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

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 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- -Down Units CNS Down Units CNS Neuroscience ICU & Step Myra Cook MSN, RN, ACNS- -BC, CCRN BC, CCRN Myra Cook MSN, RN, ACNS Renee McHugh, MSN, RN, CCNS Renee McHugh, MSN, RN, CCNS

FastTrac™ Methodology to Reduce Restraint Use and Improve NDNQI Data 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 Fastrac™ Team Physician and Nursing leadership, staff nurses and nurse educato Physician and Nursing leadership, staff nurses and nurse educators. rs.

Significance Significance Significance • ICU patients are frequently intubated intubated and and ICU patients are frequently • 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 extubation extubation through through “ “sedation vacation sedation vacation” ” • Early 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

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

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

Family Education Brochure Family Education Brochure Family Education Brochure

Family Education Brochure Family Education Brochure Family Education Brochure

Family Education Brochure Family Education Brochure Family Education Brochure

Ventilator Liberation Ventilator Liberation Ventilator Liberation Algorithm Algorithm

Early Weaning and Extubation Extubation Early Weaning and Patient Sticker Ventilator Liberation Process Perform Pass Wean Fio2/Peep to SAT Safety SAT per Pass SBT Safety Pass Perform SBT keep O2 Sat >90 Screen unit specific Screen guidelines Fail RN____ Time____ Obtain ABG in 30 Reassess Q Fail Fail minutes 24 hrs and Reassess PRN Reassess Q Q 24 hrs 24 hrs and and PRN Review PRN Results SAT Safety Screen SBT Safety Screen with MD/LIP • No active seizures • MAAS 3-4 • No paralytics • Oxygen sat > 90 RT____ • No alcohol withdrawal • Fio2 < .50 Adjust vent settings • No MI • Peep < 8.0 cm H20 No and sedation for Ready to Extubate? • No excessive bleeding • Presence of patient comfort/safety. • Minimal Inotropic spontaneous breaths Yes Reassess readiness to support • RR < 35 breaths/min extubate at least daily Presence of all criteria •+ Cough/gag reflex Extubate (more frequently as pt required to pass Presence of all criteria patient once condition improves). required to pass order obtained by RT to perform MD/LIP RN to perform Perform post- SAT=Spontaneous Awakening Trial (e.g. “sedation vacation”) extubation survey SBT= Spontaneous Breathing Trial RN/RT to perform This document is not permanent part of medical record

Algorithm References Algorithm References Algorithm References Spontaneous Awakening Safety (SAT) Screen Spontaneous Breathing Trial (SBT) Failure Failure • Anxiety • Respiratory Rate > 35 breaths per minute • Agitation • Respiratory Rate < 8 breaths per minute • Pain • SpO2 < 88% • Respiratory Rate > 35 breaths per minute • Respiratory Distress • SpO2 <88% • Mental Status Change • Respiratory Distress • Acute Cardiac Arrhythmia • Acute Cardiac Arrhythmia Post-Extubation Safety Survey • Strong cough, Able to maintain airway/clear secretions Unit-Specific Customization • 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

Restraint Minimization Restraint Minimization Algorithm

Decision Algorithm Decision Algorithm ICU Restraint Minimization Algorithm ICU Restraint Minimization Algorithm YES YES Is patient exhibiting behaviors that may warrant restraints? Is patient exhibiting behaviors that may warrant restraints? NO NO Assess Causes Assess Causes Do not restrain or d/c Do not restrain or d/c Continuously Continuously restraints restraints Hypoxia, pain, anxiety, delirium Hypoxia, pain, anxiety, delirium assess mental status of patient assess mental status of patient ANXIETY? ANXIETY? PAIN? PAIN? DELIRIUM ? DELIRIUM ? Check MAAS Check MAAS Check NPAT score or visual Check NPAT score or visual analog scale analog scale Check... Tool to be decided Check... Tool to be decided Acute Acute Chronic Chronic Anxiety? Anxiety? Anxiety? Anxiety? Negative for Negative for Positive for Positive for If pain is present, administer If pain is present, administer delirium delirium delirium delirium YES YES YES YES pharmacologic/non- pharmacologic/non- pharmacologic as appropriate pharmacologic as appropriate Assess for hypoxia Assess for hypoxia Reassure. Encourage Reassure. Encourage immediately. immediately. visitation if calming to visitation if calming to Reassess pain at least q1hr after Reassess pain at least q1hr after Assess toileting needs. Assess toileting needs. patient. patient. Consider Consider Agitated? Agitated? intervention and prn intervention and prn anxiety anxiety Comfort, Reassure. Comfort, Reassure. NO NO Pain Pain YES YES Consider anxiolytic Consider anxiolytic Hyper Hyper Controlled? Controlled? Hypo Hypo Contact Psychiatry Contact Psychiatry delirium delirium YES YES delirium delirium if unable to control if unable to control NO NO behavior. behavior. Continue to Continue to Consider pain Consider pain monitor monitor mgmt. consult mgmt. consult effectiveness of effectiveness of •Review home medications & resume as necessary •Review home medications & resume as necessary interventions interventions Determine cause: Determine cause: •R/O delirium •R/O delirium Drugs: Drugs: •Don’t give an anxiolytic if delirium is suspected - •Don’t give an anxiolytic if delirium is suspected - •Opiates, •Opiates, •Anxiolytics •Anxiolytics this will exacerbate delirium this will exacerbate delirium •Anticholinergics: •Anticholinergics: benedryl, ditropan benedryl, ditropan pepcid, steroids, pepcid, steroids, Disease Processes: Disease Processes: •Encephalopathy •Encephalopathy •DrugIntoxication or •DrugIntoxication or drug interactions drug interactions Use Restraints as a Last Resort Use Restraints as a Last Resort •Alcohol withdrawal •Alcohol withdrawal Restrain patient to prevent self-harm or risk of physical injury and where staff are in immediate risk of harm. Review medications with 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. pharmacist and review medications to identify: Potential drug withdrawal , alcohol withdrawal, reactions/interactions. All patients: soft music, minimal environmental stimuli. Maintain circadian rhythms: lights on during day, dark at night. All patients: soft music, minimal environmental stimuli. Maintain circadian rhythms: lights on during day, dark at night. Clocks & calendars in room. Clocks & calendars in room.