Critical Care / Emergency / Trauma

What Works: Improving documentation of restraints in the neuro ICU

When cognition and judgment are impaired in patients in a neuro ICU, they may display poor safety awareness and interfere with treatment protocols. For instance, a patient may pull out a needed endotracheal tube. In other ICU patient populations, sedation can be used in an attempt to maintain safety and reduce anxiety during times of severe agitation and confusion. But because even subtle changes in the neuro patient’s cognitive status can be the first sign of neurological compromise, providers are reluctant to administer sedatives that may mask early warning signs. When less restrictive alternatives to keep the neuro ICU patient safe have failed, restraints are a last resort, making these patients a high-risk population for their use. The ultimate goal is to keep patients safe while protecting their dignity and maximizing their autonomy.

Our neuro ICU set restraint reduction as a unit priority and began examining restraint documentation through electronic health records (EHRs) for clinical trends. Though we met regulatory standards by limiting restraint use to clinically appropriate and adequately justified situations after nonrestrictive and innovative alternatives failed, we identified many instances where our restraint documentation did not provide meaningful data to support our actions. Examples included restraint documentation that was inconsistent, ambiguous, conflicting, and incomplete.

The goal of our project was to improve the accuracy and validity of restraint documentation to provide a more comprehensive clinical picture of the restrained neuro patient and the nursing care provided so that future data collected could guide restraint reduction initiatives and improve the safety and quality of patient care.

How it works

We decided to adopt the following guidelines: Park M, Tang J, Ledford L. Evidence Based Practice Guideline: Challenging the Practice of Physical Restraint Use in Acute Care. The University of Iowa Gerontological Nursing Interventions Research Center (GNIRC), Research Translation and Dissemination Core (RTDC). 2005

Our project unfolded in four phases:

  1. Restraint document education
  2. Creation of a restraint application note
  3. Creation of a shift-to-shift handoff note
  4. Evaluation

Our unit’s clinical nurse manager, clinical nurse specialist, and I provided restraint documentation education to the RNs on the unit. The education included specific patient care evaluations, restraint order policies, and mandatory documentation requirements. Posters, handouts, and one-on-one sessions supplemented the formal programs.

Two new notes helped improve communication. The “restraint application note” provided key insight as to the patient’s behavior, neuro-cognitive status, restraint justification, and response to less restrictive alternatives attempted. Similar detailed information indicating why restraints were continued throughout the nurse’s shift was documented in the “shift-to-shift handoff note” (see below).

Nonviolent and/or non-self-destructive restraint application note

Specific patient behavior:

Life-sustaining or pertinent lines, drains, or airways in place:

Specific less-restrictive alternatives that were attempted before restraint application:

Less restrictive alternatives were ineffective due to:

Nonviolent and/or non-self-destructive restraints placed on patient; physician notified:

Use the Restraint Documentation Flowsheet for Restraint Monitoring.

Retrospective chart audits, nurse surveys, and daily interdisciplinary rounding were used to audit restraint data and evaluate the effectiveness of education efforts. Daily interdisciplinary rounds encouraged real-time improvement in practice, while retrospective data helped determine effectiveness of our changes.

We reviewed organizational policies and attempted to establish consistent definitions of assessment terminology on our unit, especially when using subjective terms rather than objective metrics. We advised nurses to clarify in the comment section of the adult sedation score whether the patient was receiving specific medications that would alter their sedation score at the time of the scoring. For example, charting included the patient’s adult sedation score was a “3 on sedation,” and a “1 when the sedation was held.” We also clarified the length of time that each assessment represented, meaning a specific snap shot in time (such as a heart rate) as opposed to a summary of the patient’s status from the previous documented assessment (such as restless for the majority of the time period but not necessarily in a constant state of restlessness).

Time investment

The primary cost of the project was time. Performing chart audits and conducting education took time from already busy schedules. Time was also a factor in addressing key stakeholders for needed organization and software changes. The outcomes listed below clearly outweighed the costs.


Our project resulted in the following:

  • Increased accuracy and detail of the restrained patient’s “story,” specifically patient behavior and neuro-cognitive status
  • Increased documentation of less restrictive alternatives attempted before restraint application and the patient’s response to those interventions
  • A reduction in overall restraint hours
  • Increased restraint justification according to patient behavior and cognition
  • A shift in use from most-restrictive restraints toward least-restrictive restraints
  • Increased RN awareness of restraint use
  • Increased compliance and consistency of assessment definitions.

Surmounting barriers

Here are some challenges to be aware of if you would like to implement a similar project:

  • You may encounter institutional barriers. We had to correct the inefficient organization of EHR document flowsheet content, revise policies, and establish consistent assessment definitions.
  • Most staff don’t find the documentation improvement to be an interesting topic. We engaged staff in brief, one-on-one education sessions where they could openly discuss their learning needs, questions, and concerns related to restraint use. We also reviewed the risks of restraint use on patient outcomes and how regulatory requirements impact the use and documentation of restraints.
  • Staff perceptions of restraint use can affect how and when they are applied and documented. A percentage of nurses felt that restraint use was absolutely necessary to keep agitated and confused patients safe, while others responded using restraints was a form of punishment and undermined patients’ sense of dignity and autonomy. We addressed these perceptions in our education programs.
  • Perceived stigma of restraint use by organizations could affect institutional policies and ultimately patient care. Again, we addressed these perceptions in our education programs.
  • EHR software capabilities and limitations can make it difficult to retrieve data in a meaningful way. We worked with our IT department to facilitate data retrieval.

It’s also important to understand that no single indicator captures the entire neuro-cognitive-behavioral status, which makes it challenging to define absolute criteria and metrics for restraint use in the neuro ICU population.

Making a change

Effective change takes a catalyst at the unit level and at the organizational level. By working as a team, your unit can have success in enhancing its restraint documentation too.

For more information, refer to: U.S. Department of Health and Human Services. Centers for Medicare and Medicaid Services Page. Accessed April 5, 2013.

Amy Whitbeck is a registered nurse at the University of Wisconsin Madison Hospital and Clinics in Madison, Wisconsin.

Selected references

Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care. 2008;17(5):408-15.

Huang YT. Factors leading to self-extubation of endotracheal tubes in the intensive care unit. Nurs Crit Care. 2009;14:(2):68-74.

Hurlock-Chorostecki C, Kielb C. Knot-So-Fast: a learning plan to minimize patient restraint in critical care. Dynamics. 2006;17:(3):12-8.

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