1
|
Via-Clavero G, Acevedo Nuevo M, Gil-Castillejos D, Rodríguez Mondéjar JJ, Alonso Crespo D. Non-pharmacological interventions to reduce physical restraints in critical care units. ENFERMERIA INTENSIVA 2024; 35:e8-e16. [PMID: 38461127 DOI: 10.1016/j.enfie.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/23/2023] [Indexed: 03/11/2024]
Abstract
Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.
Collapse
Affiliation(s)
- G Via-Clavero
- Enfermera Clínica, Área del Paciente Crítico, Hospital Universitari de Bellvitge-GRIN-IDIBELL, Spain; Profesora Asociada, Departamento de Enfermería Fundamental y Clínica, Facultad de Enfermería, Universitat de Barcelona, Barcelona, Spain; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain.
| | - M Acevedo Nuevo
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; UCI Médica y Unidad Coronaria, Hospital Universitario Puerta de Hierro, Majadahonda, Spain; Grupo de Investigación en Cuidados de la Fundación de Investigación de Puerta de Hierro Majadahonda, Spain
| | - D Gil-Castillejos
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; Enfermera Clínica, Área del Paciente Crítico, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Profesora Asociada, Departamento de Enfermería, Universitat Rovira i Virgili, Tarragona, Spain; Grupo de investigación Sepsia, Inflamación y Seguridad del Paciente Crítico/Inteligencia Artificial (SIS/IA)"(AGAUR SGR 01414), Spain
| | - J J Rodríguez Mondéjar
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; UME-2, Gerencia de Urgencias y Emergencias Sanitarias 061 Región de Murcia, Servicio Murciano de Salud, Murcia, Spain; Facultad de Enfermería, Universidad de Murcia, Campus Mare Nostrum, Murcia, Spain; Instituto Murciano de Investigación Biosanitaria Pascual Parrilla (IMIB-Arrixaca), Murcia, Spain
| | - D Alonso Crespo
- Grupo de Investigación en Cuidados de la Fundación de Investigación de Puerta de Hierro Majadahonda, Spain; UCI, Hospital Álvaro Cunqueiro, Vigo, Spain; Grupo de Investigación Traslacional en Cuidados, Hospital Álvaro Cunqueiro, Vigo, Spain
| |
Collapse
|
2
|
Hostiuc S, Drima E. Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1588. [PMID: 37763707 PMCID: PMC10537082 DOI: 10.3390/medicina59091588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.
Collapse
Affiliation(s)
- Sorin Hostiuc
- Department of Legal Medicine and Bioethics, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Eduard Drima
- Medical Clinical Department, Dunărea de Jos University, 800201 Galați, Romania;
| |
Collapse
|
3
|
Jones A, Goodarzi Z, Lee J, Norman R, Wong E, Dasgupta M, Liu B, Watt J. Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis. PLoS One 2022; 17:e0276504. [PMID: 36288382 PMCID: PMC9604990 DOI: 10.1371/journal.pone.0276504] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited. Objectives To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use. Design Retrospective cohort study with a time series analysis. Participants Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020. Main measures We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR). Key results We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83). Conclusions The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.
Collapse
Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University Hamilton, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- * E-mail: (AJ); (JW)
| | - Zahra Goodarzi
- Division of Geriatric Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Norman
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Monidipa Dasgupta
- Division of Geriatric Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Watt
- ICES, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- * E-mail: (AJ); (JW)
| |
Collapse
|
4
|
Cui N, Qiu R, Zhang Y, Chen D, Zhang H, Rao H, Jin J. Why are physical restraints still in use? A qualitative descriptive study from Chinese critical care clinicians' perspectives. BMJ Open 2021; 11:e055073. [PMID: 34732505 PMCID: PMC8572407 DOI: 10.1136/bmjopen-2021-055073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To understand why critical care clinicians still implement physical restraints, to prevent unplanned extubation and to explore the driving factors influencing the decision-making of physical restraints use. DESIGN A qualitative descriptive design was used. The data were collected through one-to-one, semistructured interviews and analysed through the framework of thematic analysis. PARTICIPANTS AND SETTING The study was conducted from December 2019 to May 2020 at one general intensive care unit (ICU) and one emergency ICU in a general tertiary hospital with 3200 beds in Hangzhou, China. The sampling strategy was combined maximum variation sampling and criterion sampling. RESULTS A total of 14 clinicians participated in the study. The reason why critical care clinicians implemented physical restraints to prevent unplanned extubation was that the tense healthcare climate was caused by family members' rejection of mismatched expectations. As unplanned extubation was highly likely to create medical disputes, hospitals placed excessive emphasis on unplanned extubation, which resulted in a lack of analysis of the cause of unplanned extubation and strict measures for dealing with unplanned extubation. The shortage of nursing human resources, unsuitable ward environments, intensivists' attitudes, timely extubation for intensivists, nurse experiences and the patient's possibility of unplanned extubation all contributed to the decision-making resulting in the use of physical restraints. CONCLUSIONS Although nurses played a crucial role in the decision-making process of using physical restraints, changing the healthcare climate and the hospital management mode for unplanned extubation are fundamental measures to reduce physical restraints use.
Collapse
Affiliation(s)
- Nianqi Cui
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Ruolin Qiu
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuping Zhang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Dandan Chen
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hui Zhang
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hongyu Rao
- Faculty of Nursing, Yunnan University of Business Management, Kunming, Yunnan, China
| | - Jingfen Jin
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
- Changxing Branch Hospital, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Huzhou, Zhejiang, China
| |
Collapse
|