EFFECTIVELY RESTRAINING PATIENTS

One factor that contributes to violence and poor outcomes among critically ill patients and out-of-control emergency departments is a failure to restrain patients effectively. Accrediting organizations emphasize that the use of restraints is to be considered a last resort—to be employed only when all other methods of preventing injury to the patient or others have failed.  JCAHO goes so far as to say that using restraints represents a failure of management in psychiatric patients. There are people out there who believe that all restraints violate constitutional rights.  To comply with JCAHO a clinician appears obligated to defer his clinical judgment and experience regarding what will work and what will not to waste time on ineffective methods.

To please JCAHO many hospitals have removed leather restraints from the ED, or greatly restrict their use.  In some EDs, the leather restraints are locked up or otherwise made inaccessible by requiring a nursing supervisor’s presence or approval. Yep, we’ve got effective restraints. Nope, we can’t use them. In some EDs, nurses are required to use ineffective gauze before using leather restraints. Documentation of the use of restraints has become so onerous that the paperwork alone discourages their use. Well-intentioned people are making it difficult to use effective restraints when they are needed the most.  This may force the clinician to use even more risky methods of gaining control of a deteriorating patient—paralyzing and intubating the patient.

I recently read an article which stated that intubated patients who were restrained were statistically more likely to extubate themselves than non-restrained patients.  No mention was made of how the patient was restrained or how the endotracheal tube was stabilized or what the mental status of the patient was.  As a critical care specialist directing multiple respiratory ICUs, I have intubated and ventilated more than 1000 patients.  When leather restraints are applied properly, endotracheal tubes are stabilized properly, and the patient is immobilized and properly sedated, it is nearly impossible for a ventilated patient to extubate himself. There is an association between episodes of physical violence and applying restraints (ENA 2011 Emergency Department Violence Surveillance Study).  I wonder whether this association is due to lacking effective restraints, a lack of training applying restraints, or a lack of help from an officer.

I have been called to ICUs hundreds of times to re-insert an endotracheal tube after patient self-extubation. Almost without exception, the patient’s hands were not immobilized to the hand rail as far away from the endotracheal tube as possible, or the tube was secured improperly, or the patient was not sedated properly.  It is possible for a patient to slide down in his bed such that he can bring the endotracheal tube to his restrained hands, but if the hands are fully extended at his side, this maneuver is very difficult, and triggers alarms.  A posey will keep the patient from sitting up or sliding down. Almost all patients on ventilators do better with sedation, and all patients on ventilators should have cameras monitored outside the room. My point is that there is a lot of BS out there regarding physical restraints—mostly from people who have little, if any, clinical background. In their ideal minds, clinicians should be able to use drugs and soothing voices on out-of-control hypotensive patients with no IV.

The most bothersome side effect of restricting the use of effective restraints is the negative consequences.  The folks who make the rules are not responsible for the negative consequences. Their agenda is to minimize the use of restraints. Lost in this agenda is the harm done when critically ill patients pull out their only IV, their central lines, their chest tubes, and their endotracheal tubes. At night, there may not be anyone in the hospital capable of replacing these devices. Not every ED physician can run upstairs and re-insert a central line or an endotracheal tube in a massively obese patient in respiratory distress. Often these central lines were inserted by ultrasound, unavailable at night.  When an obese patient with respiratory distress rips out the only IV and endotracheal tube, re-intubating in the sitting position without sedation and paralysis requires uncommon skill and experience.

I’ve never lost a patient due to too many restraints, but I have seen multiple deaths due to failure to restrain a patient properly.  How many well-meaning JCAHO experts have witnessed a patient bleed to death or have a cardiac arrest where the event was triggered by the patient’s own actions combined with a failure to properly restrain?

I would like to recommend the best emergency department violence study I’ve seen—The Emergency Nurses Association’s November 2011 Emergency Department Violence Surveillance Study.  This is an excellent summary of the scope of the problem.  I am going to use some of this data to fashion a logical plan of action in a subsequent post.