30 Paula Snyder The neurosurgical intensive care unit (NICU) faces unique challenges when it comes to providing patient safety. Patients are often confused, impulsive, restless, and agitated. They may lack the ability to make sound judgments regarding their medical care. Frequently, NICU patients are unaware of their physical limitations. We as health care workers are charged with the responsibility of protecting our patients from physical harm, while at the same time preventing psychological distress. Restraint usage reduction is the primary intent of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) patient care initiatives.1 Guidelines from the Centers for Medicare and Medicaid Services (CMS; formerly the Health Care Financing Administration) also emphasize restraint reduction. Both institutions regard restraints and seclusion as last-resort measures and encourage acute care hospitals to use them only when less restrictive means fail. Restraint use must be guided by state and federal law and by hospital licensing or accreditation requirements at your facility. A restraint can be defined as any device or method used to restrict a person’s movement, mobility, or access to his or her body.2 Medical restraint can be applied in a variety of settings for a variety of reasons. When a restraint is used to promote medical treatment, such as intravenous (IV) therapy and medications; to prevent pulling lines and therapeutic tubes, such as endotracheal tubes, indwelling catheters, intracranial monitors, or drains; or to prevent disturbing surgical dressings and incisions, it is considered medical restraint, no matter the hospital setting. All other alternative means of preventing the undesired behavior should be exhausted before application of restraint. That being said, if we allow our patients to harm themselves by self-extubation or by pulling out their subdural drain or other medically necessary tubes and lines, then we have not helped them. Patient safety must be foremost in our minds when using restraints. A JCAHO sentinel event alert from 1998 reports 20 deaths in the previous 2 years of patients in restraints.3 These deaths had various root causes. Death by strangulation occurred in geriatric patients with vest restraint, half of whom made their way between split side rails. Forty percent of deaths occurred as a result of asphyxiation, and the remainder were due to cardiac arrest and fire (while the patient was attempting to burn off the restraints). The JCAHO identified potential contributing factors as Care should be taken to decrease the risk of problems, such as those listed above. All smoking supplies should be removed from the patient’s person and environment, and visitors should be advised of restriction due to fire risk. A thorough assessment of appropriateness of planned restraint device, considering the patient’s unique physical needs, must be performed prior to application. Proper positioning and observation of the restrained patient are imperative. A nonintubated patient with an altered level of consciousness should not be restrained flat on his or her back because of the risk of aspiration. The head of the bed should be elevated whenever possible. Rarely, if ever, will an NICU patient need to be restrained in the prone position, but if the prone position is used, the airway must be kept unobstructed at all times. The prone position is not recommended for obese, elderly, and pediatric patients. JCAHO’s Provision of Care, Treatment and Services (PC) PC.11.10 through PC.11.100 delineate the appropriate measures for restraint use in hospitals.1 These standards establish that assessment and reassessments of need for restraint, and alternatives to use are performed according to hospital policy. Additionally, hospital leaders must set forth the institutions’s philosophy regarding and standards for restraint use and define the situations in which restraint use is allowable based on clinical evidence. Hospital policies will direct appropriate, safe use of restraint. Restraints must be either ordered by a licensed independent practitioner (LIP) or applied upon specific order according to a hospital-approved protocol that defines clinical criteria for use. Patients are to be monitored while in restraint, and restraint use is to be thoroughly documented in the patient’s medical record according to hospital policy. The hospital works via its performance improvement process to find ways to prevent use, develop alternative measures, and improve processes to decrease the risks related to restraint use. These standards are not intended to address behavioral restraint. Restraint is never used as a disciplinary measure. Let’s put the above information to practical use. Important alternatives to restraint use are adequate pain relief to prevent the confused patient from disturbing a wound or dressing, allowing the patient’s family to remain at the bedside to prevent or decrease anxiety and fear, and reorienting the patient frequently. Using bedside sitters to monitor the patient’s behavior and prevent him or her from pulling tubes and lines or wandering may also be beneficial. Diversional activities such as games, drawing, and television may be helpful for some patients. When an NICU patient has an altered level of consciousness and is intubated on a ventilator, however, the only safe method of preventing self-harm is increased vigilance along with wrist restraint.
Restraints and the Neurosurgical
Intensive Care Unit Patient
Guidelines for Restraint Use
Procedures for Application of Restraints
References
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