Physical Restraints and Side Rails in Acute and Critical Care Settings   23  

Cheryl M. Bradas, Satinderpal K. Sandhu, and Lorraine C. Mion

OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) defines physical restraint as “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely” (U.S. Department of Health and Human Services [USHHS], 2007). Examples include wrist or leg restraints, Geri-chairs, and, in certain situations, full side rails and reclining chairs. Many consider hand mitts a restraint only when wrist ties are used, but this is not universally agreed on; others consider hand mitts a type of restraint because they involuntarily limit the individual’s ability to feed and groom himself or herself. Despite the federal regulations placed on hospitals since 1999, eliminating the use of physical restraints for the management of patients in acute nonpsychiatric settings has remained challenging. It is typical for health care professionals to use physical restraints and/or side rails to protect the patient or others (Evans & FitzGerald, 2002). However, the use of physical restraints or side rails for the involuntary immobilization of the patient may not only be an infringement of the patient’s rights, but can also result in patient harm, including soft tissue injury, fractures, delirium, and even death (Bower, McCullough, & Timmons, 2003; Evans, Wood, & Lambert, 2003; Krexi, Georgiou, Krexi, & Sheppard, 2015; McPherson et al., 2013; Miles, 1993).

The standards from The Joint Commission (TJC) and regulations from CMS have raised concerns among hospital professionals about the feasibility and safety of eliminating use of physical restraints and side rails in hospitals. The almost nonexistent use of physical restraint in the United Kingdom in comparable settings provides evidence that this can be achieved (O’Keeffe, Jack, & Lye, 1996; Williams & Finch, 1997). This chapter focuses on the issues of physical restraint in acute, nonpsychiatric hospital settings with particular attention to older adult patients.

BACKGROUND AND LEGAL ISSUES

U.S. Regulations and Accrediting Standards

In 1992, the U.S. Food and Drug Administration (FDA) issued a medical alert on the potential hazards of restraint devices (U.S. FDA, 2006a). Any harm that arises from the use of a restraining device, which now includes bedside rails, must be reported to the FDA. TJC hospital standards began to address the use of physical restraints in the early 1990s. In the ensuing years, the standards have become increasingly prescriptive.

In 1999, CMS established an interim rule for hospitals and, in December 2006, finalized the Patients’ Rights Condition of Participation (USDHHS, 2007). These conditions establish the minimum protections of patients’ rights and safety and may be superseded by state regulations or accrediting agencies. In brief, the use of physical restraint should be used as a last resort, only used when less restrictive mechanisms have been determined to be ineffective, the use of restraint must be in accordance with a written modification to the patient’s plan of care, used in accordance with the order of a physician or licensed independent practitioner (LIP), and must never be written as an “as needed” order. Each order must be renewed every 24 hours for nonviolent behavior and every 4 hours for violent or self-destructive behavior. Orders must be renewed in accordance with hospital policy. Last, restraint must be discontinued at the earliest possible time.

Risks of Liability

A major obstacle in reducing clinicians’ use of physical restraint or side rails is the fear of liability if restraints are not used. Case law has been mixed; hospitals have been found liable both for the use of physical restraints and for not using physical restraints (Kapp, 1994, 1996). Although hospitals have a clear duty to protect patients from harm, they do not have a duty to restrain patients. As the practice in hospitals becomes one of reduced restraints because of changing legal and accrediting standards, it will become easier for hospitals to justify nonuse of restraints in instances of patient injury in which use of nonrestraint interventions was clearly demonstrated (Kapp, 1999).

Professional Standards of Care

A number of organizations have established guidelines for the use of physical restraints, including the American Nurses Association and the Society for Critical Care Medicine (American Nurses Association, 2001; Maccioli et al., 2003). The National Quality Forum has designated physical restraint as a nursing-sensitive measure to be monitored in hospitals and nursing facilities. Last, as part of the condition for participation as a Magnet™ facility, hospitals must examine the use of physical restraint in relation to nursing skill mix and hours. These guidelines have become the standard for customary practice and are used as an appropriate legal standard that defines the parameters of liability. Furthermore, these guidelines, in combination with TJC and CMS requirements, are used to establish hospital-based policies and procedures and quality of performance activities.

PREVALENCE AND RATIONALE OF STAFF

Extent of Use

These standards and guidelines have led to an overall decrease in physical restraint use in acute care and a change in practice patterns. In the 1980s, the overall prevalence rate of physical restraint use on general floors ranged from 6% to 13%, with higher rates (18%–22%) among older adult patients (Frengley & Mion, 1998). In the late 1990s, the overall hospital restraint prevalence decreased but varied as much as threefold, with rates ranging from 39 restraint days/1,000 patient days to 82 restraint days/1,000 patient days (Minnick, Mion, Leipzig, Lamb, & Palmer, 1998; Mion et al., 2001). For the first time, restraint use was examined in critical care units and was noted to be as high as 500 restraint days/1,000 patient days. Intensive care unit (ICU) rates varied markedly, among units in the same hospital setting as well as matched units among hospitals.

A U.S. national prevalence study involving 434 units in 40 acute care hospitals selected at random from five geographical areas was completed in 2005 (Minnick, Mion, Johnson, Catrambone, & Leipzig, 2007). Findings from this study revealed overall hospital prevalence of 50 restraint days/1,000 patient days but with a ten-fold variation among hospitals from a rate of 9 to 94 restraint days/1,000 patient days. The majority of use was accounted for in the ICUs. The pattern of differences by type of unit was again present (e.g., medical vs. surgical and adult vs. pediatric). However, even when controlling by type of unit, more than ten-fold variation existed among similar settings. For example, overall prevalence among the 41 general ICUs was 202.6 restraint days/1,000 patient days with a range of 9 to 351/1,000 patient days. Further, analyses revealed that variation in practice persisted even when controlling for size of hospital, academic or nonacademic status, geographical region, type of hospital (e.g., nonprofit, profit, and government), staffing ratios, and nursing skill mix. Clearly, there are major practice differences even when controlling for patient population.

Similarly, a recent Canadian study involving 51 ICUs revealed that (a) more than half of the patients were in restraints and (b) patient and hospital characteristics were not associated with restraint use of duration (Luk et al., 2014). Rather, treatment characteristics, such as use of sedative, analgesic, and antipsychotic drugs, were predictive of restraint use and duration.

Decision to Use Physical Restraint

Today’s hospital nurses cite prevention of patient therapy disruption as the primary reason for restraint use (reported for 75% of restraint days), presence of “confusion” (25.4% of the restraint days), and fall prevention (17.6% of the restraint days; Minnick et al., 2007). Other less commonly voiced reasons included management of agitation or violent behavior, wandering, and positioning. Although most nurses cite patient care issues as the rationale to use physical restraint, a small proportion of nurses have cited insufficient staffing or legal concerns (Diercks de Casterle, Goethals, & Gastmans, 2014; Evans & FitzGerald, 2002; Minnick et al., 1998).

The CMS regulations mandate that physicians or LIPs must order physical restraint. Similar to nurses, physicians vary in their decisions to order physical restraint (Mion et al., 2010; Sandhu et al., 2010). Factors associated with physicians’ decisions to order restraint include (a) lack of knowledge of physical restraint and hospital policy, (b) higher appraisal of patient harm, (c) specialty (family practice or general surgery), (d) trusting the nurse; (e) patient behavior; and (f) presence of dementia. Given the variation in actual use of restraint, it appears that the decision to use physical restraint continues to be one based on individual judgment and beliefs rather than on scientifically validated guidelines or protocols.

ETHICAL ISSUES IN THE USE OF PHYSICAL RESTRAINT

The primary ethical dilemma resulting from physical restraint is the clinician’s value or emphasis of beneficence versus the patient’s autonomy (Schafer, 1985; Slomka, Agich, Stagno, & Smith, 1998). Clinicians believe that physical restraint prevents patient falls and patient disruption of therapy (Frengley & Mion, 1998; Lamb, Minnick, Mion, Palmer, & Leipzig, 1999). The presence of a physical restraint, by its very nature, is applied against a patient’s wishes and inevitably compromises the individual’s dignity and diminishes respect for the person. Beneficence requires that at least no harm should arise from the use of physical restraint and that, optimally, a good outcome would result from use. The lack of beneficial results from the use of physical restraints has been well documented in many health care settings. Little is known, however, of the risk-to-benefit ratio of use or nonuse of physical restraint in patients who are critically ill (Maccioli et al., 2003).

The discussion of physical restraints from an ethical viewpoint must also incorporate the sociocultural and political contexts. For example, clinicians have reported on low to nonexistent use of physical restraint in the United Kingdom, stemming perhaps from a legal mandate existing since the 1800s prohibiting their use. It has been suggested that in the United States, the domination of risk in geriatric assessment (e.g., prevent harm, prevent falls) shapes much of clinicians’ understanding of old age (Kaufman, 1994). If one’s primary focus is on the likelihood of patient risk resulting in harm, one is less likely to see self-esteem or dignity as the more important value or model to guide clinical decisions (Slomka et al., 1998). Interestingly, Slomka and associates point out the contradictory nature of the frequent use of physical restraint in the United States—that is, a society that places a high value on autonomy yet is so willing to violate that autonomy in the interest of perceived patient benefit (Slomka et al., 1998).

The discussion of ethics in clinical practice must also acknowledge the realities of reduced resources and escalating costs (Minnick et al., 2007; Slomka et al., 1998). Decisions and protocols about the use of physical restraints and methods to reduce and/or eliminate restraints will be impacted by cost-containment efforts, and clinicians and administrators alike may be reluctant to minimize or eliminate restraints. If alternatives to physical restraints in acute care settings can be shown to contribute to quality outcomes (e.g., patient safety, patient dignity, or satisfaction) and within existing cost-containment efforts, then there is an increased likelihood of successfully implementing and maintaining practice guidelines. There is a chance, however, that if restraint reduction efforts are seen as too expensive (e.g., use of “sitters”), then the emphasis on cost constraint may trump other considerations (Slomka et al., 1998).

ADMINISTRATIVE RESPONSIBILITIES

Changing established practices and philosophies of care can be a daunting task. Although education and training are important, the single most important factor in affecting a major shift in the present paradigm of care to one that is restraint-free care is the commitment by administrators and key clinical leaders (Mion et al., 2001; Williams & Finch, 1997). Indeed, the huge variation seen in the rates among 40 hospitals that cannot be explained by size of hospital, type of hospital, or geographical location lends support to this observation. Administrators, including nurse managers, set the tone for the practice on the unit. Reducing health care providers’ reliance on physical restraint in managing confused or agitated patients, especially in the critical care units, is a major shift that leaves many staff uneasy. Clinical staff, especially the frontline care providers, must feel supported during the transition period. The goal set and supported by administration of a restraint-free environment would establish the presence of a physical restraint as an outlier that requires a full analysis as for a sentinel event. The outcome of such analyses may well lead to the recognition of system problems and organizational arrangements that can be improved, which, in turn, lead to even fewer restraints in use.

INTERVENTIONS AND CARE STRATEGIES

The studies of the prevalence of the use of physical restraints for nonpsychiatric purposes in hospitals have shown that there is great discrepancy among general medical and surgical units and ICUs in terms of the extent of use and rationale for it. Therefore, the use of physical restraints and approaches to possible alternatives can be considered separately for general hospital units and critical care units.

General Medical and Surgical Units

Although rates of physical restraint use on general medical and surgical units have declined in the past 20 years, wide variation exists: from 3 to 123 restraint days/1,000 patient days on medical units and from 0 to 65 restraint days/1,000 patient days on surgical units (Minnick et al., 2007). It is apparent that there are units that demonstrate best practices, but also that further efforts are needed to eliminate this practice as a national standard. Otherwise, significant numbers of patients will continue to be restrained.

Many hospitals provide care for acutely ill, frail older adults in settings that are not designed environmentally for the care of such older people (Catrambone, Johnson, Mion, & Minnick, 2009; Mion et al., 2006; Palmer, Landefeld, Kresevic, & Kowal, 1994). Environmental structure can either facilitate or inhibit monitoring and surveillance, noise control, appropriate lighting, socialization, cognition, and function (Catrambone et al., 2009; Diercks de Casterle et al., 2014; Palmer et al., 1994). Studies in long-term care settings have demonstrated that the use of environmental strategies can enhance function among those suffering from dementia; similar strategies need to be considered in acute care settings.

Besides environmental strategies, organizational factors, such as systems to determine staffing numbers and mix, models of care delivery, and transmission or communication of the plan of care among multiple disciplines and departments, are gaining increased recognition in the patient safety movement (Leape & Berwick, 2005). Many health care providers lack the knowledge, skills, and sensitivity in providing appropriate care to older adults. TJC standard to ensure age-specific education and training is a step in the right direction, but further efforts are required.

No single approach to eliminating physical restraints on general medical and surgical units can be successful. Studies in a variety of settings have shown that the use of advanced practice nurses, comprehensive interprofessional approaches to enhance cognitive and physical function, staff education, organizational strategies, and environmental interventions can eliminate or reduce physical restraints in a cost-effective manner while promoting other patient outcomes such as reduced fall rates (Amato, Salter, & Mion, 2006; Enns, Rhemtulla, Ewa, Fruetel, & Holroyd-Leduc, 2014; Inouye et al., 1999; Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995; Mion et al., 2001).

Critical Care Units

The use of physical restraints now predominantly occurs within the ICUs to maintain needed life-sustaining therapies or life-maintaining therapies (Luk et al., 2014; Minnick et al., 2007). Strategies that have been used with success in long-term care settings, rehabilitation settings, and general hospital units are not as successful in critical care environments (Mion et al., 2001). The severity of illness of patients, the intensity and delivery of care, the pace of activity, and the consequences of interruptions, delays, or disruptions of therapeutic devices differ significantly between non-ICUs and ICUs. The thought of delirious patients dislodging external ventricular drains with subsequent brain damage, pulling out central lines with threat of hemorrhage, or self-extubation from mechanical ventilation with subsequent respiratory arrest is one that heavily influences critical care nurses’ decisions to use physical restraints (Frengley & Mion, 1998; Happ, 2000; Luk et al., 2014).

Efforts to limit physical restraint use in the ICU are hampered by lack of information regarding the extent of therapy disruption in these units or the resulting immediate and subsequent harm to patients (Maccioli et al., 2003). A number of studies, mostly single site, have examined self-extubation from mechanical ventilation (Frengley & Mion, 1998). Rates have ranged from 0.3% to 14.3%, with higher rates in medical ICUs. Reintubation after self-extubation ranged from 11% to 76%. It is important to note that 33% to 91% of those who self-extubated did so while physically restrained. As part of the national prevalence study described earlier, the authors also examined the prevalence of patient-initiated device removal, patient contexts, patient risk-adjusted factors, and consequences (Mion, Minnick, Leipzig, Catrambone, & Johnson, 2007). In 49 ICUs in 39 hospitals, the authors collected data on 49,482 patient days. Patients removed 1,623 devices on 1,097 occasions for an overall rate of 22.1 episodes/1,000 patient days. Similar to results on physical restraint prevalence, wide variation in rates was noted: from none to 102.4 episodes/1,000 patient days. Approximately half the episodes occurred on day shift, and 44% were in physical restraint at the time of the episode. Patient harm occurred in 250 (23%) events, mostly minor in nature. In 10 (0.9%) episodes, patients incurred major harm. No deaths occurred. The authors examined rates of reinsertion and found these varied by type of device. Devices that are easily applied, such as monitor lead or oxygen masks, had much higher reinsertion rates than devices that are more complex and difficult to insert (such as endotracheal tubes or surgical drains). It may be that devices are used too long, which could contribute to prolonged use of physical restraint. In turn, physical restraint may contribute to agitation and delirium (Inouye & Charpentier, 1996). Additional hospital resources (e.g., x-rays, laboratory tests) were used in slightly more than half the episodes; thus posing a potentially costly problem (Fraser, Riker, Prato, & Wilkins, 2001).

Information gathered on staffing levels and mix showed little variation among these ICUs; hence, there was no association between staffing ratios and therapy disruptions. Of the three studies on self-extubation that examined relationship to staffing levels, two also showed no association (Boulain, 1998; Chevron et al., 1998; Marcin et al., 2005). The authors found no association between a unit’s restraint rate and rate of therapy disruption, a finding similar to some studies (Kapadia, Bajan, & Raje, 2000; Mion et al., 2001) but not others (Carrión et al., 2000; Tominaga, Rudzwick, Scannell, & Waxman, 1995).

Finally, the pattern of sedation and analgesia in these units was unclear, and 30% of the patients had received no analgesia or sedation in the 24 hours before the episode. Others have reported on inconsistent sedation and analgesia practices in ICUs (Bair et al., 2000; Egerod, Christensen, & Johansen, 2006; Mehta et al., 2006). In an earlier cohort study, the authors examined medical intensive care unit (MICU) patient outcomes after implementing sedation and analgesia guidelines and found that those cared for with the guidelines had less self-extubation events and less use of physical restraints (Bair et al., 2000). Examining appropriate strategies for sedation and analgesia in critically ill patients may well result in improved clinical outcomes while providing care in a more humane fashion.

Attention to the environment of the ICU is as important as any other setting. Indeed, the environment can affect more strongly persons whose personal competence is low and who are unable to exert control over the environment. Inouye and Charpentier (1996) exquisitely demonstrated the inverse relationship of the individual’s level of vulnerability with that of environmental or process insults on subsequent development of delirium among hospitalized older adults. Environmental features, such as noise, light, and unit design, have been shown to be associated with agitation, anxiety, and disorientation of ICU patients (Frengley & Mion, 1998).

Lack of communication with ICU patients by care providers has been documented and results in distress, anxiety, and confusion (Fontaine, 1994). Attention to the physical environment, use of communication techniques with seemingly noncommunicative patients; encouragement of collaborative practice among ICU disciplines; and nonpharmacological approaches to relieve patient distress, anxiety, and agitation have been suggested but largely untested (Maccioli et al., 2003). Nevertheless, a multipronged approach to optimize physical and cognitive function, address onset, as well as manage delirium and appropriate and adequate pain control is likely to affect nurses’ and physicians’ reliance on physical restraint.

ALTERNATIVES TO PHYSICAL RESTRAINTS

This book has provided the reader with a number of protocols addressing care issues such as falls, delirium, sleep, nutrition, medications, and function. The reader is encouraged to review these protocols closely. Implementing best practices aimed at these areas in itself will reduce the use of physical restraints. A brief overview of an approach that the authors have found successful is presented herein.

Addressing the two major reasons for using physical restraints, to prevent therapy disruption and falls, requires comprehensive yet targeted approaches. The act of self-terminating therapy among hospitalized, acutely ill older adults is most likely a manifestation of delirium and less likely a desire to enact a clinical decision, as with advance directives. Both falls and delirium are well-known syndromes with significant morbidity and mortality among older adults. Both are complex syndromes with multiple underlying etiologies that require a combination of individual-, environmental-, and organization-specific strategies (Tinetti, Inouye, Gill, & Doucette, 1995). Inouye et al. (1999) have demonstrated a multicomponent approach to preventing delirium in a randomized controlled trial subsequently implemented in a number of hospitals (Bradley, Webster, Schlesinger, Baker, & Inouye, 2006). Fall prevention also requires a multicomponent approach (Hempel et al., 2013; Oliver, Healey, & Haines, 2010). Given the complexity of falls and delirium, it is unlikely that any single intervention will suffice as an alternative to physical restraint. Rather, attention to the environment and organization of the unit, as described in the two previous sections, combined with patient-specific approaches, provides the most successful way to eliminate restraint use (Amato et al., 2006; Enns et al., 2014; Mion et al., 2001).

Fall Prevention

Falls are common, serious events in hospitalized older patients. Although nurses perceive that physical restraint prevents falls from occurring, the reality is that physical restraints have not been shown to prevent falls and can actually contribute to fall injury (Frengley & Mion, 1998). The goal is to minimize the risk or probability of falling without compromising the older individual’s mobility and functional independence. Using a systematic or standardized approach, the nurse and physician assess the patient for intrinsic (personal), extrinsic (environment), and situational (activity) factors. Common intrinsic risk factors include impaired gait or balance, sedating medications, vision and hearing impairments, and cognitive impairment, including impaired memory, impulsiveness, or poor judgment. Given the multiple potential causes of falls, no single intervention or combination of interventions has been found effective in preventing falls in hospital settings (Cameron, Murray, & Gillespie, 2010; Hempel et al., 2013). A number of fall risk assessment guidelines are available (Oliver et al., 2010). The reader is referred to Chapter 19, “Preventing Falls in Acute Care,” for a more in-depth discussion. What is important to note is that the evaluation for intrinsic factors need not be complex or time consuming. For instance, the nurse can do a simple evaluation of gait and balance by simply observing the person’s ability to transfer in and out of bed or chair and ability to walk to and from the bathroom. The nurse can quickly note any difficulty with steadiness, ability to stand up independently without using a rocking motion or use of upper extremities, ability to sit down without “plopping” onto the surface of the chair, and the ability to walk steadily to the bathroom without holding onto objects or the wall. At this time, notation can be made of lightheadedness or dizziness, presence of orthostatic hypotension, and use of sedating medications.

Extrinsic factors include clothing and footwear. Shoes or slippers should be nonskid, but rubber-soled footwear is not recommended because this material can “grip” the floor causing the person to pitch forward. Furniture design, such as beds at a proper height and chairs with extended armrests for easier leverage, can facilitate mobility. Reclining chairs are helpful for those with poor trunk control and who slide out of chairs with a 90° seating angle. On the other hand, reclining chairs can act as a type of restraint if used for patients with general deconditioning or weakened states who subsequent struggle to rise out of the chair. Beds low to the floor assist with preventing fall injury because the distance from bed to floor is reduced (Bower, Lloyd, Lee, Powell-Cope, & Baptiste, 2008). Padded floor mats may be used in combination with the very low beds. However, caution must be taken in determining which patients receive very low beds with or without the floor mats. There have been case reports of patient falls and injury from very low beds or floor mats (Bower, et al., 2008; Doig & Morse, 2010). Falls can occur either because of difficulty rising to a standing position from a very low height and/or tripping on the mat. Thus, care must be taken in determining those patients most likely to benefit from these beds. We suggest use of these beds for patients who are identified at moderate to high risk for falls, unable to stand without assistance, and who forget or refuse to call for help (B. Bower, et al., 2008; Capezuti et al., 2008; Doig & Morse, 2010; Tzeng & Yin, 2008). Use of these beds is no guarantee that falls or fall injuries will be reduced. Haines, Bell, and Varghese (2010) conducted a cluster randomized trial and found no effect on either falls or fall injury with the use of these beds. Similarly, we found that bed and chair alarms have no effect on overall fall rates on general medical and surgical floors (Shorr et al., 2010). Last, hospital equipment can contribute to falls, such as legs collapsing on bedside commodes, wheelchairs tipping when a patient leans forward, or tubing from lower extremity intermittent-compression devices that may be left on when a patient stands up from bed. In determining equipment use, the nurse must weigh each patient’s risk factors for the most effective and appropriate use.

The findings of either intrinsic or extrinsic factors should lead to targeted interventions. There are some fall-prevention strategies that one can consider “universal,”—that is, to be implemented for all patients regardless of the risk level. For instance, all patients should have beds at appropriate heights for ease of exiting and entering, have call bells within reach, and have clear pathways. Depending on the type of unit, some units may elect to incorporate universal interventions that other floors would consider a targeted intervention. For example, an acute stroke unit may elect to automatically place all patients on a toileting schedule at time of admission and reevaluate continually whether this intervention is required, whereas the other units in the hospital would elect to use this as a targeted intervention only for those patients with cognitive impairment and incontinence. An important fall-prevention strategy in any setting is mobilization and exercise. Even in critical care settings, there is a growing body of literature that demonstrates the physiological and physical benefits of early mobilization and rehabilitation (Truong, Fan, Brower, & Needham, 2009).

Protection of Medical Devices

Disruption of therapy or self-termination of devices can be dealt with by first identifying the underlying reason for the patient’s attempts to terminate therapies. In many cases, the nurse will identify “confusion” as the underlying cause. As discussed in earlier chapters, the nurse needs to differentiate dementia, delirium, or delirium superimposed on dementia. Additionally, the interprofessional team must discern the underlying causes of delirium, including pain. A systematic approach to determine the cause of the behavior is necessary for treatment. For example, if an older adult is suffering from alcohol withdrawal, it is unlikely that interventions, such as increased surveillance or pain relief, will have much impact on the person’s agitation and delirium. Refer to Chapter 6, “Assessing Cognitive Function,”; Chapter 16, “Dementia: A Neurocognitive Disorder”; and Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment” for further protocols to identify cognitive impairments and to prevent and manage delirium.

In the past, the options for managing agitation in the critical care unit have been sedation and/or physical restraint. The type and amount of sedation, however, may actually contribute to delirium and agitation (Wunsch & Kress, 2009). Multiple studies suggest that limiting the use of benzodiazepines and use of an alternative medication, dexmedetomidine, can decrease ventilator time, length of stay, and long-term brain dysfunction (Wunsch & Kress, 2009). The use of physical restraint in critical care settings has been associated with delirium as well as posttraumatic stress disorder (Jones et al., 2007; McPherson et al., 2013; Micek, Anand, Laible, Shannon, & Kollef, 2005; Nirmalan, Dark, Nightingale, & Harris, 2004; Wallen, Chaboyer, Thalib, & Creedy, 2008).

As the health care team works to address the patient’s behavior, nonpharmacological approaches to protecting the device from self-termination can be made. First, evaluate daily whether the device is absolutely necessary. Since the CMS designation of nonpayment of nosocomial catheter infections (e.g., urinary tract infections from indwelling catheters, ventilator-related pneumonia), many ICUs have implemented multidisciplinary daily mandatory checklists that incorporate assessment for compliance to infection control and timely discontinuation of devices (Byrnes et al., 2009; DuBose et al., 2010). Even in the critical care environment, major therapy devices may not be reinserted once a patient pulls it out. Thus, always question whether the device is absolutely necessary or whether a less noxious device or approach may be used instead. For example, if a nasogastric tube is used for nutrition, request the assessment of other disciplines, such as speech or occupational therapists (OTs), to determine whether oral feeding could be introduced. If long-term enteral feeding is required, an interprofessional team plan with the patient and family is warranted given the known deleterious effects of tube feedings with certain conditions.

Some therapeutic devices cannot be altered or discontinued, for example, use of endotracheal tubes, nasal cannula, or oxygen masks. A second approach is to use anchoring techniques to secure the device against the patient’s attempts to dislodge the device or to use camouflage to “hide” the device from the patient. Proper anchoring addresses comfort as well as stabilization of the device(s). For example, it is not unusual for pressure ulcers to develop on nares or behind ears and neck because of undue pressure from the device; clearly a source of discomfort for the patient. Proper stabilization of the tube or device with secure anchoring can minimize accidental dislodgment as well as deter more purposeful removal. For instance, a nasogastric tube can be placed so as to not interfere with or interrupt the person’s visual field. Seeing the tube dangling in front of one’s eyes or pulling on one’s nares is an obvious irritant. If a gastrostomy tube is determined to be appropriate in the person’s plan of care, abdominal binders can aid in reducing the person’s ability to pull it out. There are a number of commercial products available to secure various tubes, including nasogastric tubes, endotracheal tubes, IV lines, and indwelling bladder catheters. Although none of these devices is likely to prevent a determined person from pulling out a device, they do provide anchoring and stability of the device that is probably more secure than taping methods.

Side Rails

A discussion on physical restraints in hospitals would not be complete without mentioning side rails. Side rails, in and of themselves, are not considered a restraining device by either TJC or CMS. It is the nurse’s intent of their use that determines whether side rails are a restraining device or a protective device. This has led to some confusion by nurses. Full side rails to transfer patients in carts, during procedures (e.g., conscious sedation), or protect a sedated or lethargic patient from rolling out of the bed can be considered as protective devices. A number of specialty beds, such as ICU pulmonary beds or bariatric beds, require full side rails in use. Many bed manufacturers have bed controls and call systems embedded in the side rail frames, resulting in patients requesting the side rails be kept raised for ease of control. Hospital patients have also been observed to request partial to full side rails to be raised because of the narrowness of the beds or to facilitate movement (e.g., transfers, repositioning).

In ICU settings, full side rails are used predominantly because of bed equipment specification (e.g., pulmonary beds) or because of procedural considerations (e.g., sedation protocols; Minnick, Mion, Johnson, Catrambone, & Leipzig, 2008). In non-ICUs, nurses use full side rails primarily for fall prevention (46%), especially for older patients (Minnick et al., 2008). Full side rails used to keep patients in bed who desire to leave the bed are restraints. It does not matter what the cognitive level of the person is. If a severely demented patient wishes to leave the bed, full side rails are considered a restraint, even if the nurse believes that the side rails are for “patient safety.” Side rails have been shown to increase fall injuries because patients either try to squeeze through rails or climb over the foot of the bed; hence they are not recommended as a fall prevention strategy for conscious patients, even in the presence of cognitive impairment (Braun & Capezuti, 2000). Rather, side rails should be limited for use with patients who may inadvertently roll off the bed because of impaired levels of consciousness from sedation, anesthesia, or medical conditions. Indeed, the FDA has received reports of more than 400 deaths as a direct result of side rail entrapment from a variety of health care settings, including hospitals (U.S. FDA, 2006b). The reader is referred to Braun and Capezuti (2000) for an excellent review of the legal and medical aspects of side rail use.

SUMMARY

The pattern and rationale for physical restraint use has changed over the past two decades. Focusing on assessment and prevention of delirium and falls will likely minimize their use. Further work is needed in the ICU setting for best strategies to identify, prevent, and manage delirium that would include nonpharmacological as well as pharmacological approaches. To avoid the use of physical restraints, practical and cost-effective strategies need to be devised and tested. This would best be done in an interprofessional patient-centered fashion.

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