Use of Restraining Therapies in the ICU

Abstract & Commentary

Synopsis: A consensus group making recommendations on the use of restraining therapies in the ICU emphasizes the inadequacy of the evidence base in this area and calls for studies to generate better data.

Source: Maccioli GA, et al. Crit Care Med. 2003;31: 2665-2676.

A multidisciplinary task force was convened from the memberships of the American Association of Critical Care Nurses, American College of Critical Care Medicine, and Society of Critical Care Medicine, to evaluate the use of restraints in the ICU and to develop practice guidelines for appropriate use for both adult and pediatric patients. Consensus was derived from a review of published literature using Cochrane methodology and expert option. Consensus recommendations were developed, and the document was reviewed and approved by the Society of Critical Care Medicine Council. Nine recommendations were made by the task force with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the ICU (see Table below). The task force anticipates that the implementation of these guidelines will decrease the inappropriate use of restraints. It recommends that these guidelines serve as a benchmark for regulatory agencies in assessing appropriate use of restraining interventions in the ICU.

Comment by Karen Johnson, PhD, RN

These professional organizations should be applauded in their efforts to jointly tackle this practice issue that is laden with medical, ethical, and legal implications. It is also noteworthy that the task force included a broad range of critical care practitioners including representatives from medicine, nursing, respiratory therapy, and pharmacy. As clinicians, we struggle on a daily basis with the issue of whether to use restraints. There is constant tension (within us and between us) in our desire to use them to protect the patient and the patient’s rights.

Practice guidelines should help clinicians make decisions in specific clinical circumstances. Do the 9 recommendations listed above do that? No. Quite frankly, most of these recommendations are already in place in many ICUs to meet external regulatory standards (eg, JCAHO). But don’t blame the messenger (the task force). The real message here is that we don’t know what to do because we don’t have the evidence to back clinical practice. The task force acknowledged (and rightfully so) that the development of these recommendations was difficult due to the lack of carefully performed trials assessing the risks and benefits of restraining therapies in the ICU setting. The task force concluded that despite numerous questions about the benefits, risks, and practices of the use of restraints in critically ill people, there is little prospective information in the literature that can be used for evidence-based guidelines. The overwhelming majority of the studies reviewed were uncontrolled case series or case reports, graded as Cochrane level 4 and 5. The grade for each of these recommendations was a C.

Should ICU clinicians even bother reading the article in its entirety? Absolutely! The task force did address some fundamental questions about the use of restraints in the ICU and summarized some strategies that are clinically relevant and useful. Here are just of few of the questions addressed in the article: What defines restraining therapy? What are indications for the use of restraining therapies in the ICU? How do we determine which patients need restraining therapies? What alternatives to restraining therapies should be considered? How should restraining therapies be initiated? How frequently should patients be assessed with regard to their need for restraining therapies? How frequently should monitoring for complications be performed in patients subjected to restraining therapies? How should restraint use be documented in the medical record? These are questions we have all dealt with in developing our own ICU restraint policies and procedures. There are some excellent strategies identified and presented in table format that will guide clinical decision making on alternatives to restraining therapies, categories of physical restraints, and recommendations for initiation, monitoring, and documentation of physical restraints.

Areas in need of investigation to develop more evidence-based guidelines for the use of restraining therapies in critically ill patients were identified. These include a randomized, controlled trial to assess the: (1) efficacy of various restraining therapies in reducing the incident of inadvertent device removal; (2) optimal methods for safely weaning or discontinuing restraining therapies ("release trial"); and (3) hypothesis that ICU staffing patterns affect the need for and implementation of restraining therapies.

Karen Johnson, PhD, RN, School of Nursing, University of Maryland, is Associate Editor of Critical Care Alert.