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Weill Cornell Graduate School of Medical Sciences ​hi how's everyone doing I hope you enjoyed my presentation this is my PDF a project the topic is reduction in restraint use and I see you sitting once again my name is ome okiaf uh I'm doing this project on behalf of glass about cafe university's named Marcos and let's go ahead and begin okay so let me just move this up a little bit alright and this presentation I'm going to talk about reducing the use of restraints in the intensive care unit a setting as a quality standard issue restraints can refer to a wide variety of devices as defined by researchers case law and organizational practices and if the patient's ability to perform certain movement they can include simple items like at a club as you see here on the left all the way up to restraints meant to mobilize most of the upper body which is this device here uh and sometimes the lower body as well the national guidance the national Caroline Clearinghouse guidelines for the use of physical restraint state that there are many reasons for using these restraints these reasons mainly involve preventing patients from removing devices including ventilators and major gastric nasal gastric tube on their own to prevent falling and to keep cognitively disturbed patients from harming themselves or others until psychiatric pharmacological in physical assessment can be done to determine a treatment route that does not require restraint certainly medical restraints do have a time and place when they are appropriate for use in ICU however the agency for Healthcare Research and quality has noted that the majority of states over used for strength suggesting that I see you must take the lead in reducing their usage okay next slide okay plan quality variance this map shows the relative usage by quartiles or how frequently hospitals in different states make use of physical restraints the best days that are closely dotted these tapes here they use restraints less than 1.4 percent of the time while the worst states has shown in green or restraining an average of almost six percent of patients and this is taking from research from the AHRQ from 2010 while both the h RQ and NGC suggested that restraint should be used as really as possible perhaps on no more than one point five percent of I see patients this map shows that normally several times the expected standard of patients are restrained in most states even if they are the only restrained temporarily that is not for the entire duration of their stay and I see older data from research suggests that more than six percent of patients are actually restrained and that nationwide between seven and twenty two percent of ICU patients receive some form of restraint including protective clothing like love when not counting the use of rails on their beds national guidelines me don't know why that's there five of us national guidelines researchers and legal authorities agree that the levels of restraint usage are unacceptably high ok next slide o war sorry but up okay root cause analysis to understand how restraint youth can be reduced in ICU we have to first understand why restraints are used and perhaps overused begin with the research the researchers heavener i created this decision will that you can see here on my left on the use of restraints in my AC based on observations and interviews with 32 nurses in the major urban hospital the red line the red outline as a matter of fact diagram outlines the most common causes where restraints is appropriately used that is when a patient is the pendant or semi independent on a healthcare staff for assisting them with basic functions which can include going to the bathroom without falling or most serious issues like making sure and NG tube stays in place if the patient would experience a life-threatening problem by interrupting their care for example by removing a medical device on their home and if the patient is either agitated or actively combative the restraint maybe orange it however other studies have suggested that in real world situations several other factors contribute to the use of restraint including admitting psychiatric patients or intoxicated patients if an initial assessment determines that the patient may pose a risk to themselves or others restraint use is also more common among patients 80 years of age or older which this age population was majority of the patients data we we analyzed and used at my hospital of st. Mary's for this project if nurses believe that the patient's meet the criteria for delirium are uncertain about how to pharmacologically managed delirium and believe that delirium will pose a fall risk when considered alongside the patient's physical health needs J next slide okay plans open a problem restrained use in ICU is a complex problem because it involves so many stakeholders as this table shows here the foremost stakeholders are the patient's themselves there is a need to make sure that patients do not remove medically necessary devices like assisted ventilation to prevent patients from falling and to prevent patients from harming themselves or others the safety and well-being of our patients is also important a disoriented patient who is able to wander around the floor could accidentally bump into another patient or the patient's bed for example in some cases nurses have reported using physical restraints at the request of the patient family members to prevent the patient from engaging in agitating or self harming behavior while they're gone although there are also many cases where families will ask that restraint be

removed the nurses on the floor employ a combination of brief patient assessment upon admission continuing observation over time and treatment systems like valerian pain insomnia and confusion to reduce restraint use although they may apply restraint if they perceive it is necessary for the patient safety the safety of other patients or their own safety likewise physicians may request the usage of restraint based on fifth patient's physical and psychological condition medical history and health results ok next live plan solution and improvement goal reducing restraint usage at a single ICU is a feasible goes begin with even though patient safety tends to be a goal when restraints are used research estimates that a majority of patients that ended up pulling out devices like respirators were actually already restrained at the time patients who are restrained report feeling more isolated combative and hurtful towards people especially if they are among the group of people most likely to experience restraint like psychiatric patients or the elderly training ICU nurses to quickly assess patients for delirium confusion and issues contributing to altered mental state such as psychiatric disorders drug use a sudden lack of medication that is usually prescribed can be used as a basis for additional nursing interventions and medical assessment staff staff education should include teaching staff members about alternatives to restraint the reality of restraint is not always preventing patient extubation the use of sedatives psychiatric medication and pain management medication for patients who need it in a development of target goals to reduce ICU restraint use patient and staff surveys and restraint data should be collected to show the impact of intervention with the goal of reducing restraint usage to an overall average of less than 1.5 precipitation and decreasing restraint use by sixty-six percent among high-risk patients as this table here shows to have occurred in a red boxes other studies have found in ninety-eight percent reductions and restraint usage applying staff education methods so these results are supported by research greatly next slide okay do steps to effect the change this solution will take about five months and will largely focus on ICU nurses who tend to make many other restraints decisions for patients and most less than hospitals although I see physicians will be involved as well because they also have the power to decide if the patient's of deep string the first step conducted over a two-week period is to create a change team of ICU staff who are designed to change vision define overall goal of decreasing restraint used to 1.5% are left who would sell this change to administration by demonstrating the potential savings in patient trauma as well as pressure sores and other injuries from restraints mainly circulatory um savings from possible lawsuits and improving patient outcomes and satisfaction the team would then spend another two weeks interviewing other IC stakeholders including nurses physicians even samples of patients and their family members the key would be to find out who is being most commonly restrained for what reasons and whether the reasons are being adequately reported based on this information the team will develop a targeted intervention for thy cease providing general training for ICU members and training specific volunteer staff to be team leaders who would make sure every ICU staff member understands to role in reducing restraint and knows how to know how their workflow would have to change to make the work plan make a plan work for that matter this page would take roughly two months for example some nurses might have might make initial assessments about patient state of consciousness medical histories and understanding of where they are which will lead to a qualified ATM advanced practice nurses or physicians making further evidence based assessment and developing individualized patient orders as needed instead of leaving it up to individual staff to decide to restrain patients for how long and with which methods staff will be taught over two months decision-making criteria for when to restrain versus alternative care methods from talking to the patient to administering necessary medication to providing ways to avoid invasive intubation if possible okay next slide which I study data collection data collection will be vital to make sure that the solution meets the goals one method of data collection will be to use hospital ICU records to determine how often restraints were used every month measurement would then be taken for six months before and six months after to intervention to determine whether there was a significant decrease in restraint use whether the decrease left the 1.5% patient restraint gold and whether these outcomes continue to be effective over time during the months after the end of the intervention patient surveys might also be conducted to make sure that those results align with the medical records of the restraint you also sub analyses should include the proportions of patience restraint or in categories of commonly restrained patients like the elderly as well as delirious patients and intoxicated patients along with the number and types of alternative interventions use restraint percentage use her shift may be plotted using a box-and-whisker graph similar to the one shown here to see whether certain shifts or certain staff members are more likely to use restraints than others finally patients and patients family members surveys and staff surveys would be used to assess stakeholder opinion staff knowledge of the need for the intervention their understanding of the intervention content and whether there are areas they feel the intervention could improve in okay next slide axe measures to be taken and this is the final slide here so taking measures of the change is important yet these measures must be applied properly to make sure that this plan actually reduces for a string use and I see you the change team will be responsible for providing data collection one month after the intervention and every six months

after that they will be responsible for discussing the results and the potential need to maintain the change or to revise and reintroduced the intervention if it has not had its desired effects the team will present results on restraint usage types of restraints views and reasons documented as shown in this image here to the hospital administrators to show whether there have been changes in the use of restraint and whether the goals have been met and what the cost savings have been patient patient experience surveys and staffs knowledge surveys will also be grasped and presented as two types of other outcome measures if the goals are being met the meetings with the ICU staff will congratulate them and provide some form of recognition for their accomplishments like bringing in lunch during meeting to present the results tour other additional refreshments staff could be surveyed or asked to spend now staff could be surveyed or ask to speak during the meeting about what has helped them change their behavior so that this information could be incorporated into training new ICU staff and into the ICU staff performance review if the goals are not met the restraint used data staff survey data and patient data will need to be analyzed to determine why for example if staff do not understand their role do not see the need for restraint alternatives are simply sliding back into old habits or other other reasons the meetings with staff will emphasize the positive changes made and the need and prove further to make the ICU even more effective and patient-centered stuff ideas will be solicited and Retraining will be used perhaps with different methods in order to convey the messages and more frequent follow-up measures will be taken to make sure the staff remembers the use of the information provided okay so i hope you enjoyed our presentation these are the references that i use the back of my findings through our project at st. Mary's and I hope you learned something valuable and enjoyed my presentation thank you very much and have a great day New York University, West Village, Manhattan.