ICU Restraint Reduction: ICU Restraint Reduction: ICU Restraint - - PowerPoint PPT Presentation

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ICU Restraint Reduction: ICU Restraint Reduction: ICU Restraint - - PowerPoint PPT Presentation

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ICU Restraint Reduction: ICU Restraint Reduction: ICU Restraint Reduction: Development of Evidence Based Development of Evidence Based Development of Evidence Based Tools to Guide Interventions Tools to Guide Interventions Tools to Guide

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ICU Restraint Reduction: Development of Evidence Based Tools to Guide Interventions ICU Restraint Reduction: ICU Restraint Reduction: Development of Evidence Based Development of Evidence Based Tools to Guide Interventions Tools to Guide Interventions

January 2012 January 2012 Sandy Maag, BSN, RN Sandy Maag, BSN, RN Manager of Nursing Quality Manager of Nursing Quality Malissa Mulkey, MSN, APRN, CCRN, CCNS Malissa Mulkey, MSN, APRN, CCRN, CCNS Neuroscience ICU & Step Neuroscience ICU & Step-

  • Down Units CNS

Down Units CNS Myra Cook MSN, RN, ACNS Myra Cook MSN, RN, ACNS-

  • BC, CCRN

BC, CCRN Renee McHugh, MSN, RN, CCNS Renee McHugh, MSN, RN, CCNS

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Problem Statement

Restraint use in many ICUs was above the NDNQI benchmark for hospitals with 500 or more beds. It is imperative that nurses ensure patient safety and dignity as well as the basic right of a patient to be free from restraint. How can we move closer to, or get below, the NDNQI benchmark of 20.89% while still ensuring patient and staff safety?

Benefits

  • Improved Patient Safety
  • Improve Patient and Family Satisfaction
  • Maintain Clinician Safety

FastTrac™ Methodology to Reduce Restraint Use and Improve NDNQI Data

Physician and Nursing leadership, staff nurses and nurse educato Physician and Nursing leadership, staff nurses and nurse educators. rs. Fastrac™ Team

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Significance Significance Significance

  • ICU patients are frequently

ICU patients are frequently intubated intubated and and prone to develop pain, anxiety and delirium; prone to develop pain, anxiety and delirium; assessing and treating the underlying causes, assessing and treating the underlying causes, is imperative is imperative

  • Early

Early extubation extubation through through “ “sedation vacation sedation vacation” ” reduces the need for restraints reduces the need for restraints

  • Managing and monitoring patients at risk

Managing and monitoring patients at risk using innovative tools and family involvement using innovative tools and family involvement while maintaining patient safety can reduce while maintaining patient safety can reduce the need for restraints the need for restraints

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Most Wanted Improvements (MWIs)™ ICU Restraint Best Practices Across ICUs and within Other Similar Healthcare Organizations Develop a Family Education Brochure Ventilator Liberation Algorithm Restraint Minimization Algorithm

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ICU Best Practices ICU Best Practices ICU Best Practices

  • Phone conferences conducted with

Phone conferences conducted with similar healthcare organizations similar healthcare organizations

  • Inquiries on List Serves were reviewed

Inquiries on List Serves were reviewed

  • Results

Results-

  • across the country: all

across the country: all tertiary large teaching organizations tertiary large teaching organizations are struggling due to patient acuity. are struggling due to patient acuity. No significant best practices No significant best practices identified identified

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SLIDE 6

Family Education Brochure Family Education Brochure Family Education Brochure

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Family Education Brochure Family Education Brochure Family Education Brochure

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Family Education Brochure Family Education Brochure Family Education Brochure

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Ventilator Liberation Ventilator Liberation Ventilator Liberation

Algorithm Algorithm

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Ventilator Liberation Process

Wean Fio2/Peep to keep O2 Sat >90 SAT Safety Screen Pass Perform SAT per unit specific guidelines RN____ Time____ SBT Safety Screen Pass Pass Perform SBT Obtain ABG in 30 minutes Review Results with MD/LIP RT____ Extubate patient once

  • rder
  • btained by

MD/LIP Fail Reassess Q 24 hrs and PRN Fail Reassess Q 24 hrs and PRN Fail Reassess Q 24 hrs and PRN SAT Safety Screen

  • No active seizures
  • No paralytics
  • No alcohol withdrawal
  • No MI
  • No excessive bleeding
  • Minimal Inotropic

support Presence of all criteria required to pass SBT Safety Screen

  • MAAS 3-4
  • Oxygen sat > 90
  • Fio2 < .50
  • Peep < 8.0 cm H20
  • Presence of

spontaneous breaths

  • RR < 35 breaths/min
  • + Cough/gag reflex

Presence of all criteria required to pass Ready to Extubate? Yes No Adjust vent settings and sedation for patient comfort/safety. Reassess readiness to extubate at least daily (more frequently as pt condition improves). RT to perform RN to perform RN/RT to perform SAT=Spontaneous Awakening Trial (e.g. “sedation vacation”) SBT= Spontaneous Breathing Trial Perform post- extubation survey

This document is not permanent part of medical record Patient Sticker Early Weaning and Early Weaning and Extubation Extubation

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Algorithm References Algorithm References Algorithm References

Spontaneous Awakening Safety (SAT) Screen Failure

  • Anxiety
  • Agitation
  • Pain
  • Respiratory Rate > 35 breaths per minute
  • SpO2 <88%
  • Respiratory Distress
  • Acute Cardiac Arrhythmia

Post-Extubation Safety Survey

  • Strong cough, Able to maintain

airway/clear secretions

  • Able to vocalize
  • Calm and Cooperative
  • Awake and Alert, Able to follow simple

commands

  • No Stridor
  • Hemodynamically Stable
  • Perform Survey Q15 mins for one hour

following extubation.

  • No change in mental status

Spontaneous Breathing Trial (SBT) Failure

  • Respiratory Rate > 35 breaths per minute
  • Respiratory Rate < 8 breaths per minute
  • SpO2 < 88%
  • Respiratory Distress
  • Mental Status Change
  • Acute Cardiac Arrhythmia

Unit-Specific Customization ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________

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Restraint Minimization Restraint Minimization

Algorithm

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ICU Restraint Minimization Algorithm

Is patient exhibiting behaviors that may warrant restraints?

PAIN? DELIRIUM ? Check NPAT score or visual analog scale If pain is present, administer pharmacologic/non- pharmacologic as appropriate Reassess pain at least q1hr after intervention and prn

YES NO

  • Reassure. Encourage

visitation if calming to patient.

Continue to monitor effectiveness of interventions Consider pain

  • mgmt. consult

Positive for delirium Negative for delirium

Consider anxiety YES

Hyper delirium

NO

Hypo delirium

All patients: soft music, minimal environmental stimuli. Maintain circadian rhythms: lights on during day, dark at night. Clocks & calendars in room. Consider anxiolytic Contact Psychiatry if unable to control behavior.

Continuously assess mental status of patient

Do not restrain or d/c restraints

Assess Causes

Hypoxia, pain, anxiety, delirium

Use Restraints as a Last Resort

Restrain patient to prevent self-harm or risk of physical injury and where staff are in immediate risk of harm. Review medications with pharmacist and review medications to identify: Potential drug withdrawal , alcohol withdrawal, reactions/interactions.

YES NO

Check... Tool to be decided

YES YES

  • Review home medications & resume as necessary
  • R/O delirium
  • Don’t give an anxiolytic if delirium is suspected -

this will exacerbate delirium

Assess for hypoxia immediately. Assess toileting needs. Comfort, Reassure. ANXIETY? Check MAAS Determine cause:

Drugs:

  • Opiates,
  • Anxiolytics
  • Anticholinergics:

benedryl, ditropan pepcid, steroids, Disease Processes:

  • Encephalopathy
  • DrugIntoxication or

drug interactions

  • Alcohol withdrawal

Chronic Anxiety? Acute Anxiety?

Agitated?

Pain Controlled?

ICU Restraint Minimization Algorithm

Is patient exhibiting behaviors that may warrant restraints?

PAIN? DELIRIUM ? Check NPAT score or visual analog scale If pain is present, administer pharmacologic/non- pharmacologic as appropriate Reassess pain at least q1hr after intervention and prn

YES NO

  • Reassure. Encourage

visitation if calming to patient.

Continue to monitor effectiveness of interventions Consider pain

  • mgmt. consult

Positive for delirium Negative for delirium

Consider anxiety YES

Hyper delirium

NO

Hypo delirium

All patients: soft music, minimal environmental stimuli. Maintain circadian rhythms: lights on during day, dark at night. Clocks & calendars in room. Consider anxiolytic Contact Psychiatry if unable to control behavior.

Continuously assess mental status of patient

Do not restrain or d/c restraints

Assess Causes

Hypoxia, pain, anxiety, delirium

Use Restraints as a Last Resort

Restrain patient to prevent self-harm or risk of physical injury and where staff are in immediate risk of harm. Review medications with pharmacist and review medications to identify: Potential drug withdrawal , alcohol withdrawal, reactions/interactions.

YES NO

Check... Tool to be decided

YES YES

  • Review home medications & resume as necessary
  • R/O delirium
  • Don’t give an anxiolytic if delirium is suspected -

this will exacerbate delirium

Assess for hypoxia immediately. Assess toileting needs. Comfort, Reassure. ANXIETY? Check MAAS Determine cause:

Drugs:

  • Opiates,
  • Anxiolytics
  • Anticholinergics:

benedryl, ditropan pepcid, steroids, Disease Processes:

  • Encephalopathy
  • DrugIntoxication or

drug interactions

  • Alcohol withdrawal

Chronic Anxiety? Acute Anxiety?

Agitated?

Pain Controlled?

Decision Algorithm Decision Algorithm

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Implementation During Q4 2010 Implementation Implementation During Q4 2010 During Q4 2010

  • The final products were presented to all ICU leadership

The final products were presented to all ICU leadership and key stakeholders and key stakeholders

  • To promote the use of the tools, a poster of the

To promote the use of the tools, a poster of the interventions was developed and displayed interventions was developed and displayed at at competency days for viewing competency days for viewing

  • Posters were then distributed to each ICU and education

Posters were then distributed to each ICU and education provided to nursing staff by Clinical Instructors and provided to nursing staff by Clinical Instructors and Clinical Nurse Specialists Clinical Nurse Specialists

  • The brochure was made available to all families of ICU

The brochure was made available to all families of ICU patients patients

  • The ventilator liberation algorithm was also distributed

The ventilator liberation algorithm was also distributed to ICU Respiratory Therapists and Medical Directors to ICU Respiratory Therapists and Medical Directors

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ICU Restraint Minimization Algorithm ICU Restraint Minimization Algorithm

Assess for PAIN Assess for ANXIETY First Assess for hypoxia Assess for DELIRIUM

Family Brochure Is patient exhibiting behaviors warranting restraints?

Ventilator Liberation Process

  • Daily Assessment of Readiness to Extubate
  • Daily Awakening (e.g. “Sedation Vacation”) &

Breathing Trials per unit protocol

  • RN and respiratory therapist driven process!

Restraint use in our ICU’s is above the NDNQI benchmark for hospitals > 500 beds. As nurses, it is imperative that we ensure patient dignity, safety and the basic patient right to be free from restraints.

Use Restraints as a Last Resort

Restrain patient to prevent self-injury & where staff are in immediate risk of

  • harm. Review medications to identify: Potential drug / alcohol

withdrawal, or reactions/interactions.

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Restraint Prevalence ICUs Q3 2010 - Q3 2011

0% 5% 10% 15% 20% 25% 30% Q3 10 Q4 10 Q1 11 Q2 11 Q3 11

NDNQI Mean 08-09 20.54, 09-10 20.89 beds >500

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Sustaintment Sustaintment Sustaintment

  • Monthly restraint prevalence

Monthly restraint prevalence

  • bservations using the NDNQI criterion
  • bservations using the NDNQI criterion
  • Using data to drive improvements

Using data to drive improvements

  • Distribution of monthly trend reports

Distribution of monthly trend reports and quarterly NDNQI reports and quarterly NDNQI reports

  • Review data with bedside staff and

Review data with bedside staff and display display

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Sustaintment Sustaintment Sustaintment

  • Quarterly monitoring of intubated and

Quarterly monitoring of intubated and sedated patients that are restrained sedated patients that are restrained

  • Daily rounding by Clinical Nurse

Daily rounding by Clinical Nurse Specialists to sustain the use of the Specialists to sustain the use of the tools tools

  • Ongoing reinforcement of nursing

Ongoing reinforcement of nursing education education

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A Unit Story A Unit Story A Unit Story

Neuro ICU Neuro ICU’ ’s Journey to s Journey to Reduce Restraint Use Reduce Restraint Use

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Neuro ICU Unit Description Neuro ICU Unit Description Neuro ICU Unit Description

  • Combined Neurological and Neurosurgical patients

Combined Neurological and Neurosurgical patients

  • Most common diagnosis

Most common diagnosis

  • Subarachnoid Hemorrhage

Subarachnoid Hemorrhage

  • 22 NICU Beds

22 NICU Beds

  • 2 physical units

2 physical units

  • 2:1 Nurse to Patient Ratio

2:1 Nurse to Patient Ratio

  • Staff

Staff

  • 1 Nurse Manager

1 Nurse Manager

  • 4 Assistant Nurse Managers

4 Assistant Nurse Managers

  • 1 Clinical Nurse Specialist

1 Clinical Nurse Specialist

  • 1 Clinical Instructor

1 Clinical Instructor

  • 64 Registered Nurses

64 Registered Nurses

  • 11 Clinical Technicians

11 Clinical Technicians

  • Staff rotate between units

Staff rotate between units

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How They Got There How They Got There How They Got There

  • CNS met with Nursing Leadership and Medical

CNS met with Nursing Leadership and Medical Provider team to discuss current state and Provider team to discuss current state and ensure buy in ensure buy in

  • Implementation of restraint reduction algorithm,

Implementation of restraint reduction algorithm, ventilator liberation algorithm, family brochure ventilator liberation algorithm, family brochure

  • CNS began including restraint use in daily

CNS began including restraint use in daily rounding rounding

  • Initially targeted patients with Glasgow Coma

Initially targeted patients with Glasgow Coma Scale of 3 Scale of 3-

  • 5 then increased to more

5 then increased to more challenging patients challenging patients

  • Encouraged removal of restraints on select

Encouraged removal of restraints on select patients patients

  • The CNS to write new restraint order if needed

The CNS to write new restraint order if needed

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How They Got There How They Got There How They Got There

  • CNS reported to Nursing Leadership on

CNS reported to Nursing Leadership on regular basis regular basis

  • Joint Nurse Manager/CNS rounds

Joint Nurse Manager/CNS rounds

  • Assistant Nurse Managers include

Assistant Nurse Managers include appropriate restraints use discussion in appropriate restraints use discussion in daily rounds daily rounds

  • Restraint prevalence results reviewed

Restraint prevalence results reviewed by Clinical Director and Nurse Manager by Clinical Director and Nurse Manager and shared with bedside staff and shared with bedside staff

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NICU Success NICU Success NICU Success

Restraint Prevalence NICUs Q3 2010 - Q3 2011

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Q3 10 Q4 10 Q1 11 Q2 11 Q3 11

NDNQI Mean 08-09 20.54, 09-10 20.89 beds >500

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Lessons Learned Lessons Learned Lessons Learned

  • Reducing restraint use was achieved

Reducing restraint use was achieved through educating frontline staff and family through educating frontline staff and family involvement involvement

  • Assessing the need for restraints, these

Assessing the need for restraints, these tools enhance nurse tools enhance nurse’ ’s decision making s decision making process by placing the focus on underlying process by placing the focus on underlying causes for patient behaviors causes for patient behaviors

  • Appropriate interventions are chosen to

Appropriate interventions are chosen to improve patient outcomes improve patient outcomes

  • ICU nurses must keep vital therapies intact

ICU nurses must keep vital therapies intact while maintaining human dignity while maintaining human dignity

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References References References

  • Cole MG,

Cole MG, Primeau Primeau FJ, FJ, Elie Elie LM. Delirium: prevention, treatment, and

  • LM. Delirium: prevention, treatment, and
  • utcome studies. J Geriatric Psychiatry
  • utcome studies. J Geriatric Psychiatry Neurol

Neurol 1998;11:126 1998;11:126-

  • 37.

37.

  • Vaurio

Vaurio, L., Sands, L., Wang, , L., Sands, L., Wang, Y.,Mullen Y.,Mullen, A., & Leung, J. (2006). , A., & Leung, J. (2006). Postoperative delirium: The importance of pain and pain manageme Postoperative delirium: The importance of pain and pain management. nt. Anesthesia and Analgesia, 102 Anesthesia and Analgesia, 102, 1267 , 1267– –1273. 1273.

  • Ely EW,

Ely EW, Margolin Margolin R, Francis J, et al. Evaluation of R, Francis J, et al. Evaluation of delirium in critically delirium in critically ill patients: validation of the ill patients: validation of the confusion assessment method for the confusion assessment method for the intensive care intensive care unit (CAM unit (CAM-

  • ICU).

ICU). Crit Crit Care Med 2001;29:1370 Care Med 2001;29:1370-

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9.

  • Milisen

Milisen, K., , K., Lemiengre Lemiengre, J., Braes, T., & Foreman, M. D. (2005). Multi , J., Braes, T., & Foreman, M. D. (2005). Multi-

  • component intervention strategies for managing delirium in

component intervention strategies for managing delirium in hospitalized older people: A systematic review. hospitalized older people: A systematic review. Journal of Advanced Journal of Advanced Nursing, 52 Nursing, 52(1), 79 (1), 79– –90. 90.

  • Pun BT

Pun BT, , Dunn J Dunn J. The sedation of critically ill adults: Part 1: . The sedation of critically ill adults: Part 1:

  • Assessment. The first in a two
  • Assessment. The first in a two-
  • part series focuses on assessing

part series focuses on assessing sedated patients in the ICU. sedated patients in the ICU. Am J Am J Nurs Nurs. . 2007 Jul;107(7):40 2007 Jul;107(7):40-

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  • Pun BT

Pun BT, , Dunn J Dunn J. The sedation of critically ill adults: part 2: . The sedation of critically ill adults: part 2: management. management.Am Am J J Nurs Nurs. . 2007 Aug;107(8):40 2007 Aug;107(8):40-

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  • Girard TD, Kress JP, Fuchs BD, Thomason JW,

Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert Schweickert WD, Pun BT, , WD, Pun BT, ,… …Ely Ely

  • EW. (2008). Efficacy and safety of a paired sedation and ventila
  • EW. (2008). Efficacy and safety of a paired sedation and ventilator weaning

tor weaning protocol for mechanically ventilated patients in intensive care protocol for mechanically ventilated patients in intensive care (Awakening and (Awakening and Breathing Controlled trial): a Breathing Controlled trial): a randomised randomised controlled trial. controlled trial. Lancet Lancet, , 371 371(9607), (9607), 126 126-

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