Adopting critical care assessment tools as an innovative assessment practice to minimize documentation discrepancy and nonbehavioral physical restraints in critical care
Creators: name: Murillo, Evelyn A.
Publisher: name: No Publisher Supplied
Year: 2021

description: Purpose of Project: The main problem identified at the project site was that the existing guidelines are generalized and are not focused on critical care patients. This lack of focused guidelines may be one reason that the prevalence of restraint use has increased. The purpose of this project was to address the discrepancy in the documentation of assessed risk factors in relation to nonbehavioral physical restraint use, which was expected to reduce the use of nonbehavioral physical restraints in critically ill patients. The goals were to (a) provide education to increase self-awareness among critical care nurses about interventions to prioritize before deciding to physically restrain a patient or to implement when a patient is already restrained so as to discontinue the restraints, (b) improve the current physical-restraint-assessment process by providing critical care nurses with guidelines to decide whether to continue or discontinue physical restraints, and (c) encourage nurses to use critical care assessment tools (e.g., the Richmond Agitation-Sedation Scale (RASS); Confusion Assessment Method for the ICU (CAM-ICU); Critical Care Pain Observation Tool (CPOT), and Glasgow Coma Scale (GCS) as part of their routine assessment for nonbehavioral physical restraints and minimize the use of physical restraints. Methodology: This was a project improvement project using a pre-/posttest to a sample of 168 critical care nurses and a 50 retrospective and 50 prospective chart reviews (total 100 charts). This project was conducted in five critical care units of a 965-bed, level-one trauma, urban, state-of-the-art teaching acute care hospital in Central New Jersey. The study intervention comprised a synthesized, tailored, educational module that focused on promoting the use of the current critical care assessment tools (e.g. RASS, CAM-ICU, CPOT, and GCS) as a new assessment practice and a tailored cut-off score assessment guideline to help the nurses re-evaluate the need of physical restraint use and promote discontinuation. Results: Using a Wilcoxon signed ranks test to evaluate statistical significance between the test scores, knowledge scores increased significantly between the pre-intervention (M = 59.9, SD = 11.01) and post-intervention (M = 72.0, SD = 18.86) periods (z = -7.443, p &lt; .0001). A McNemar test was used to analyze documentation discrepancies (nurses assessment) for each assessment tool independently and across all assessment tools in unison. The results showed statistical significance using the RASS (discrepancy occurrences decreased from pre-intervention 84% to post-intervention 48%, p &lt; 0.001) and GCS (discrepancy occurrences decreased from pre-intervention 80% to post-intervention 60%, p = .041). There were no significant differences across the other individual assessment tools. The proportion of documentation discrepancy using all assessment tools in unison decreased from 36 times (72%) to 18 times (36%) (p &lt; 0.001). There was an improvement in the documentation of justifiable continuation of physical restrain “consistent” use by 36%.A Wilcoxon signed ranks test was used to evaluate statistical significance between the time of physical restraint use pre-/post intervention. There was a statistically significant pre- to post-intervention decrease in the timing of physical restraint when using the assessment tool RASS (Pre: M = 19.14, SD = 3.283 and Post: M = 15.38, SD = 5.617; z = -4.201, p &lt; 0.001); the GCS (Pre: M = 20.36, SD = 3.306 and Post: M = 18.16, SD = 5.471; z = -2.424, p = .015); and the CPOT (Pre: M = 20.98, SD = 3.172 and Post: M = 19.22, SD = 5.112; z = -2.020, p = .043). There were no significant differences using the other tools.Implications for Practice: This DNP project emphasized the importance of addressing and treating preventable and treatable risk factors to reduce documentation discrepancies and minimize the use of physical restraints. This project found a statistical significant increase in adopting the guideline in practice. Therefore, the findings may encourage organizational stakeholders to adopt a tailored, revised policy that (1) provides patients with the most competent nursing care and best practices, (2) decreases patients’ adverse effects, (3) improves patient safety, (4) decreases avoidable monetary loss, (5) complies with federal recommendations about physical restraint interventions and documentation, and (6) decreases physical restraint use compared to national benchmarks and competitors. Adopting this project’s tailored guideline can help reduce liability to providers, nurses, and the institution. It can also improve the quality of care for critically ill, physically restrained patients by complying with the highest quality evidence-based practices and standards for patient care. Addressing the overuse of nonbehavioral physical restraints by incorporating this project into practice is imperative for quality and safety.