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Restraint Reduction, Restraint Elimination, and Best Practice: Role of the Clinical Nurse Specialist in Patient Safety

Kirk, Anna Purcell MSN, RN; McGlinsey, Andrea MSN, RN; Beckett, Alanna BSN, RN; Rudd, Patricia BSN, RN; Arbour, Richard MSN, RN, FAAN

doi: 10.1097/NUR.0000000000000163
Feature Article

Purpose: Baseline restraint prevalence for surgical step-down unit was 5.08%, and for surgical intensive care unit, it was 25.93%, greater than the National Database of Nursing Quality Indicators (NDNQI) mean. Project goal was sustained restraint reduction below the NDNQI mean and maintaining patient safety.

Background/Rationale: Soft wrist restraints are utilized for falls reduction and preventing device removal but are not universally effective and may put patients at risk of injury. Decreasing use of restrictive devices enhances patient safety and decreases risk of injury.

Description: Phase 1 consisted of advanced practice nurse–facilitated restraint rounds on each restrained patient including multidisciplinary assessment and critical thinking with bedside clinicians including reevaluation for treatable causes of agitation and restraint indications. Phase 2 evaluated less restrictive mitts, padded belts, and elbow splint devices. Following a 4-month trial, phase 3 expanded the restraint initiative including critical care requiring education and collaboration among advanced practice nurses, physician team members, and nurse champions.

Evaluation and Outcomes: Phase 1 decreased surgical step-down unit restraint prevalence from 5.08% to 3.57%. Phase 2 decreased restraint prevalence from 3.57% to 1.67%, less than the NDNQI mean. Phase 3 expansion in surgical intensive care units resulted in wrist restraint prevalence from 18.19% to 7.12% within the first year, maintained less than the NDNQI benchmarks while preserving patient safety.

Interpretation/Conclusion: The initiative produced sustained reduction in acute/critical care well below the NDNQI mean without corresponding increase in patient medical device removal.

Implications: By managing causes of agitation, need for restraints is decreased, protecting patients from injury and increasing patient satisfaction. Follow-up research may explore patient experiences with and without restrictive device use.

Author Affiliations: Critical Care Educator and Staff Nurse (Ms Kirk), Postanesthesia Care Unit, Virtua Health, Philadelphia; Staff Nurses, Surgical Intensive Care Unit (Mss McGlinsey and Beckett) and Surgical Step-down Unit (Ms Rudd), Albert Einstein Medical Center, Philadelphia; and Neuroscience Clinical Nurse Specialist, Lancaster General Hospital, and Critical Care Advanced Practice Nurse/Educator/Researcher (Mr Arbour), Philadelphia, Pennsylvania.

The authors report no conflicts of interest.

Correspondence: Richard Arbour, MSN, RN, FAAN, Department of Nursing Administration, Lancaster General Hospital, 555 North Duke St, Lancaster, PA 17602 (

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