Cleveland Clinic’s main campus implemented a quality improvement initiative to help decrease restraint usage in its 18 adult intensive care units (ICU). “Our rates are higher for restraint usage than we see in the national benchmark because our patient population is so critically ill,” says Susan Ignasiak, BSN, RN, Nursing Quality Program Manager. “We don’t think we will ever reach zero, but we thought there were some opportunities to decrease the use of restraints.” At the heart of that effort is one-on-one communication with ICU nurses.

Talking to nurses at the bedside

Ignasiak and Sandy Maag, BSN, RN, Assistant Director of Nursing Quality, recognize that the safety and dignity of patients are improved when restraint usage is kept to a minimum. However, patients in Cleveland Clinic’s ICUs—which have a combined 235 beds—are at risk for removing life-saving equipment. Many are intubated as well as on machines for dialysis, extracorporeal membrane oxygenation (ECMO) and other treatments. In addition, patients may experience some delirium. Therefore restraint usage is sometimes necessary.

Even so, the nurses thought they could decrease restraint use. In 2013, they instituted one-on-one discussion with bedside nurses during monthly restraint prevalence rounding for the National Database of Nursing Quality Indicators (NDNQI). “We do a lot of yearly education on restraint usage, but we felt that having a one-on-one conversation at the bedside might have more impact,” says Ignasiak. “It’s much more concrete when you’re talking to a nurse that has a patient in restraints rather than discussing a hypothetical situation.”

When members of the Nursing Quality Team see a patient in restraints during their monthly prevalence rounding, they talk to the assigned bedside nurse about the following:

• The behavioral justification for restraint use
• Use of the least restrictive restraint
• Prompt removal when clinically justified

“The goal is obviously to get patients out of restraints as soon as possible and as soon as it’s safe for the patient,” says Maag.

Nursing Quality also provides a report to nurse managers and the clinical director that shows which patients are in restraints, the name of the nurse on duty, the type of restraint, the length of time in the restraint, the reason for the restraint and notes on the discussion with the nurse. Sharing information with nursing leadership helps promote accountability and data-driven decision-making toward a common goal.

Restraint usage decreases

When the quality improvement initiative began in early 2013, 14.53 percent of patients in Cleveland Clinic’s main campus adult ICUs were observed in restraints during monthly restraint prevalence rounding. That figure decreased to an average of 9.84 percent in 2014.

Ignasiak and Maag note that other factors may have contributed to the decreased rate, such as programs focused on early weaning from ventilators and “sedation vacations.” But they are confident that one-on-one discussions with staff nurses around restraint usage are beneficial to patients. The Nursing Quality Team discusses restraint use and minimization in its pediatric ICUs, too.

“We emphasize that every patient has the right to be free of restraints and treated with dignity,” says Ignasiak. “We recognize that sometimes nurses have to use restraints. But the least amount of time and the least restrictive device is critical.”