August 25, 2008
"We have achieved a culture where everyone understands that restraints are the last resort," said Dora Yap, R.N., Surgical Intensive Care Unit nurse manager. "Our employees are very dedicated and we take seriously the job of serving those who have served our country." Above, Yap (middle) checks on U.S. Army veteran Edward Werner with Susan Mathew, R.N. PHOTO: Bobbi Gruner, MEDVAMC Public Affairs Officer
Written by Faisal Momin, M.B.A., M.H.A., Administrative Fellow
HOUSTON - Since the introduction of the VA’s Patient Restraint Policy in 2001, the Michael E. DeBakey VA Medical Center (MEDVAMC) has made significant progress in minimizing the use of patient restraints by its staff. A restraint can be defined as any device that restricts freedom of movement or normal access to one’s body. This achievement is yet another example of VA’s commitment to provide the best health care possible for our veterans.
MEDVAMC’s success of moving toward a restraint-free environment was born out of a system-wide culture change. Across the facility, nursing units have taken ownership of the change and created champions to ensure the highest level of patient safety with a minimal use of restraints. Nurses and doctors have collaborated to create a fundamental shift in the way restraints are used at MEDVAMC.
“In the past, restraints were commonly used if a patient was intubated,” said Monike Harvey, R.N., Medical Intensive Care Unit (MICU) nurse manager. “With education, we were able to change the way staff looks at restraint use.” The culture change of the entire clinical team has made the difference in reducing restraint usage by more than 75 percent.
Nurses now make an assessment of need before any restraint is applied to a patient. In the MICU, the total number of hours patients are restrained has fallen from approximately 1,300 hours per month in 2006 to an astonishing 11 hours this past June.
During daily briefings with her staff, Harvey discusses restraint alternatives to increase the overall comfort and well-being of each patient and how restraint hours can be kept to a minimum. Before considering restraints, staff examines all available alternatives. If restraints are necessary for a patient’s safety, their use is carefully documented. A restrained patient must be constantly monitored using an established time table.
On the Surgical Intensive Care Unit (SICU), Dora Yap, R.N., SICU nurse manager, credits the decrease in restraint hours to constant education and reinforcement. “I draw on evidence-based practices to educate physicians and nurses that restraints do not equal safety.”
In some cases, restraints are medically required to ensure a patient is not injured. In those cases, the SICU staff is already thinking ahead to a plan of care leading to the removal of any restraints as soon as possible. A poster in the hallway proudly displays the unit’s achievement of 12 consecutive days with no restraint use.
Physicians often order restraints when there is concern a patient may inadvertently remove tubes or lines critical to recovery. After surgery, a patient’s natural reaction may be to tug on tubes or make sudden movements that shift tube placement. To avoid this, many nursing units have started a program to educate patients about what to expect during recovery and the risks of removing any tubes.
“Once the patient knows what to expect, they are more cooperative,” says Harvey. “They are also happier when their movement is not restricted.”
Staff members are trained to use the least restrictive measures first. For example, a ‘Freedom Splint’ restricts the movement necessary to remove tubes while allowing a greater range of safe movement.
“Decreasing the number of restraint hours is a team effort here at the Michael E. DeBakey VA Medical Center,” said Harvey. “Unit clerks and technicians are involved in the process right along with the nurses and physicians.”
MEDVAMC has made tremendous progress in bringing patient restraints to a minimum; however, the nursing units are now committed to bringing the hours down to zero. “We have achieved a culture where everyone understands that restraints are the last resort,” said Yap. “Our employees are very dedicated and we take seriously the job of serving those who have served our country.”
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