quality cohort, and case control studies). The literature evaluating the risk-to-benefit ratio of restraining interventions is methodologically weak, and the authors recommend future randomized controlled trials to examine the efficacy of various restraining therapies; to assess optimal methods for safety weaning or discontinuing restraints; and to address the hypothesis that staffing patterns influence the use of restraints.
, 百拇医药
Objectives of restraining therapies in ICU include restricting patient movement or access to his or her body to preserve treatment (such as a catheter or splints); preventing the removal of life-saving devices (such as endotracheal tubes); and facilitating the performance of bedside procedures in patients who cannot cooperate (for example, the insertion of a catheter in a delirious patient).
Study Highlights
Practice Guidelines:
, 百拇医药
1.The least restrictive but safest environment should be created when restraints are used. Alternatives to physicial restraints to reduce patient agitation should be considered, including pharmacologic agents such as sedatives, analgesics, and neuroleptic agents. Other alternatives include more frequent supervision, avoiding unnecessary arousal, and use of caregivers as "sitters."
2 .Restraining therapies should be used only when clinically appropriate, when the risk of untoward treatment interference by the patient outweighs the physical, psychological, and ethical risks of their use.
, 百拇医药
3. Evaluation should always be undertaken to identify and manage a problem that would obviate the need for restraints. These problems include agitation (treatment of its underlying cause is recommended), pain, hypoxemia, hypercapnia, and other organic conditions.
4. The type of restraint used should be the least invasive, optimizing patient safety, comfort, and dignity. Neuromuscular blockade should always be accompanied by adequate analgesic, amnestic, and sedative medications.
, 百拇医药
5. The rationale for restraint must be documented in the medical record and the order should be limited to a 24-hour period, to be rewritten if restraints are to be continued. Documentation should include the unsuccessful use of alternatives to restraining therapy. The potential to discontinue restraining therapies should be considered at least every 8 hours. The initial decision should be made by a team consisting of the treating physician, nurse, and other critical caregivers. An initial verbal order by a physician should be followed by a bedside assessment by the physician as soon as possible. Physicians should be notified of restraint application within one hour, and physicians should examine the patient within 4 hours. Patients restrained to prevent treatment interference should have their physician notified within 12 hours and should be examined by a physician within 24 hours of application of restraint.
, http://www.100md.com
6. A calm patient should be monitored for complications at least every 4 hours, while an agitated patient should be monitored at least every 15 minutes until the patient becomes calm. Each assessment for complications should be documented. The patient should be evaluated by the critical care team at least every 24 hours.
7. Patients and their significant others should receive ongoing education on the need for and the nature of restraining therapies. Although in one study reviewed by the task force only 40% of discharged ICU patients recalled being restrained and did not report undue distress related to the restraining therapy, the effect of restraining therapies on subsequent posttraumatic stress disorder has not been studied. Ongoing psychological and spiritual support is recommended for patients and their families.
, 百拇医药
8. Analgesics, neuroleptics, and sedatives should be used only for specific treatment of pain and anxiety of psychiatric disturbance and should not be overused as a method of chemical restraint.
9. Patients receiving neuromuscular blockade require frequent assessment to minimize the serious sequelae associated with long-term paralysis.
Recommendations for Study:
1. With pediatric patients, the team should be attentive to maintaining body alignment and correct device positioning when restraints are used, and nursing evaluation of consciousness, extremities, and circulation should occur every 2 hours.
2. Staff training and quality assurance for proper application of restraints and annual retraining and competency review is recommended.
3. If death occurs while a patient is in physical restraints, an institutional review should be conducted., 百拇医药