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Swan L, Hullick C, Etherton-Beer C, Arendts G. Holistic approach to undifferentiated acute severe behavioural disturbance in older emergency department patients. Emerg Med Australas 2021; 33:1100-1105. [PMID: 34535981 DOI: 10.1111/1742-6723.13865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Lachlan Swan
- Department of Emergency Medicine, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Carolyn Hullick
- Department of Emergency Medicine, Hunter New England Health Service, Newcastle, New South Wales, Australia.,Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | | | - Glenn Arendts
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
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Farzanegan B, Elkhatib THM, Elgazzar AE, Moghaddam KG, Torkaman M, Zarkesh M, Goharani R, Bashar FR, Hajiesmaeili M, Shojaei S, Madani SJ, Vahedian-Azimi A, Hatamian S, Mosavinasab SMM, Khoshfetrat M, Khatir AK, Miller AC. Impact of Religiosity on Delirium Severity Among Critically Ill Shi'a Muslims: A Prospective Multi-Center Observational Study. JOURNAL OF RELIGION AND HEALTH 2021; 60:816-840. [PMID: 31435840 DOI: 10.1007/s10943-019-00895-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.
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Affiliation(s)
- Behrooz Farzanegan
- Tracheal Diseases Research Center, Anesthesia and Critical Care Department, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Alaa E Elgazzar
- Department of Chest Diseases, Zagazig University, Sharkia, Egypt
| | - Keivan G Moghaddam
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Torkaman
- Department of Pediatrics, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Zarkesh
- Department of Pediatrics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Goharani
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farshid R Bashar
- Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mohammadreza Hajiesmaeili
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedpouzhia Shojaei
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed J Madani
- Trauma Research Center, Medicine Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Sevak Hatamian
- Anesthesia and Critical Care Department, Alborz University of Medical Sciences, Karaj, Iran
| | - Seyed M M Mosavinasab
- Anesthesiology Research Center, Anesthesia Care Department, Modares Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoum Khoshfetrat
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Khatam-o-anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ali K Khatir
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Andrew C Miller
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.
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Abstract
Objectives To study the practice of seclusion in an emergency department (ED) and to explore high-risk elements during seclusion. Methods The study consisted of two parts: an in-depth analysis on all incidents associated with seclusion in a six-year period (1998–2004) and a two-year (2002–2004) retrospective analysis of secluded patient records to understand the rationale and patient outcome. Results Part 1: A total of 9 incident records were collected. Four patients were related to setting fire. Five patients had violence or threat of violence. The median length of stay (LOS) in seclusion at the time of incident was 129 minutes. Although 66.7% of the patients had additional restraint prior to the seclusion, incidents still occurred. Two staff sustained injuries and hospital facilities were damaged in some of the incidents. Six patients were later admitted to psychiatric hospital. Part 2: 141 patient data were collected in the study (M: 89 and F: 52). The average monthly number of patients secluded was about 6. The mean age was 45 years (SD 19) and the mean LOS was 616 minutes (SD 478). There were three incidences (2.1%) during the two-year period. A total of 82 patients (58.2%) were associated with violence or threat of violence and 38 (46.3%) of the group had psychiatric illness; and 50 patients (35.5%) were associated with alcohol or drug intoxication. Ultimately, 56 patients (39.7%) were admitted to psychiatric hospital and 64 patients (45.4%) were treated and discharged from the ED. Conclusion Seclusion is a high-risk practice. In our department, the most frequent indication was violence (58.2%), with nearly half of them having history of psychiatric illness. Psychiatric illness had the highest risk for incidents, especially those with violence or threat of violence. The LOS in seclusion was relatively long in the ED and might be one of the risk factors for incidents. Inadequate removal of potentially dangerous belongings from patients before seclusion may end up with catastrophic outcomes. Curiously, ED nurses are not allowed to search patients before seclusion. They are exposed to legal liability in exercising restraint and in searching for potentially dangerous items from patients. It is suggested that clear protocols and quality assurance programs should be instituted to ensure safe seclusion.
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Abstract
Critically ill patients are at high risk for the development of delirium and agitation, resulting in non-compliance with life-saving treatment. The use of physical restraint appears to be a useful and simple solution to prevent this treatment interference. In reality, restraint is a complex topic, encompassing physical, psychological, legal and ethical issues. This article briefly discusses the incidence of delirium and agitation in critically ill patients and examines in detail the method of physical restraint to manage treatment interference. The historical background of physical restraint is discussed and the prevalence of its use in critical care units across the world examined. Studies into the use of physical restraint are analysed, and in particular the physical effects on patients discussed. The use of physical restraint raises many legal, ethical and moral questions for all health care professionals; therefore, this study aims to address these questions. This article concludes by emphasizing areas of future practice development in intensive care units throughout the UK.
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Affiliation(s)
- Karen Hine
- Intensive Care Unit, County Hospital, Lincoln, UK.
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Abstract
Patient safety is a major concern in the pediatric ICU. The acuity has never been higher, patient needs are extremely complex, and the margin for error is small. The concentration on safety needs to revolve around designing safe systems and processes. This article discusses communication, patient identification, catheter-related bloodstream infections, unplanned extubations, restraints and medication administration. The health care system of the future must be transparent, making safety information to insurers, patients and health care providers easily available.
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MESH Headings
- Catheters, Indwelling/adverse effects
- Child
- Communication
- Critical Care/organization & administration
- Cross Infection/etiology
- Cross Infection/prevention & control
- Disclosure
- Health Services Needs and Demand
- Hospital Mortality
- Humans
- Infection Control/standards
- Intensive Care Units, Pediatric/organization & administration
- Length of Stay
- Medical Errors/nursing
- Medical Errors/prevention & control
- National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division
- Organizational Objectives
- Outcome and Process Assessment, Health Care
- Patient Identification Systems
- Pediatric Nursing/organization & administration
- Practice Guidelines as Topic
- Quality Assurance, Health Care/organization & administration
- Quality Indicators, Health Care
- Restraint, Physical/standards
- Safety Management/organization & administration
- Total Quality Management/organization & administration
- United States/epidemiology
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Affiliation(s)
- Bonnie A Rice
- Quality and Outcome Department, All Children's Hospital, 801 Sixth Street South, Saint Petersburg, FL 33701, USA.
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Abstract
• Background Although controversial, physical restraints are commonly used in adult critical care units in the United States to prevent treatment interference and self-inflicted harm. Use of physical restraints in Norwegian hospitals is very limited. In the United States, an experimental design for research on use of restraints has not seemed feasible. However, international research provides an opportunity to compare and contrast practices.• Objectives To describe the relationship between patients’ characteristics, environment, and use of physical restraints in the United States and Norway.• Methods Observations of patients and chart data were collected from 2 intensive care units (n = 50 patients) in Norway and 3 (n = 50 patients) in the United States. Sedation was measured by using the Sedation-Agitation Scale. The Nine Equivalents of Nursing Manpower Use Score was used to indicate patients’ acuity level.• Results Restraints were in use in 39 of 100 observations in the United States and not at all in Norway (P = .001). Categories of patients were balanced. In the Norwegian sample, the median Nine Equivalents of Nursing Manpower Use Score was higher (37 vs 27 points, P < .001), patients were more sedated (P < .001), and nurse-to-patient ratios were higher (1.05:1 vs 0.65:1, P < .001). Seven incidents of unplanned device removal were reported in the US sample.• Conclusions Critical care units with similar technology and characteristics of patients vary between nations in restraint practices, levels of sedation, and nurse-to-patient ratios. Restraint-free care was, in this sample, safe in terms of treatment interference.
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Affiliation(s)
- Beth Martin
- Carolinas Medical Center, Charlotte, NC (BM), and Rikshospitalet University Hospital, Oslo, Norway
| | - Lars Mathisen
- Carolinas Medical Center, Charlotte, NC (BM), and Rikshospitalet University Hospital, Oslo, Norway
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Abstract
During the past two decades, significant research and several government and health care quality groups have advised against the use of physical restraints in hospitals and nursing homes, yet older adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation, or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors from delirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or to others. Physical restraints should be eliminated as an intervention in older adults with dementia because they are also very likely to cause acute functional decline, incontinence, pressure ulcers and regressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangers of this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States.
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Affiliation(s)
- Valerie T Cotter
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
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Bray K, Hill K, Robson W, Leaver G, Walker N, O'Leary M, Delaney T, Walsh D, Gager M, Waterhouse C. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nurs Crit Care 2004; 9:199-212. [PMID: 15462118 DOI: 10.1111/j.1362-1017.2004.00074.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Critical care nurses in the United Kingdom have become increasingly concerned about the use, potential abuse and risks associated with physical restraint of patients. Restraint in critical care is not only confined to physical restraint but can also encompass chemical and psychological methods. There are concerns regarding the legal and ethical issues relating to the (ab)use of physical restraint techniques in critical care. The aim of this article was to present the British Association of Critical Care Nurses (BACCN) position statement on the use of restraint in adult critical care units and to provide supporting evidence to assist clinical staff in managing this process.
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Affiliation(s)
- Kate Bray
- BACCN, Nurse Consultant Critical Care, Sheffield Teaching Hospitals, Sheffield, UK.
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Capezuti E. Minimizing the use of restrictive devices in dementia patients at risk for falling. Nurs Clin North Am 2004; 39:625-47. [PMID: 15331306 DOI: 10.1016/j.cnur.2004.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.
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Affiliation(s)
- Elizabeth Capezuti
- John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, Steinhardt School of Education, New York University, 246 Greene Street, 6th Floor, New York, NY 10003-6677, USA.
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Maccioli GA, Dorman T, Brown BR, Mazuski JE, McLean BA, Kuszaj JM, Rosenbaum SH, Frankel LR, Devlin JW, Govert JA, Smith B, Peruzzi WT. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med 2003; 31:2665-76. [PMID: 14605540 DOI: 10.1097/01.ccm.0000095463.72353.ad] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.
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Vance DL. Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study. AACN CLINICAL ISSUES 2003; 14:82-91. [PMID: 12574706 DOI: 10.1097/00044067-200302000-00010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The literature is replete with articles describing restraint reduction strategies used in long-term care settings, geriatric specialty units, and medical/surgical units in the acute care setting. The feasibility, effectiveness, and appropriateness of such strategies cannot be capriciously applied to the intensive care setting. This article provides an overview of the implementation and outcomes of a pilot study using an algorithmic approach that is clinically appropriate and justifiable for restraint use in the intensive care environment. It provides the critical care nurse with a standardized method for decision analysis when managing patients at risk for treatment interference.
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Affiliation(s)
- Diana L Vance
- Summa Health System Hospitals, Akron, Ohio 44309-2090, USA.
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Abstract
Reduction of physical restraint use in the acute and critical care setting is a complex issue. Ethical considerations, regulatory and professional standards, legal liability concerns, healthcare team members' knowledge and attitudes, and unit culture and practice traditions must all be considered. Restraint reduction programs may use a process improvement format that engages the support of the organization's leadership. Specific interventions for restraint reduction, such as understanding the meaning of a patient's behavior, using a team approach, and involving the family can be evaluated and modified for application in the acute and critical care setting. Successful initiatives to decrease the use of restraint in this setting require an understanding of the many factors that support and oppose this practice.
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Affiliation(s)
- Beth Martin
- Carolinas Medical Center, and Queens College, Charlotte, NC, USA.
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