Title: - Clinical Guidelines for the use of physical restraints in the Intensive Care and High Dependency Units.
Version Number as from June 2008: - One.
Document Type: - Guideline.
Scope: - All trust employees involved in the care of patients on the Intensive Care and High Dependency Units.
Classification: - Clinical Guideline.
Author: - Steven Wilson. Diarmid Cochran
Groups Consulted: - Anaesthetic Consultants, ICU & HDU Management Teams, ICU & HDU Staff, Governance Committee, Equality and Diversity Manager. Trust solicitors
Validated by: - Clinical Effectiveness Committee.
Equality Impact Assessed: - June 2008
Authorising Body & Date: - Clinical Effectiveness Committee
Master document Controller:-
Review Date: - 6 months from authorisation.
Key Words: - Sedation, Agitation, Confusion, Chemical Restraint, Consent and Capacity.
Index: - Background page 2
Patient Identification page 2
Ethical Considerations page 3
Methods of physical restraint page 4
References page 6
Appendix 1 Use of restraints order page 7
Appendix 2 Confusion Assessment Method page 8
Appendix 3 Mental Capacity Act test page 9
Background
Of the critically ill patients who require ICU and HDU care, up to 80% become agitated or confused during their stay. This may have harmful and adverse consequences for their recovery and pose a significant problem to those caring for them.
Some agitated patients are at a risk to themselves if they remain unrestrained. They may remove intravascular lines, catheters or tubes essential to their care; they may suffer cardiorespiratory problems or they may injure themselves, their family or their carers.
Restraint of critical care patients to aid recovery and to protect themselves and staff is often used. “Chemical Restraint” is employed in the majority of cases, with anaesthetic agents, sedatives, opiates and muscle relaxants utilised in the initial stages of intensive care to allow for intensive ventilatory support. In the weaning ‘recovery’ phases of critical illness, these methods are also used and are widely perceived as ‘kinder’ than non-chemical alternatives.
Chemical restraint, however, is not benign, and as with all interventions is associated with risks and benefits. Prolonged and excessive sedation increases the length of stay in critical care, which may have serious consequences for patients, such as repeated episodes of infection, muscle wasting and neuropathy. Current evidence in critical care has emphasised breaks from sedation as part of the approach to lessening the duration of ventilatory support and critical care stay. Furthermore, in the long term sedative agents may be relatively ineffective at controlling agitation and may actually provoke or prolong agitation.
It would seem prudent therefore to introduce a different method of restraining patients to give clinicians and nursing staff an additional therapy with which to treat and care for agitated and/or confused patients.
Patient Identification
The use of physical restraints should be considered in patients who fulfil the following criteria; -
§ Adult patient over the age of 16 being cared for within the ICU or HDU environment.
§ The patient scores positive for delirium as assessed by the CAM-ICU criteria (Appendix 2) or the patient lacks capacity as laid down by the Mental Capacity Act (Appendix 3) and is agitated.
§ The patient is a potential risk to themselves or others if unrestrained.
§ The patient would require boluses or infusions of sedatives or psychoactive medication to ensure they are not a risk to themselves or others if physical restraints are not utilised.
Physical restraints should not be considered if;-
§ The patient is autonomous and refusing treatment
§ The patient has physical injuries which may be aggravated by the application of restraints.
There are many factors that may lead to agitation, disorientation and non-compliance with attempted treatment in a critical care setting, many of which are potentially treatable. Identification of a patient as outlined above should initiate a search for potential trigger factors which are treatable such as; -
§ Hypoxia,
§ Dyspnoea,
§ Airway irritation,
§ Pain,
§ Full bladder,
§ Hypoglycaemia,
§ Electrolyte imbalance,
§ Sepsis,
§ Acute withdrawal from addictive substances,
§ Anxiety,
§ Constipation,
§ Hunger/thirst,
§ Patient positioning
§ Cold/warm.
The presence of trigger factors, however, does not preclude the use of physical restraints
There may also be environmental factors affecting the patient, such as excessive noise, light and interruption that are interfering with the establishment of a cyclical sleep pattern.
If any of the above are identified the attending team should try to resolve the problem(s) and reassess the impact upon the patient’s agitation and requirements for restraint and/or sedation.
Ethical Considerations
The purpose of restraints be it chemical or physical is to allow optimal care for the patient. By definition patients who require restraints must be incapacitated in some way. Section 6 of the 2005 Mental Capacity Act makes provision for the use of restraint where the practitioner reasonably believes it to be necessary to prevent harm and only then if the restraint used is ‘proportionate to the likelihood and seriousness of the harm’.
The use of restraints must uphold the principle of beneficence i.e. that they will ‘do some good’. This may be in the form of prevention of self harm or reducing the risk of injury. Also restraints must uphold the principle of non-maleficence i.e. that no harm is done to the patient. Care must be taken that restraints are not going to aggravate any existing physical injuries or that they may injure the patient in any way.
Physical restraints have been used in a variety of guises as an alternative to pharmaceutical methods, but widespread use in the UK remains a controversial and emotive subject with many moral and ethical considerations. Given the sensitivity of the subject it is recommended that the decision to utilise physical restraints be made by the senior clinician on duty in consultation with the nurse in charge of the unit. This decision must be documented (Appendix 1) and reviewed on a twice daily basis. Restraints must also be removed 2 hourly in order to allow the patient to move their limbs and to allow inspection of the areas where restraints have been applied for problems. All usual care and repositioning should be carried out as normal as restraints are an adjunct to and not a replacement for medical and nursing attention and vigilance.
Before the use of restraints, attempts should be made where feasible to explain to the patient the rationale behind the care team’s actions. Staff will also need to provide frequent communication and reassurance to patients who have restraints in place.
Before the use of restraints, attempts should also be made, where feasible, to discuss with patient’s next of kin
§ Why restraints are being used
§ What alternatives have been tried and why they have been discounted
§ How the restraints will work
§ How often their use will be reviewed.
§ The availability of support services
Methods of Physical Restraint.
There will be three types of physical restraint available to ensure that levels of agitation can be dealt with the least restriction possible.
1 Posi Mitt (boxing glove)
These gloves remove the use of the fingers and as such the patient’s dexterity and ability to hold objects whilst not reducing the mobility of the arms. The intention is that the patient has freedom of movement but will be unable to hold or grasp objects such as central lines, catheters or airways and pull them out.
2 Soft Arm Splints
Soft arm splints are positioned over the elbow joint and are tightened by means of Velcro straps. The intention is to restrict the flex of the elbow joint ensuring the patient cannot access any part of the upper body whilst still being able to move their arms. Care should be taken not to over tighten the splints and ideally the practitioner should be able to pass their finger between the splint and the patient’s skin. The patient would still be able to access any femoral devices and urinary catheter.
3 Restraining Straps
Restraining straps would be assembled from ‘Collar and cuff’ support and a plastic tie. The collar and cuff material should be placed in loop around the wrist or ankle of the patient and secured with the plastic tie. The loop should be of a size that it is difficult for the hand or foot to be extracted through it, but not so tight as to cause pressure or compression to the limb. Once again the practitioner should be able to pass a finger between the loop and the patient’s skin. The end of the plastic tie should be cut and then encircled with sticking plaster so that no sharp edge protrudes that may cause injury to the patient. The free end of the restraint should then be secured with a double knot to the bed frame, the intention being that there is sufficient length for the patient to move the limb but not enough that they may reach any therapeutic devices. Scissors should be attached to the bed frame with ET tape close to the restraint to facilitate quick removal of the restraint in an emergency.
It is intended that physical restraints will only be utilised and monitored by staff trained and competent to do so. Training will be provided by the ICU/HDU teams.
It is also intended that the use of physical restraints will be audited regularly to evaluate its safety and effectiveness. Patient experience will be monitored through feedback from the follow-up clinic. This process is expected to take place every 6 months
References
Bray, K Hill, K Robson, W Leaver, G Walker, N O'Leary, M Delaney, T Walsh, D Gager, M Waterhouse, C, 2004, ‘British Association of Critical Care Nurses. position statement on the use of restraint in adult critical care units’, Nursing in Critical Care, 9(5), pp.199-212.
Department of Health. Mental Capacity Act 2005 – Summary. Accessed at http://www.dh.gov.uk/en/PublicationsAndStatistics/Bulletins/ChiefExecutiveBulletin/DH_4108436 on 17th May 2007
Ely, E Wesley, MPH Margolin, R Francis, J May, L Truman, B Dittus, R Speroff, T Gautam, S Bernard, GD Inouye, SK 2001, ‘Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU)’, Critical Care Medicine, 29(7), pp.1370-1379.
Ely, EW Inouye, SK Bernard, GR Gordon, S Francis, J May, L Truman, B Speroff, T Gautam, S Margolin, R Hart, RP Dittus, R 2001, ‘Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)’, JAMA, 286(21), pp.2703-2710.
Hine, K 2007, ‘The use of physical restraint in critical care’, Nursing in Critical Care, 12(1), pp. 6-11.
Hofso, K & Coyer, FM 2007, ‘Part 1.Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: contributing factors’, Intensive and Critical Care Nursing, 23(5), pp.249-255.
Hofso, K & Coyer, FM 2007, ‘Part 2.Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: patient perspective’, Intensive and Critical Care Nursing, 23(6), pp.316-322.
Kotak, D & Lawson, A 2007, ‘The Mental Capacity Act 2005 and the Intensivist’, Journal of the Intensive Care Society, 8(1), pp.65-69.
Kress, JP Pohlman, AS O’Connor, MF Hall, JB 2000, ‘ Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation’, New England Journal of Medicine, 342(20), pp.1471-1477.
Maccioli, GA Gerald,A Dorman, T Brown, BR Mazuski, JE McLean, BA Kuszaj, JM Rosenbaum, SH Frankel, LR Devlin, JW Govert, JA Smith, B Peruzzi, WT 2003, ‘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’,Critical Care Medicine, 31(11), pp.2665-2676.
Nirmalan, M Dark, PM Nightingale, P Harris, J 2004, ‘Physical and pharmacological restraint of critically ill patients: clinical facts and ethical considerations’, British Journal of Anaesthesia, 92(6), pp.789- 92.
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S Wilson CN & D Cochran Con Anaesthetist RBH June 2008 Rev March 2009