Implementation of an Evidenced Based Nursing

Practice Guideline on Physical Restraints

Linda Stevens, MS, RN-BC, CPHQ

Clinical Nurse Specialist Quality and Safety

University of Wisconsin Hospital and Clinics

Objectives

Describe a process for implementing evidence based practice guideline on restraintsIdentify metrics for monitoring restraint utilization

UW HealthLocated in Madison, WisconsinAcademic medical center and health

system for the University of WisconsinIncludes:

UW Hospital536 licensed beds

American Family Children’s HospitalUW Paul P. Carbone Comprehensive

Cancer Center

University of Wisconsin Hospital and Clinics

UW Hospital and Clinics (FY10)

Licensed Beds 536 ICU Beds-Peds & Adult 83Inpatient admissions 25,901Emergency Dept Visits 42,534Clinic visits 577,729

Employees 7468

Awards and RecognitionJanuary 2010-HIMSS Analytics Stage 7 Award

May 2009-Magnet hospital designation by the American Nurses Credentialing Center

January 2009- Named #1 academic medical center nationwide for outstanding nursing quality by American Nurses

UWHC and NDNQI

Member of NDNQI since 2003UWHC has participated in RN Satisfaction Survey for 8 years (2003-2010)Published monograph in ANA’s publication “Transforming Nursing Data into Quality Care: Profiles of Quality Improvement in US Healthcare Facilities”Previous poster and podium presentations

Definition

Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely.

Restraint Program Goals for Fiscal Year 2010

Roll Out Restraint GuidelineImplement New Restraint PolicyChange Health Link build Reduce restraint daysIncrease restraint documentation compliance

Nursing Practice Guidelines at UWHC

Nursing Practice Guidelines Committee established in 2006– Subcommittee of Nursing Practice Council– Developed definition of terms– Developed development process– Developed implementation process– Endorse priority topics– Recommend guidelines to Nursing

Practice Council– 18 Nursing Practice Guidelines

Guideline ProcessPractice topics chosen (4-5/year)Lit review → evidence synthesized

Nursing Practice Guideline Committee reviews and makes recommendations

Practice Council approvesImplementation

Evaluation

Workgroup develops new guideline or adopts external guideline

Guidelines updated every 3 years

Development & Approval Flow Diagram

Development & Approval Flow Diagram

Development & Approval Flow Diagram

Development & Approval Flow Diagram

Restraint and Personal Safety Attendant

Patients with the Actual or Potential Need for Restraint or Personal Safety Attendant Nursing Practice GuidelineExternal Guideline Adopted– “Changing the Practice of Physical Restraint Use

in Acute Care” from the University of Iowa College of Nursing (Park, M., Tang, J. H., & Ledford, L., 2005)

– Critical Care Considerations Addendum– Pediatric Nursing Considerations– Personal Safety Attendant Tools

Nursing Restraint and Patient Safety Attendant (PSA) Guideline

Unknown benefits of restraints Use of physical restraints is associated with numerous risks– increase risk for falls with injury– death– increase confusion– adverse effects of immobilation– emotional distress– violation of patient rights– risk of being sued for poor standard of care

Nursing Restraint and Patient Safety Attendant (PSA) Guideline

The standard of care is not to use restraintsStrive to promote restraint-free care while maintaining patient safetyUse physical restraints only when positive, nonrestrictive procedures have failed to produce the desired behavioral change and remove them as soon as possible

Implementation Strategies

Taken from Registered Nurses Association of Ontario (2002). Toolkit: Implementation of Clinical Practice Guidelines. Toronto, Canada: Registered Nurses Association of Ontario.

Implementation PlanTypical four hour education– Offered three times – Videotaped session available on internet

Meet with unit leadership– Review guideline– Review data– Develop plan to become in line with

guideline– Develop short term and long term goals

with staff– Monitor progress with data

Restraint Guideline Roll OutEducation March 2010Began pilot roll out January 2010 with Trauma and Life Support Center (TLC)Met with Leadership & Unit Councils on:– Neurosurgery, Neuro ICU, General

Medicine & Geriatrics, Family Practice & Forensics

Developed content for guidance on less restrictive alternatives and least to most restrictive restraint types

Restraint Days

One Day Prevalence -– NDNQI– Includes limb and vest

Health Link Data– All documented restraints– All restraint types

Percent of patients in restraintsShare information via Focus on Quality Newsletter, Nursing Quality Council, Safety Resource Nurses

Percent of Patients with Physical Restraint

3.87% 4.15%

7.00%6.70%

5.10%

6.90%

7.90%

6.00%

4.60%

5.90%

4.80%4.30%

7.20%

5.10% 5.00%4.60%

5.60%

4.40% 4.70%5.40%

5.70%5.00%

2.20%

6.00%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Overall Nursing-One Day Prevalence UCL LCL

Rest r ai nt Pr eval ence = Percent of pati ents wi th l imb or vest r est rai nt on day of pr evalence study. Rest rai nt pr evalence data based upon one-day pr eval ence study (conducted with pressur e ulcer audit ). Upper Contr ol Limi t (UCL) +2 Standar d devi at ions f rom meanLower Contr ol Limi t (LCL) -2 Standar d deviat ions f r om meanMean based upon 24 data points

Number of Restraint Types Documented in Health Link

197

219209

170

193

231

179

203

222233

248

196187

213 210193

176

196 190179

8 13 9 5 4 3 4 5 114 3 3 2 6 6 2 2 3 2 6

2035

4430 28 27 28 25

32 32 28 3244 42 40 33 28 23 25 22

6 4 5 4 5 3 6 2 1 5 5 2 6 3 4 7 2 3 2 30 0 016

7 916 10 15

5 11 11 7 135

13 10 10 12 1825 29

13 11 12 9 620 19

6 12 12 18 22 21 167 10 14 12

0

50

100

150

200

250

300

350

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Limb (R Wrist) Total

Lap Belt Total

Vest Total

Enclosure Bed Total

Mitts (R) Total

Elbow Immobilizer (R)TotalLinear (Limb (R Wrist)Total)

Number of Restraint Types Documented in Health Link

20

35

44

30 28 27 28 2532 32

2832

44 42 4033

2823 25

22

6

4

5

4 53

6

2

15

52

63

4

7

2

32

3

6

6

4

4 78

13

9

54

34

511

4

3

3

26

6

0

25

50

75

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Lap Belt TotalEnclosure Bed TotalVest Total

Pilot ImplementationTrauma and Life Support Center (TLC)24 Bed Intensive Care UnitStarted meeting in January, 2010

Oct‐09

Nov‐09

Dec‐09 Jan‐10

Feb‐10

Mar‐10

Apr‐10

May‐10 Jun‐10 Jul ‐10

Aug‐10

Sep‐10

Sep‐10 Total # Restraint Pt's

44.4% 40.9% 40.9% 35.0% 45.5% 41.2% 42.1% 10.5% 56.3% 29.2% 13.3% 13.6% 3

Goals for TLC

Increase use of less restrictive restraint typesDecrease the length of time in restraintsDecrease the number of patients in restraintsReview data at monthly meetings

Strategies

Stock bedside carts with less restrictive restraint typesReview need for restraints daily on roundsReview need for tubes, lines, drainsRestraint not automatic for life sustaining devicesClinical Nurse Specialist daily rounding of patients in restraints

TLC Restraint Prevalence

14.3%

63.2%

47.6%

60.0%

23.5%23.5%

42.9%

31.8%

50.0%52.9%

43.5%47.6%

61.1%

50.0%47.4%

54.5%

35.0%

47.8%

62.5%

47.8%

30.0%

44.4%40.9%40.9%

35.0%

45.5%41.2%42.1%

10.5%

56.3%

29.2%

13.3%13.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%Ja

n-08

Feb-

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May

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Jun-

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l-08

Aug-

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p-08

Oct

-08

Nov

-08

Dec

-08

Jan-

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b-09

Mar

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Apr-

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Jul-0

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Sep-

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Feb-

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May

-10

Jun-

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Aug-

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9335 TLC Adult Critical Care Trendline

Number of Restraint Types Documented in Health LinkTLC

0 1 0 0 0 2 0 0 1 0 0 0 1 1 0 0 0 1 0 04 2 4 3

95

1

9 8 6 5 63 4 5 6

2 4 3 10 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 01 1 1 0 2 2 3 3 51

4 26 6 5 6

1521

32

21

83

9296

82

98

108

79

89

104 105 105

94

82

106

98

84

72

9188

73

5 4 3 3 3 2 27

2 1 2 3 38

4 4 3 3 4 30

25

50

75

100

125

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Lap Belt TotalVest TotalEnclosure Bed TotalMitts (R) TotalLimb (R Wrist) TotalElbow Immobilizer (R) TotalLinear (Limb (R Wrist) Total)

Number of Restraint Types Documented in Health LinkTLC

8392 96

82

98108

7989

104 105 10594

82

10698

8472

91 88

73

1

11

0

2

2

3

3

5 1 4

2

6

6

5

6

15

21 32

215

43

3

3

2

2

7

21

2

3

3

8

4

43

3

4

3

0

10

20

30

40

50

60

70

80

90

100

110

120

130

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Elbow Immobilizer (R) TotalMitts (R) TotalLimb (R Wrist) Total

TLC Average Days in Restraints as Documented in Health Link

0

1

2

3

4

5

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

Sep

-10

Restraint Hours

Abstracting hours in restraintsDependent upon correct documentation

TLC Unplanned Extubations

52/60 (87%) of the patients were in soft wrist restraints when they had an unplanned extubation for calendar year 2009 (Respiratory Therapy Data)

Documentation Compliance

Restraint Documentation Overall Performance By Month

53 .2 %

6 1.7% 61.7 %

73 .1%

83 .1% 83 .1%

60 .7% 5 9.8%6 4.0%

5 9.6%

75 .3 %

84 .8 %

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Nov-09 Dec-09 Jan-10 Feb-10 Mar -10 Apr -10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10

General Medicine & Geriatrics

Presented data to unit leadershipShared with unit councilChart review completedNurse resident project beginning on Perceptions of Restraint Use

Neuro ICU

Restraints used per guidelineBenchmark with other neuro ICUChart review – evidence of guideline

25.0% 37.5% 18.8% 31.3% 38.5% 58.3% 35.7% 20.0% 58.3% 40.0% 42.9% 25.0% 3

Oct‐09Nov‐09

Dec‐09 Jan‐10

Feb‐10

Mar‐10 Apr‐10

May‐10 Jun‐10 Jul‐10 Aug‐10 Sep‐10

Sep‐10 Total # Restraint 

Pt's

F8/4 Neuro ICU Average Days in Restraints as Documented in Health Link

0

1

2

3

4

5

6

7

8

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

Sep

-10

Conclusions

Implementation of an evidence based guideline occurs slowly over timeRequires constant attentionRegular review of the data assists in process Appears to be a strong relationship between restraint documentation data and restraint prevalence data submitted to NDNQI

ReferencesPark, M., Tang, J. H., & Ledford, L. (2005).

Evidence-Based Practice Guideline: Changing the Practice of Physical Restraint Use in Acute Care. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center (GNIRC), Research Translation and Dissemination Core (RTDC).

Registered Nurses Association of Ontario (2002). Toolkit: Implementation of Clinical Practice Guidelines. Toronto, Canada: Registered Nurses Association of Ontario.