Proper Wrist Restraint Tying Technique

Unplanned extubation in critical care patients has been greatly scrutinized over the past years because of its contribution in higher risk for mortality, morbidity, and resource utilization (Epstein et al, 2000). Unplanned extubation is defined as a "premature removal of the endotracheal tube by the patient" (Chevron et al, 1998), i.e., self-extubation or "premature removal during nursing care and manipulation of the patient" (Betbese et al, 1998), i.e., accidental extubation.

From the review of literature, the incidence of unplanned extubation averages about 10% (Moons et al, 2004). The percentage presented in the literature varies on the type of units (medical versus surgical) and the duration of intubation.

In the post anesthesia care unit (PACU), patients at risk for unplanned extubation usually have insufficient sedation (Chevron et al, 1998). When the patient's sedation is discontinued during the ventilation weaning process, the wrist restraint is routinely applied . Unplanned extubation usually occur at this time secondary to improper tying of the wrist restraints. Even though reintubation may not be required for many of these patients, they should still be closely monitored. Reintubation can be quite difficult, necessitating highly skilled airway management (Christie et al, 1996).

Project Goal The goal of this project is to establish safe and consistent guidelines for the use of wrist restraints to ensure that patients will not be able to self-extubate in the PACU. All patient care staff in the PACU will undergo individual workshop on restraints "quick release" tying technique. Competency must also be demonstrated during this workshop and at the clinical setting. The training of all staff will be completed within one week. Methodology

The staff will be requested to attend a demonstration on how to make a "quick release" tie in the PACU during the unit‘s downtime. The instructions and demonstration by the project leader will take about five to ten minutes and the staff's return demonstration will take about two minutes. The staff will subsequently be evaluated on their technique in the clinical setting on the same day.

The instructions for this technique are from the commercial wrist restraint (Posey) instruction sheet. First, wrap the attachment strap once around the movable part of the bed frame leaving at least an 8" tail. Fold the loose end in half to create a loop and cross it over the other end. Make sure straps are secured at a juncture of the frame and will not slide in any direction, changing position of device. The second step involves inserting the folded strap where the straps cross over each other, as if tying a shoe or making a tourniquet knot. Pull on the loop to tighten. Next is to fold the loose end in half to create a second loop. Then insert the second loop into the first loop. Lastly, pull on the loop to tighten.

Outcomes The evaluations will be gathered for about three months. At the end of three months, self extubation in the PACU secondary to improper tying technique of wrist restraint should be eliminated. Staff satisfaction and quality of care will be enhanced by the improvement of patient safety.

References Betbese A.J., Perez M., Bak E., Rialp G., Mancebo J. (1998). A prospective study of unplanned endotracheal extubation in intensive care unit patients. Critical Care Medicine, 26, 1180–1186. Chevron V., Menard J.F., Richard J.C., Girault C., Leroy J., Bonmarchand G. (1998). Unplanned extubation: risk factors of development and predictive criteria for reintubation. Critical Care Medicine ,26, 1049–1053.

Christie J.M., Dethlefsen M., Cane R.D. (1996). Unplanned endotracheal extubation in the Intensive Care Unit. Journal of Clinical Anesthesia, 8, 289-293. Epstein S.K., Nevins M.L., Chung J. (2000). Effect of unplanned extubation on outcome of mechanical ventilation. American Journal of Respiratory and Critical Care Medicine, 161, 1912–1916.

Moons P., Sels K., De Becker W., De Geest S., Ferdinande P. (2004) Development of a risk assessment tool for deliberate self-extubation in intensive care patients. Intensive Care Medicine, 30, 1348–1355.

Safety Information for the Use of Posey Torso and Limb Restrictive Products. Access March 9, 2007, from http://www.posey.com/poseystore/files/2510.pdf