Intensive and Critical Care Nursing (2009) 25, 221—222

avai lab le at www.sc iencedi rec t .com

journa l homepage: www.e lsev ier .com/ iccn

Research reviews

Tina Day

James Clerk Maxwell Building, Waterloo Road, London SE1 8WA, United Kingdom

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Accepted 21 April 2009

1. Turgay AS, Sara D, Genc RE. Physical restraint usein Turkish Intensive Care Units. Clinical Nurse Specialist.2009;23(2):68—72.

ObjectivesPhysical restraint is described as imposing any limita-

tion to a person’s freedom of movement or access to theirbody by use of a mechanical or other physical device. Theuse of physical restraint is reported to vary from 24% to56% across ICU’s and this practice is highly contentiousfrom professional, ethical and legal standpoints. There arealso serious implications around patient safety. This paperexplored intensive care nurses’ reasons for using physicalrestraint in Turkey. The aim of this study was to investigatewhich types of restraints are used and why they are applied.The relationships between the nurses’ characteristics anduse of restraint were also explored.

MethodsThe study was conducted using a descriptive and cross-

sectional research design, and took place in seven ICU’sacross Turkey. The sample was 190 ICU nurses. Data werecollected by self-administered questionnaires containingopen-ended questions. Data were analysed using bothdescriptive (subject characteristics, frequencies and mean)and inferential statistics (chi square).

FindingsThe majority of participants reported that they initiated

restraint without medical consultation. Common reasons forrestraint included the maintenance of medical devices andinvasive lines (86.8%), restless behaviour (86.3%), impairedmental status (79.5%), treatment (53.7%), and convenience

E-mail address: tina.day@kcl.ac.uk.

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23.2%). Wrist and ankle ties were the most common formssed (84.7%) and less than half (40.5%) documented thatestraint had been used in the nursing notes. Younger nursesaged 20—30 years) were also more likely to use physicalestraint (�2 8.46, d.f. = 1, p = 0.04).

onclusion and recommendationsThe authors make it clear that the focus of the study was

ot to reduce the use of restraint in ICU but to establish theypes of restraint and reasons for its use. The findings doupport those of other studies and highlights the commonse of physical restraint in Turkey. The results suggest fur-her education is required in this area of practice and thatore research is needed to identify appropriate alternatives

o restraint.

ommentThis is an interesting and controversial area of practice

hat many of us may have historically experienced at someoint in the ICU setting. Of particular concern, the majorityf nurses took the decision to use constraint independently,ithout medical consultation, and without documentation.onvenience was also reported as a significant factor. This

s an area that requires further research from a national andnternational perspective in order for suitable alternativeso be found.

. Forcina MS, Farhat AY, O’Neill WW, Haines DE Cardiacrrest survival after implementation of automated externalefibrillator technology in the in-hospital setting. Criticalare Medicine. 2009;37(4):1229—36.

ObjectivesEarly defibrillation significantly improves the chance

f survival after ventricular fibrillation (VF) or ventric-lar tachycardia (VT) arrest. The automated external

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aresearch is required and a more rigorous testing of the avail-able tools. Further education about pain assessment and

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efibrillator (AED) has increased out-of-hospital survivalates post-arrest through early access to defibrillation. Theim of this study was to determine whether the introductionf a hospital-wide biphasic defibrillator with AED capacityould increase survival rates following in-hospital cardiacrrest.

ethodsThe study took place at a large teaching hospital in

he USA. Following an initial period of training, all stan-ard defibrillators were replaced with AED’s. The sampleize was 561 patients who had suffered a cardiac arrestnd resuscitation had been attempted. Data were recordedne year prior to the introduction of AED’s (control group)nd one year after the change (intervention group) usingprospective patient database. Primary outcome measuresere survival to discharge after initial VF/VT and survival

o discharge after initial asystole (AS)/pulseless electricalctivity (PEA) arrest. Secondary outcome measures wereime to first shock, effectiveness of shock, return of spon-aneous circulation and survival. Data were analysed usinghi square, fisher’s exact test and Wilcoxon’s rank test.

indingsThe results showed that AED’s were not associated with

mprovements in time to first shock in patient’s whose ini-ial rhythm was VF/VT (median time 1 min, p = 0.79 for bothntervention and control group). Similarly, no improvementsere seen in relation to survival to discharge (31% compared

o 29%, p = 0.80) in either groups. In patient’s whose initialhythm was AS or PEA, AED’s were associated with a sig-ificantly worse outcome in terms of survival (15% versus3%, p = 0.04) compared to standard defibrillators. Overall,o difference in rates of survival to discharge was foundetween the AED and the standard defibrillator.

onclusion and recommendationsThe study concluded that replacing standard monopha-

ic defibrillators with biphasic AED’s did not change survivalates following in-hospital VF/VT arrest. Survival rates inatients with AS or PEA arrest were also associated with aorse outcome. The authors themselves state that the study

s limited by introducing several interventions at the sameime; including an extensive educational campaign to sup-ort AED use, and that due to the retrospective nature ofhe study it is difficult to ascribe any effect to one singlentervention.

ommentThis is an interesting study the results of which are

erhaps somewhat surprising. In this particular study, theon-significant results might have been due to an alreadyapid cardiac arrest response team, as demonstrated by aailure to reduce time to first shock. The authors argued that

f AED’s are to be used, they should be primarily deployedo areas where mainly only basic life support facilities arevailable. However, this is not an issue in most acute carerusts as access to advanced life support is readily availablehrough cardiac arrest teams.

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T. Day

. Pudas-Tähkä SM, Axelin A, Aantaa R, Lund V, Sälanterä

. Pain assessment tools for unconscious or sedated inten-ive care patients: a systematic review. Journal of Advancedursing. 2009;65(5):946—55.

bjectivesPain can play a significant part of the patient’s ICU expe-

ience with many unpleasant or uncomfortable procedures.ue to the critical nature of their condition and the usef sedative agents, patients are often unable to communi-ate, which makes pain recognition and assessment difficult.he aim of this systematic review was to describe toolseveloped for pain assessment in unconscious, sedated ICUatients.

ethodsThe review followed the framework for systematic review

eported by the Centre for Reviews and Dissemination2001). A systematic literature search was undertaken from987 to 2007 by both a reviewer and a librarian. Key wordsere selected and there is a comprehensive description of

he search strategy. The search revealed 1586 papers whichere reviewed by two reviewers. Eight papers were included

n the final analysis. The papers were analysed using a qual-ty assessment instrument previously developed to evaluateain assessment tools.

indingsThe results identified five different pain assessment tools

or use in the sedated, unconscious ICU patient. Theseapers included behavioural indicators such as facial expres-ions, movement of the upper limbs and compliance withechanical ventilation. Three of these papers also includedhysiological indicators, such as heart rate, blood pressure,espiratory rate, perspiration, flushing, etc. The psychome-ric properties of the instruments were evaluated by qualityssessment criteria such as validity and reliability testingnd the papers were subsequently allocated scores. Mostapers received low scores, demonstrating that further test-ng is required.

onclusion and recommendationsFrom the pain assessment tools reviewed, it was not pos-

ible to fully establish their usefulness in practice as thesychometric properties varied considerably. The authorscknowledge that as the instruments are relatively new,alidity and reliability testing is still at an early stage andecommend further testing before any specific tool can beecommended in preference to another.

ommentThis is a useful review of the literature relating to pain

ssessment in ICU. The review has highlighted that further

anagement should also be a priority as this perhaps doesot play as important a part in critical care programmes ast should do.