Abstract

Aim and Objectives. To critically review the evidence relating to the management

of agitation within the Adult Critical Care Unit (ACCU) environment, identify the risks

and benefits of current management strategies.

Background. Admission to an ACCU can be traumatic and potentially life altering for

the patient. Patient agitation is common in ACCUs and is associated with the

potential for harm. Despite the inherent safety risks, there is a paucity of evidence-

based guidance underpinning the care of agitation in adult patients with critical

illness.

Study Design Integrative review and narrative synthesis

Method A systematic procedure for searching and selecting the literature was

followed and applied to databases including CINAHL, British Nursing Index,

Cochrane Library, Proquest, Ovid including Embase and Medline.Selected

manuscripts were analysed using a structured narrative review approach.

Results 208 papers were identified and following a systematic de-selection process

24 original articles were included in the review. It was identified that agitation in the

setting of ACCU is associated with high-risk events such as unplanned removal of

life-supporting devices. There were consistent links to sepsis, previous high alcohol

intake and certain medications, which may increase the development of agitation.

Prompt assessment and early liberation from mechanical ventilation was a major

contributing factor in the reduction of agitation. Administration of anti-deliriogenic

mediation may reduce the need for physical restraint and improve outcome. There

was repeated uncertainty about the role of physical restraint in developing agitation

and its effective management.

Conclusions

Synthesising the available evidence has unearthed that this is a poorly researched

area, of low quality evidence, in a high-risk care environment There are real

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dilemmas for clinical teams about the effectiveness of applying physical and/or

pharmacological restraint. The review has highlighted that the risk of self-extubation

increases with the presence of agitation, reinforcing the need for constant

observation and vigilance.

Key words: agitation, intensive care, critical care, systematic narrative review,

nursing

INTRODUCTIONPatient agitation is a conditon of psychomotor disturbance, characterized by

increased motor and psychological activity (Chevrolet & Jolliet, 2007). This definition

of agitation supported by Intensive Care Society (ICS) who add that agitation is

accompanied by disorganised thought and is common among ACCU patient

(Snelson et al., 2014). An agitated patient can exhibit behaviour, such as

restlessness or thrashing, placing themselves and others at risk (Tate et al., 2012b).

The occurrence of agitation in the ACCU is frequently cited as ‘common’ across the

literature, yet research related to agitation is lacking. High risk behaviour stemming

from agitation is also reported in a highly variable way (Tate et al., 2012b). The

presence of patient agitation in adult critical care is associated with the potential for

harm including unplanned removal from organ supportive treatments, higher rates of

nosocomial infection, and increased length of both critical care and hospital stay

(Burk et al., 2014, Whitehouse et al, 2014; Hofsø and Coyer 2007; Birkett et al, 2005;

Micek et al, 2005). To facilitate intrusive and potentially distressing treatment

interventions in critical care, analgesic and sedative drugs are frequently

administered. When withdrawing patient sedation, the process of waking can expose

feelings of anxiety and acute agitation (Chevrolet & Jolliet, 2007).

It is important that the terms agitation and delirium are not confused, agitation is not

delirium and agitation without delirium is common in the ACCU (Whitehouse et al.,

2014). In healthcare literature and practice, the terms agitation, anxiety and delirium

are often used interchangeably; however compared with the definitions for agitation

above, delirium is defined as an acute, reversible organic mental syndrome with

disorders of attention and cognitive function, where psychomotor activity can be

increased or decreased, and the sleep-wake cycle is disordered (Borthwick et al.,

2014, pg 4). There are three sub types of delirium hyperactive, hypoactive and mixed

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delirium (Van Rompaey et al, 2008) patient with mixed or hyperactive delirium potentially

displaying agitated behaviour. Whereas, the definition of anxiety is a feeling of dread or

fear and or ‘lack of control as a normal or protective response to a perceived threat to

homeostasis’ (Tate, et al, 2012, pg1).

Despite the safety risk, there is a paucity of evidence-based guidance in relation to

the risks and management of patient agitation in Adult Critical Care Units (ACCU). A

number of non-pharmacological and pharmacological strategies are referred to in

guidelines (Barr and Pandharipande., 2013) yet these fail to address how to

appropriately and safely manage a patient. Therefore, this review will focus on the

management strategies required to effectively manage risk behaviors exhibited by a

patient experiencing agitation.

AIMTo provide a critical review of the literature relating to the management of agitation

within ACCUs, and seeks to identify the risks and benefits of current management

strategies.

METHODS Search strategyA systematic search was conducted for original research manuscripts about agitation

and its management in an ACCU. The search terms used and limitations set are

summarised in Table 1. The literature search was performed in May 2017 via the

following databases: CINAHL, British Nursing Index, Cochrane Library, Proquest,

Ovid including Embase and Medline. Kress et al (2000) trial showed ventilator-

weaning time, ACCU and hospital length of stay were significantly lower in the

groups with sedation holds. These findings significantly impacted on change to

sedation practice. In light of this search publication date was limited, from 2005 to

May 2017.

[Please insert Table 1: Summary of key search terms here]

Study selection

For inclusion in this review, studies were required to have a focus on agitation

management and/or hyper delirious states, and/or focus on safety and/or risk and/or

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adverse events such as self-extubation and/or device removal in the adult critical

care population. Due to the unique nature of care delivery in ACCU studies were

excluded if they focused on another area of care such as accident and emergency,

mental health or dementia care. Studies focusing on delirium

assessment/assessment tools or the longer-term impact of delirium were reviewed

for potentially missed research sources and then excluded as not part of the inclusion

criteria. Previously published literature reviews were reviewed for potentially missed

research sources and then excluded, as non-primary sources of data. The reference

lists of the included papers were reviewed for potentially missed research sources.

Conference submissions and grey literature was not reviewed There is a lack of

research focusing on agitation in ACCU clinically related papers were included

Search Results

208 papers were identified, following the removal of duplicates (26), 182 papers were

screened based on title and abstract. This identified initially 37 papers that required

full text review resulting in 24 papers being included (Figure 1). One author (SF)

conducted the initial screening process and discussed queries with JY, PD. All

authors reviewed the included articles to ensure that they met the inclusion criteria.

(Table 2)

[Please insert Figure 1: Flow diagram illustrating the selection process here]

[Please insert Table 2 : Table of the Included Studies]

Data analysis and synthesis

The Critical Appraisal Skills Programme (CASP) tools were employed to standardise

the review of the selected papers (Burls, 2009). The included articles were subjected

to thematic analysis with the aim of identifying and bringing together the key

recurrent emerging subjects (Mays et al., 2005 b). The first author used thematic

analysis with the aim of identifying and bringing together the key recurrent emerging

statements. These were presented to the second author to confirm the statements were

grounded in the literature. The third author would facilitate any discussion around

discrepancies. The outcome of the synthesis is not an aggregation of data but an

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interpretation of the findings within the studies included (Dixon-Wood et al., 2006) A

synthesis matrix was constructed to support the development of primary themes

which were cross referenced between papers (Sally, 2013). Table 3 provides an

example of a section of the matrix.

[Please insert Table 3: A section of the synthesis matrix ]

RESULTS Globally there are different clinical policies, practices, nurse patient ratios as well as

severity of case mix within ACCU. These factors may impact on the transferability of

findings. Box one contains the country of origin for the papers included.

Please add Box One: Study Country of Origin

The diverse range of studies included prevents meta-analysis of the findings

therefore the findings from each of the studies were themed and constantly

compared, which resulted in the iterative development of three main synthetic

constructs; antecedents to agitation development, presence of agitation and harm,

and agitation management strategies

Antecedents to agitation development

Numerous variables have been linked to the likelihood of an individual developing

agitation during their ACCU admission. It was not possible to combine data to

determine overall risk due to different methods of data collection across the studies.

The presence of sepsis, previous alcohol use, use of sedatives, fever, electrolyte

disturbances and use of psychoactive drugs were found to be independent predictors

in the development of agitation (Jaber et al. 2005, Burk et al. 2014) (Burk et al

reported their finding over two publications). Additional factors associated with

agitation development are moderate to severe pain, presence of delirium and

smoking (Almeida, Azevedo, Nose, Freitas, & Machado, 2016). A retrospective

review of medical record highlighted that the use of physical restraint on admission

appears to increase the chance of developing agitation more than three times but it

could not be determined if agitation precedes or follows restraint use. Poor

oxygenation, acidemia, duration of mechanical ventilation and the presence of a

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genitourinary catheter also increased the risk of agitation development. The

recommendations that followed included prompt removal of catheters, limited use of

restraint, use of lower level of sedation and prompt extubation (Burk et al., 2014).

An ethnographic study captured patients, families and clinician views on anxiety and

agitation in the ACCU (Tate et al., 2012). Participants reported that the triggers for

anxiety and agitation were activities such as disruption of ventilator synchrony during

personal care, breathlessness, choking, being left alone or encountering an

‘uncaring’ staff member. Conversely, clincial staff reported the main trigger for

agitation was family members visiting. The perception from the staff was that families

could, “overreact to the change in the patient’s condition or overstimulate the patient“

(Tate et al., 2012 pg 8).

Presence of agitation and harm

Two studies conducted ten years apart explored the presence of agitation and

produced very similar findings. In both studies, the percentage of patients

experiencing agitation was just over half (52% of 182 patients Jaber et al., 2005 and

59% of 200 patients Burk et al., 2014). In one study, 50 adverse events were

witnessed and 92% of these were reported alongside the presence of agitation (Burk

et al., 2014). Patients identified as agitated were at a significantly higher risk of self-

extubation than non-agitated patients (16.5% agitated sample vs. 1.7% non-agitated

sample, p=0.003) and there was an increased risk of patient-initiated central line

removal (15.9% agitated sample vs. 1.2% non-agitated sample, p=0.001) (Jaber et

al., 2005). Across both studies, the presence of agitation did not increase hospital

mortality but it was associated with multiple adverse events. In a prevalence study

relating to patient-initiated removal of therapeutic devices, 58% of patients had the

presence of agitation or anxiety documented at the time of device removal (Mion et

al., 2007). Harm or injury was documented in 250 episodes of device removal (23%).

Major harm was noted in six patients with self-extubation and five patients with

central catheter removal, all requiring re-insertion. As a direct consequence of device

removal patients received:

new or additional physical restraint (n=320),

new or additional sedation (n=38)

radiography (n=140)

increased monitoring (n=84)

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surgical procedure (n=38)

additional dressings (n=69)

required consultation with specialty services (n=42).

The presence of agitation results in a longer duration of mechanical ventilation (MV)

(Jaber et al., 2005; Almeida et al., 2016). Longer MV brings inherent risk yet it’s

unclear if agitation in itself prolongs ventilation. Almeida et al., (2016) hypothesized

agitation may preclude attempts to wean mechanical ventilation.

Agitation presence and a positive outcome

Unplanned or self-extubation is frequently cited as an adverse clinical incident

associated with agitation; however there are findings, which are contradictory to this

view. The incidence, determinants and outcomes of unplanned extubation were

explored by De Groot et al., (2011). It was reported that patients with unplanned

endotracheal tube (ETT) removal had significant lower hospital mortality than the

control (19% vs. 32% p=0.028). Patients not requiring re-intubation had a

significantly shorter ACCU and hospital stay, and decreased hospital mortality. The

study reported that 47% of those with unplanned ETT removal required re-intubation

and it is this that appeared to increase the risk of negative outcomes (De Groot et

al., 2011). Similar finding were reported by Almeida et al., (2016) who discovered that

the presence of agitation prolonged ventilation but the cohort of agitated patients had

a lower hospital mortality (not agitated 28.4 % agitated 11.1 %, p = 0.043). A

prospective observational study, which focused on delirium and its consequences,

found that the hyperactive delirious patient group, demonstrating agitated behaviour,

had fewer short-term consequences and shorter duration of delirium compared to the

other two subtypes of hypoactive and mixed presentation (Van den Boogaard et al.,

2011). Conversely, the clinical staff expressed the most difficulty in relation to care

management of patient with hyperactive delirium as these patients are, ‘agitated and

consequently pull out their lines or endotracheal tube’ (Van den Boogaard et al.,

2011, pg 178)

Agitation management strategies

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The importance of ‘good clinical practice’, was frequently noted across the studies

and included orientation of the patient to time and place, offering reassurance,

managing pain, promoting sleep and ensuring a comfortable position (Da Silva &

Fonseca, 2012; Huang, 2009; Turgay, Sari, & Genc, 2009; van den Boogaard,

Schoonhoven, van der Hoeven, van Achterberg, & Pickkers, 2011). Despite this, no

studies were identified that evaluated the effectiveness of such strategies.

Kandeel and Attia (2013) reported that the behaviours most likely to result in the

application of physical restraint were; the patient attempting to remove medical

equipment (79.1%), resisting treatment (64.7%) and attempting to get out of bed

(46.4%). The rationale for application was to ensure patient care was delivered. The

term ‘agitation’ was not used within this study and alternative strategies to physical

restraint were identified as; the use of sedatives (75%), talking to the patient (31.9%),

comfort measures (9.5%) and allowing family to visits more frequently (2.6%). A

prospective observational study found patients were physically restrained on average

for 4.1 days with 83% (n=311) restrained at least once during their ACCU admission

(Luk et al., 2014). The baseline characteristics of the two groups (those with physical

restraint those without) were the same with differing treatment characteristics.. The

patients who had had physical restraint applied received higher benzodiazepine and

opioid doses experienced more adverse events and experienced higher agitation

scores and were over sedated on more days. It was hypothesised that the presence

of agitation was a predictor of physical restraint use and that agitated patients

received more mediations in combination with restraint for symptom management.

Effectiveness of Physical Restraint

One study explored the influence of physical restraint use on unplanned extubation

and found that of the 109 patients who did not have physical restraint applied only 18

had an unplanned extubation (Chang et al., 2008). Whereas the 191 who were

physically restrained 82 patients had an unplanned extubation. The views of the

clinical staff capture in a large-scale multi-disciplinary team (MDT) survey (n=1976)

found the absence of physical restraints was deemed to be the biggest risk factor for

self-extubation by 72% of those who responded (Tanios et al., 2010).

A high percentage of physical restraint use at the point of self-extubation was

reported in two studies 87% Curry et al., (2008) and 70.5% Huang et al. (2009). The

studies denoted a clear differential between a patient self-extubating and an

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accidental extubation by a staff member. Huang et al. (2009) postulated that physical

restraints had heightened patient anxiety due to limitation of freedom; however this

view was not substantiated by evidence. The inclusion of the severity of illness was

omitted in both studies, which may have impacted on the transferability of the

findings to other ACCU cohorts. Huang et al. (2009) gave limited information on

sedation and analgesic practices and nurse/patient ratio. However, following a 3 year

retrospective case control study Chang et al. (2011a) reported that unplanned

exacerbation was not associated with physical restraint. Fewer patients in the

unplanned extubation cohort were physically restrained at the time of extubation

(n=17, 80.9%) than the control of planned extubation (n=21 (100%).

Opinions on Physical Restraint Use

In the Langley et al. (2011) study, participants from both the nursing and medical

profession reported that the use of physical restraint was a ‘balancing act’ between

risk and benefit (Langley et al., 2011pg 70). There were some conflicting views as

some respondents perceived the use of physical restraint benefitted the nurse more

than the patient. Communication between team members appeared to be a major

source of tension both in relation to whom in the team decided to use restraint and

how this was documented. One nurse noted the reluctance of medical colleagues to

write a prescription for physical restraint due to the fear of litigation. In contrast, the

medical staff involved in the study expressed the view that a prescription was not

necessary as there was a policy in place to ‘cover them’ (Langley et al., 2011 page

71).

The cross-sectional survey studies conducted by Turgay et al. (2009) and Freeman

et al. (2015) sought the opinions of nurses in relation to the use of physical restraint.

In the Turgay et al. (2009) study respondents do not use the term agitation they

noted that the reason for application was to maintain medical devices. Other reasons

for application were restless behaviour (86.3%), impairment of mental status (79.5%),

performance of medical treatment (53.7%), convenience (23.2%) and suggestion by

family or other staff. The respondents did note a potential risk of physical restraint

application being skin breakdown (36.8%). Respondent in the Freeman et al. (2015)

study deemed physical restraint as either ‘essential’ or ‘necessary’ to ensure patient

safety. 89.0% of respondents (n=65) disagreed with the statement,’ I do not believe

in the use of physical restraint in ACCU’ (Freeman, et al 2015, pg 6). Both studies

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generated some interesting data to add to the debate about physical restraint

application.

Use of physical restraint in different countries

A large European study including 34 ACCU from nine different countries explored

the prevalence of physical restraint (Benbenbishty, Adam, & Endacott, 2010). The

use of physical restraint was greater in large ACCU, with lower nurse to patient ratio

and without a policy to guide decision-making; however no detail regarding local

policy or practice in relation to sedation was provided.

An observation study exploring the potential cultural differences impacting on the use

of physical restraint was conducted between America and Norway (Martin and

Mathisen,. 2005). There were significant differences in physical restraint use, patient

activity and Sedation Agitation Score (SAS). The American cohort was more likely to

be physically restrained, more active and receive lower level of sedation and/or

analgesic than the Norwegian cohort. The Norwegian unit had higher nurse to patient

ratio with a higher nurses workload score than the American unit. The study’s design

included a robust mechanism for data collection across the two countries and all

tools used for data collection were either previously validated or piloted prior to the

study. The findings were inconclusive as to whether the more agitated patients were

placed in physical restraint or patients in physical restraint become more agitated.

Medication

The evidence to support the management of agitation using pharmacological agents

was minimal across the selected studies with only two trials targeting the

management of agitated delirium using dexmedetomidine. One study compares its

uses to haloperidol, commonly prescribed for agitated delirium (Reade et al., 2009).

The second study compares the uses of dexmedetomidine to placebo (Reade et al.,

2016). Both studies found the cohort receiving dexmedetomidine had beneficial

clinical outcomes such as shorter ACCU stay and earlier removal of physical restraint

(Reade et al., 2009) as well as increased number of ventilator free days, receiving

lower levels of additional sedation or opioid, and deemed ready to extubate sooner

(Reade et al., 2016). Both studies acknowledge other factors for agitation and that

the effect of dexmedetomidine for hypo-delirious patients was not explored.

The Michaud et al. (2014) study focus was not agitation directly but the findings have

potential implications for the management of agitated patients. The study aim was to

10

assess if prompt administration of any clinically accepted delirium treatment

medication reduced the use of physical restraint. Those patients who received the

medication from the clinically agreed list within 24 hours of their first positive delirium

screen spent fewer days in physical restraint, had reduced mechanical ventilation

time, shorter length of stay in both ACCU and hospital and fewer hospital deaths than

patients where treatment was delayed.

DISCUSSION To our knowledge, this is the first narrative review of the evidence base on the

management of agitation in ACCU. The review has signaled that the triggers for

agitation are attributed to both the critical illness and medical treatment required in

ACCU. There is evidence of repeated uncertainty as to the role of physical restraint

in agitation development. Extrapolating from the evidence if the presence of physical

restraint exacerbates agitation is unattainable. Additionally, determining if the

presence of agitation results in actual patient harm is inconclusive. Furthermore, the

impact of decision-making and professional dynamics between nursing and medical

staff regarding the use of physical restraint warrant further attention.

Evidence for the predictability of agitation is limited. There are some consistent links

to sepsis, previous high alcohol intake and certain medication, which may increase

the chance of agitation development (Burk, et al 2014; Burk, et al., 2014; Jaber et al.,

2005). The presence of agitation in an ACCU patient is associated with high-risk

events such as unplanned self-extubation and device removal, posing a risk to

patient safety. There are contradictory findings as well as poor quality evidence and

different research methods across included studies.

Across the studies there were inferences with regards other possible ways in which

to manage the agitated patient. Terms such as standard practice or usual care were

used to describe intervention such as re-orientation, promotion of sleep or distracting

techniques (Da Silva & Fonseca, 2012; Huang, 2009; Turgay, Sari, & Genc, 2009;

van den Boogaard, Schoonhoven, van der Hoeven, van Achterberg, & Pickkers,

2011). None of these approaches were fully explored. The American Society of

Critical Care Medicine in 2013 provided a comprehensive clinical practice guidance:

Pain, Agitation and Delirium (P.A.D.) in the ACCU (Barr et al., 2013). The guidance

highlights the prompt identification of potential underlying causes of agitation as

crucial. This guidance continued with ensuring patient comfort, frequent re-

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orientation, and maintenance of normal sleep pattern; interventions that in some

countries may be deemed standard practice. The only reference to physical restraint

use in the PAD is under guidance to prevent iatrogenic or environmental factors

linked to delirium development, ‘…prolonged physical restraint or immobilisation may

also contribute to delirium in the ICU’ (Barr et al., 2013 pg 283)

The results from this review suggest that early liberation from mechanical ventilation

is a major contributing factor in the reduction of agitation and self-extubation (Da

Silva and Fonseca., 2012). Patients need prompt assessment and extubation

(Huang.,2009). The use of protocols may expedite the weaning of mechanical

ventialtion (De Groot et al., 2011, Curry et al., 2008). Prompt administration of anti

deliriogenic mediation may reduce the need for physical restraint and improve

outcome (Michaud, Thomas, & McAllen, 2014). The introduction of dexmedetomidine

to manage agitated delirium is another strategy to be employed (Reade et al., 2009,

2016).

What remains unclear is the causational effect of physical restraint and the

development of agitation. A number of studies noted the presence of physical

restraint whilst the patient experienced episodes of agitated behaviour and medical

device removal with no conclusive evidence of correlation between the two (Chang et

al., 2011; Chang et al., 2008; Curry et al., 2008; Kandeel and Attia, 2013; Langley, et

al., 2011; Luk et al., 2014; Mion et al., 2007; Tanios et al., 2010). Physical restraint

was deemed appropriate only when all other theraputic stratergies had been

inaffective (Turgay et al., 2009). There was a strong suggestion that physical restraint

application should be directed by practice guidelines and policy at both a local and

national level (Kandeel and Attia, 2013; De Jonghe et al., 2013; Langley et al., 2011;

Turgay et al. 2009; Chang et al. 2008). In addition to these proposals clinical

language requires more clarity to enable staff to discriminated between agitation,

anxiety and delirium.

The cultural context of the current body of research cannot be ignored. The use of

physical restraint may be more acceptable within the culture of some countries than

others. Yet its use, or not, needs to be based on the best available evidence. If the

application of physical restraint as a strategy for agitation management is helping or

hindering is inextricable from the current evidence.

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Limitations of literature included A number of the studies generated data from single sites (Jaber et al., 2005; Huang,

2009; Chang et al., 2011; van den Boogaard et al., 2011; Michaud et al., 2004; Burk

et al., 2014) limiting generalisability. Two studies undertook secondary analysis of a

previously generated data set (Tate et al., 2012; Luk et al., 2014); although the

authors sought to cross check data with the participants from the original study.

Four studies undertook a retrospective review of patients medical records (Burk et

al., 2014; Michaud et al., 2014; Chang et al., 2008; Curry et al., 2008), which may

impact on data quality. Several papers relied on staff self-report (De Jonghe et al.,

2013; Chang et al., 2008; Mion et al., 2007; Martin and Mathisen., 2005) which may

have resulted in underreporting of critical incidents such as unplanned extubation

(Chang et al. 2008) and use of physical restraint (Martin and Mathisen, 2005).

Studies focused on general surgical patients (Huang, 2009; Curry et al., 2008) and

cardiac surgical patients (van den Boogaard, Schoonhoven, van der Hoeven, van

Achterberg, & Pickkers, 2012) who normally have a shorter stay in ACCU compared

to unplanned admissions. ACCU patients are heterogeneous group yet patients

following a head injury or cardiopulmonary resuscitation, or with previous mental

health issues, pregnancy, and those undergoing treatment withdrawal, were

excluded from all studies potentially limiting research generalisability.

Strengths and limitations of the review

This review has drawn from a diverse range of research in an attempt to identify the

current care management around agitation in ACCU. It has highlighted the areas that

require further exploration. The quality evaluation of the selected papers was

undertaken using established methods and recognised appraisal tools.

The presence of agitation is multifactorial in nature. The presence of agitation is not

purely a result of delirium. There are multiple factors that can predicate the

manifestation of agitation such as fear, pain, discomfort or anxiety (Jaber, 2005; Burk

et al., (1) 2014; Burk et al., (2) 2014). Across the literature the term is inextricably

linked with the presence of delirium. As there is a lack of research focusing on

agitation in ACCU clinically related papers were included which may compromise the

reliability of the reviews findings. One researcher, potentially reducing the objectivity

of the review, undertook the search and critical analysis. There was limited

conference searching and the review is limited to English language only publications.

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CONCLUSION

This review has highlighted that the management of agitation in ACCU is

multifactorial and hampered by a limited evidence base. It has unearthed challenges

around clinical language when discussing agitation, anxiety and delirium. This needs

clarity and consistency to enable the advancement of care and research in this area.

The heterogeneity of the ACCU population creates an additional layer of complexity

when trying to manage the individual patient needs. Some actions taken may

exacerbate agitation rather than manage it. The use of physical restraint may have a

place in ACCU yet its effectiveness is still unknown. The physiological impact of

physical restraint use and the long-term effect on those who survive ACCU need

further exploration. The review has highlighted that the risk of self-extubation

increases with the presence of agitation, reinforcing the need for constant

observation and vigilance on the part of the healthcare team. Practitioners need to

take into account the contextual factors of their own ACCU and the influence these

may have on the development and management of agitation.

Relevance to clinical practice

The importance of ensuring patients are re-orientated regularly and signs of agitation

assessed and acted upon promptly are reiterated. Early identification of specific

patient profiles such as those with previous high alcohol or psychoactive drugs habit

may enable the MDT to be more be proactive in agitation management rather that

reactive. The prompt liberation from the restriction from ventilation and

encouragement of family or loved one involvement of care need to be considered

Further research is required to fully understand what ‘standard care’ is, the impact of

sedation policy and protocols and the context of the care delivery.

A notable gap within the research is the opinion of patient and families, their

experiences of agitation within ACCU and the management techniques employed.

14

Reference List

Almeida, T. M., Azevedo, L. C., Nose, P. M., Freitas, F. G., & Machado, F. R. (2016).

Risk factors for agitation in critically ill patients. Revista Brasileira de Terapia

Intensiva. http://doi.org/S0103-507X2016000400413 [pii]

Barr, J., Fraser, G. L., Puntillo, K., Wesley Ely, E., Gélinas, C., Dasta, J. F., …

Jaeschke, R. (2013). Critical Care Medicine Clinical Practice Guidelines for the

Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive

Care Unit. Crit Care Med, 263–306.

http://doi.org/10.1097/CCM.0b013e3182783b72

Benbenbishty, J., Adam, S., & Endacott, R. (2010). Physical restraint use in intensive

care units across Europe: The PRICE study. Intensive and Critical Care

Nursing, 26(5), 241–245. http://doi.org/10.1016/j.iccn.2010.08.003

Borthwick, M., Bourne, R., Craig, M., Egan, A., & Oxley, J. (2014). Detection,

Prevention and Treatment of Delirium in Critciall Ill Patients. Intensive Care

Society.

Burk, B. R. S., Grap, M. J., Munro, C. L., Schubert, C. M., & Sessler, C. N. (2014).

Predictors of Agitation in Critically Ill Adults. American Journal of Critical Care,

23(5), 414–423.

Burk, B. R. S., Grap, M. J., Munro, C. L., Schubert, C. M., Sessler, C. N., & Nset, O.

(2014). Agitation, Onset, Frequency, adn associated Temporal Factors in

Critically Ill Adults. American Journal of Critical Care, 23(4), 296–304.

Burls, A. (2009). What is critical appraisal ? Evidence-Based Medicina, 2(February),

1–8.

Chang, L.-Y., Wang, K.-W. K., & Chao, Y.-F. (2008). Influence of physical restraint on

unplanned extubation of adult intensive care patients: a case-control study.

American Journal of Critical Care : An Official Publication, American Association

of Critical-Care Nurses, 17, 408–415; quiz 416. http://doi.org/17/5/408 [pii]

15

Chang, L. C., Liu, P. F., Huang, Y. L., Yang, S. S., & Chang, W. Y. (2011a). Risk

factors associated with unplanned endotracheal self-extubation of hospitalized

intubated patients: A 3-year retrospective case-control study. Applied Nursing

Research, 24(3), 188–192. http://doi.org/10.1016/j.apnr.2009.09.002

Chang, L. C., Liu, P. F., Huang, Y. L., Yang, S. S., & Chang, W. Y. (2011b). Risk

factors associated with unplanned endotracheal self-extubation of hospitalized

intubated patients: A 3-year retrospective case-control study. Applied Nursing

Research. http://doi.org/10.1016/j.apnr.2009.09.002

Chevrolet, J.-C., & Jolliet, P. (2007). Clinical review: agitation and delirium in the

critically ill--significance and management. Critical Care (London, England),

11(3), 214. http://doi.org/10.1186/cc5787

Curry, B. K., Cobb, S., Kutash, M., Diggs, C., Curry, K., Cobb, S., … Diggs, C.

(2008). Characteristics associated with unplanned extubations in a surgical

intensive care unit. American Journal of Critical Care : An Official Publication,

American Association of Critical-Care Nurses, 17(1), 45–51; quiz 52.

http://doi.org/17/1/45 [pii]

Da Silva, P. S. L., & Fonseca, M. C. M. (2012). Unplanned endotracheal extubations

in the intensive care unit: Systematic review, critical appraisal, and evidence-

based recommendations. Anesthesia and Analgesia, 114(5), 1003–1014.

http://doi.org/10.1213/ANE.0b013e31824b0296

de Groot, R. I., Dekkers, O. M., Herold, I. H., de Jonge, E., & Arbous, M. S. (2011).

Risk factors and outcomes after unplanned extubations on the ICU: a case-

control study. Critical Care (London, England), 15(1), R19.

http://doi.org/10.1186/cc9964

De Jonghe, B., Constantin, J. M., Chanques, G., Capdevila, X., Lefrant, J. Y., Outin,

H., & Mantz, J. (2013). Physical restraint in mechanically ventilated ICU

patients: A survey of French practice. Intensive Care Medicine, 39, 31–37.

16

http://doi.org/10.1007/s00134-012-2715-9

Dixon-Wood, M., Cavers, D., Agarwal, S., Annandale, E., Arthur, A., Harvey, J., …

Sutton, A. J. (2006). Conducting a Critical Interpsretive Synethesis of the

Literature on access to Healthcare by Vulnerable Groups. BMC Medical

Research Methodology, 6(35). http://doi.org/10.1186/1471-2288-6-35

Flemming, K. (2009). Synthesis of Quantative and Qualitative Research: An Example

uning Critical Interpretive Synthesis. Journal of Advanced Nursing, 66(1), 201–

217. http://doi.org/10.1111/j.1365-2648.2009.05173.x

Freeman, S., Hallett, C., & Mchugh, Gretl. (2015). Physical restraint: experiences,

attitudes and opinions of adult intensive care unit nurses.

http://doi.org/10.1111/nicc.12197

Huang, Y.-T. (2009). Factors leading to self-extubation of endotracheal tubes in the

intensive care unit. Nursing in Critical Care, 14(2). http://doi.org/10.1111/j.1478-

5153.2008.00320.x

Jaber, S., Chanques, G., Altairac, C., Sebbane, M., Vergne, C., Perrigault, P. F., &

Eledjam, J. J. (2005). A prospective study of agitation in a medical-surgical ICU:

Incidence, risk factors, and outcomes. Chest, 128, 2749–2757.

http://doi.org/10.1378/chest.128.4.2749

Kandeel, N. A., & Attia, A. K. (2013). Physical restraints practice in adult intensive

care units in Egypt. Nursing and Health Sciences, 15, 79–85.

http://doi.org/10.1111/nhs.12000

Kress et al (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England Journal of Medicine 342 (20) 1471- 1477

Langley, G., Schmollgruber, S., & Egan, A. (2011). Restraints in intensive care units--

a mixed method study. Intensive & Critical Care Nursing : The Official Journal of

the British Association of Critical Care Nurses, 27(2), 67–75.

17

http://doi.org/10.1016/j.iccn.2010.12.001

Luk, E., Sneyers, B., Rose, L., Perreault, M. M., Williamson, D. R., Mehta, S., …

Burry, L. (2014). Predictors of physical restraint use in Canadian intensive care

units. Critical Care, 18(R46), R46. http://doi.org/10.1186/cc13789

Martin, B., & Mathisen, L. (2005). Use of physical restraints in adult critical care: A

bicultural study. American Journal of Critical Care, 14, 133–142.

http://doi.org/14/2/133 [pii]

Michaud, C. J., Thomas, W. L., & McAllen, K. J. (2014). Early Pharmacological

Treatment of Delirium May Reduce Physical Restraint Use: A Retrospective

Study. Annals of Pharmacotherapy, 48, 328–334.

http://doi.org/10.1177/1060028013513559

Mion, L. C., Minnick, A. F., Leipzig, R. M., Catrambone, C. D., & Johnson, M. E.

(2007). Patient-initiated device removal in intensive care units: a national

prevalence study. Critical Care Medicine, 35(12), 2714–2720. Retrieved from

http://search.ebscohost.com/login.aspx?

direct=true&AuthType=ip,shib&db=jlh&AN=2009749004&site=ehost-live

Reade, M. C., Eastwood, G. M., Bellomo, R., Bailey, M., Bersten, A., Cheung, B., …

Australian and New Zealand Intensive Care Society Clinical Trials Group.

(2016). Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free

Time in Patients With Agitated Delirium: A Randomized Clinical Trial. Jama,

315(14), 1460–8. http://doi.org/10.1001/jama.2016.2707

Reade, M. C., O’Sullivan, K., Bates, S., Goldsmith, D., Ainslie, W. R. S. T. J., &

Bellomo, R. (2009). Dexmedetomidine vs. haloperidol in delirious, agitated,

intubated patients: a randomised open-label trial. Critical Care (London,

England), 13(3), R75. http://doi.org/10.1186/cc7890

Sally, A. (2013). A Syntesis Matrix as a Tool for Analyzing and Synthesizing Prior

Research.

18

Tanios, M. a, Epstein, S. K., Livelo, J., & Teres, D. (2010). Can we identify patients at

high risk for unplanned extubation? A large-scale multidisciplinary survey.

Respiratory Care, 55(5), 561–568.

Tate, J. A., Devito Dabbs, A., Hoffman, L. A., Milbrandt, E., & Happ, M. B. (2012).

Anxiety and Agitation in Mechanically Ventilated Patients. Qualitative Health

Research. http://doi.org/10.1177/1049732311421616

Turgay, A. S., Sari, D., & Genc, R. E. (2009). Physical restraint use in Turkish

intensive care units. Clinical Nurse Specialist CNS, 23(2), 68–72.

http://doi.org/10.1097/NUR.0b013e318199125c

van den Boogaard, M., Schoonhoven, L., van der Hoeven, J. G., van Achterberg, T.,

& Pickkers, P. (2011). Incidence and short-term consequences of delirium in

critically ill patients: A prospective observational cohort study. International

Journal of Nursing Studies, 49(7), 775–783.

http://doi.org/10.1016/j.ijnurstu.2011.11.016

Whitehouse, T., Snelson, C., Grounds, M., Willson, J., Tulloch, L., Linhartova, L., …

England, K. (2014). Intensive Care Society Review of Best Practice for

Analgesia and Sedation in the Critical Care.

19

Search terms usedLimitations setPopulation Intervention Context Outcomes Study design

Adult AND Intensive care unit OR Critical Care OR Intensive therapy unit in anywhere

Sedation OR physical restraint OR Care, adj manag* OR Management adj strat* in anywhere

Delriu*, agitat* in anywhere

Safety, Risk adj Manag* OR adverse event*, OR self-extubation, OR devise removal in anywhere

Original study, RCT, quantitative, case controlled study

English Language text or available translation

Peer reviewed journal paper

Adult patient population

Publication date from 2005

Table One: Table of search terms used

20

Table Two: Table of included studies

Author, date andtitle

Aim Design, methods,sample,inclusion/exclusion criteria

Main Findings Strengths andLimitations

Recommendations

(Almeida et al., 2016)Risk Factors forAgitation inCritically Ill Patients

To evaluate theincidence ofagitation in thefirst 7 days afterICU admission,its risk factorsand itsassociation withclinical outcome

Prospective cohortstudy conducted in a single general 18 bedded ICU.Inclusion:Patients >18 yearsPredicated stay of >48 hoursExclusion:Pregnant womenPatient with previouspsychiatric conditionsPatients transferred from another ICUPatient who receivedhaloperidol, dexmedetomidine, riperidone, quetiapineprior to study

In a sample of 113 patients theincidence of agitation in thefirst 7 days was 31.8%

Agitation was more frequentamong patients with:History of smokingSever head injuryAcute neurological diseaseModerate to severe painMechanical ventilation (MV)DeliriumAgitated patent had fewer MV free days

Strengths:

All patient were visitedtwice daily in the first 7days prospectivelyassessing for agitation thus collecting data on riskfactors before agitationoccurrenceThe patient assessmentstrategy was robust

Limitations:

Small sample size in one single centreStudy team not available atthe weekends leading tomissed data and exclusionof potential patientsThe inclusion of many MV patient resulted in limitedassessment of pain anddeliriumAgitation treatment datanot collected

The need to recognise that in addition to delirium there are other independent factors foragitation in ICU.

Good care practices, sedation,analgesia and management ofMV could reduce the incidence of agitation

(Reade et al., 2016)Effect ofDexmedetomidine Added to standardcare on Ventilator-Free Time in patient

To determine the effectiveness ofDexmedetomidine when added tostandard care in patients with

Double blind, placebocontrolled, parallel grouprandomised clinical trialInclusion of all patient >18 years and with thephysicians opinion that

Results based on 39 patientreceiving dexmedetomidine and32 placebo. Dexmedetomidinegroup had a significantlyincreased number ofventilator free hours at 7 days

Strengths:

The study employed adouble blind, multicentre,randomised, placebocontrolled design

The addition ofDexmedetomidine tostandard care in patient withagitated delirium can result inmore ventilator free days

21

with AgitatedDelirium

agitated delirium the degree of agitation was so sever that reduction ofsedation and extubationwould be unsafe.Patient also need to meet all the additional criteria duringthe 4 hours prior torandomisation:The need for mechanical restraintAntipsychotic or sedative medication (or bothrestraint and medication)Presence of delirium using the CAM-ICU assessmentMotor Activity Assessment score >5Excluded:Pregnant patientsDementiaHead injury resulting inaltered mental stateAlready receivingDexmedetomidine orclonidinePreviously enrolled on studyKnown contraindication to haloperidol or a2–antagonised

compared with the placebo group (median difference between the groups 17.0hrs 95% CI , p=0.04).On several days significantly lower quantities of sedative or opioid was administered to theDexmedetomidine group thanplacebo group. Bedside nursingstaff felt patient were ready toextubate significantly early in theDexmedetomidine group (p<0.001)

The study had an objective enrolment criteriaThe protocol replicatedcurrent bedside practiceacross the selected unitsAll other therapies wereconsistent with currentconsensus recommendations

Limitations:

Small sample size.Sample size of 96 was estimated to provide 80% power. However under recruited (n=71) due to early termination of trial bythe sponsoringpharmaceutical companyDexmedetomidine oftencauses bradycardia whichmay have indicated to theclinical team therandomisation of patientsMAAS score were not collected throughoutresulting in missing data. The author felt this may be due to less attention being given to educate the bedside nurse regarding this data collection

(Freeman, Hallett, & Mchugh, Gretl, 2015)Physical restraint:Experiences, attitudes

To determine theexperiences, attitudesand opinions of adult

Questionnaire survey to all nursing staff within two large ACCU (n=192)Excluded:

non-qualified

38.9% (n=75) response rateAll respondents believed thatphysical restraint had a place

Majority of the view that the

Strengths:

There was a clear record ofthe research process.The questionnaire used was

Further research needed to:

Explore risk factors of treatment interference and the use or non-use of physical

22

And opinions of adultintensive care unitnurses

intensive care unitnurses

support staff other

professional groups

nursing staff not involved in direct patient care

reason for its application was tomaintain patient safety.

Some expressed discomfort aboutthe use of physical restraint.

Nurses were happy to discuss theuse of restraint with families

Perceived need for training andsupport for nursing staff

Need for medical staff to support the decision-making process

piloted and pre-tested priorto the study. More than onecenter included

Limitations:

Small sample size due toonly two sites accessed.Low response rateOnly captured the nursingview point rather than thatof the MDT

restraint.

Explore alternative measures toreduce ACCU delirium and aidpatient comfort

Explore the potential conflictbetween nursing and doctors inrelation to the application ofrestraint requires.

Explore the experience of thosein ACCU who wake up physically restrained and thephysiological impact this mayhave

Research needs to directly seekthe patient’s perspective

(Burk, Grap, Munro, Schubert, Sessler., 2014)

Agitation Onset, Frequency and Temporal factors in Critically Ill Adults(A*)

Paper A&B samestudy reportedfindings across two publications

To describeThe frequency, onsetand pattern ofagitation

Retrospective review of medical records

Patient sequentiallyselected over a twomonths

In one surgical and one medical ICUExclusion:ICU stay under 24hrsUnavailable medicalrecordsPrevious ICU admissionduring the study timeAdministration of paralytic agentsChronic neuromusculardisorders

200 patients included in the final analysis.Of the 200, 118 (59%) wereagitated at some point over the five days. 28.5% based on RASS scoresand the rest based on key words with the documentation.Mean number of hours to onset of agitation was 11.6 hrs. (SD 22.3, range 1-114) from ICU admission.44 (43.1%) reported on admission to ICU30 (29.1%) reported 1-4 hrs. after admission

Strengths:

A pilot study wasundertaken to support thefinal study processes.One investigator carried out the data collection to ensure constancyUsed a validated tool toassess severity of illness andpresence of agitation

Limitations:

Data accessed was notgenerated for researchpurposes, may beinaccurate, incomplete or of

Further research is needed toclarify factors and to identifystrategies both pharmacologicaland non-pharmacological toprevent, ameliorate or treatagitation.

23

Head traumaStrokeData were collected for the first five days of the ICUadmission

poor quality.

Limited generalisability of findings, one site accessed in one country.

(Burk, Grap, Munro, Schubert, & Sessler, 2014)

Predictors ofAgitation in CriticallyIll adults (B*)

To identifypredictors ofagitation byexamining demographic andclinical characteristics ofcritically ill patients

Retrospective review ofmedical records.Patient sequentiallyselected over a two-month period within one surgicaland one medical ICU.

Exclusion:

ICU stay under 24hrsUnavailable medicalrecordsPrevious ICU admissionduring the study timeAdministration of paralytic agentsChronic neuromusculardisordersHead traumaStrokeLook at two specific time points, admission and 24 hr. preceding. Data were collected for the first five days of the ICU admission

200 patients included in the finalanalysis. Of the 200, 118 (59%)were agitated at some point overthe five days.

Predicator of agitation both 24 hrs.before onset and at admissionwere previous drug use, height,use of physical restraint andseverity of illness.

Non-agitated patient were morelikely to be discharge back to theirprevious living accommodationthan the agitated group.

There were 49 adverse eventrecorded, 45 (92%) wererecorded with agitation present.

These were:Self-extubation (15%)Pulled out critical catheter (9%)Fell out of bed (3%)Tore off restraint (3%)Pulled out non critical catheter(91%)

Strengths:

A pilot study wasundertaken to support thefinal study processes. Oneinvestigator carried out thedata collection to ensureconstancy. They used avalidated tool to assessseverity of illness andpresence of agitation.

Limitations:

Data accessed was notgenerated for researchpurposes and may havebeen inaccurate, incompleteor of poor quality. Limitedgeneralisability of findingdue to only one siteaccessed in one country.

Further research is needed toidentify causes, interventionaltherapy for prevention andtreatment once agitation hasoccurred.

(Luk et al., 2014) To describe patternsof physical restraint

Secondary analysis of aprospective observational

Patients were physicallyrestrained on average 4.1 days

Strengths Recommended future studiesshould aim to determine the

24

Predictors of physicalrestraint use inCanadian intensivecare units

use in mechanicallyventilated patient(prevalence,number of daysused, number ofepisodes).

To identify patienttreatment andICU/hospital characteristics associated withphysical restraintuse and number ofdays

study carried out 2008-2009Original data set generatedby the I-CAN-SLEAPprospective observationalstudy, which describedanalog-sedation, antipsychotic, andneuromuscular blockeradministration and drugassessment or titrationpractice.Each ICU had a preset twoweek period and withinthat time patients included were:Initiation of mechanicalventilation within theinclusion periodAged >16yearsAcross51 Canadian ICU

(range 1-26 days.83% (n=311) were restrainedonceRestrained and never restrainedpatient had similar baselinecharacteristics however theirtreatment characteristics altered.

In the restrained group there was:

Increased use of sedation(benzodiazepine)

Double the number of ventilator days

Double the occurrence of adverse incidence.

Large multicenter studywith large sample size.Heterogeneous sample ofICUs and patients increasesthe generalisability, unsurethis would transfer to theUK NHS due to possibledifferences in healthcaredelivery.

As it was a prospectivestudy it did not rely onretrospective chartreviewing.

Limitations

The data collector had noworking definition ofphysical restraint unsure ifsplints, bedcovers, bed railsetc include.

Physical restraint onlyrecorded one per day and duration from initiation todiscontinuation not captured.

Unsure about theperception of sedative usebeing chemical restraint.

Not clear of eachdepartment had the sameassessment tool forsedation, delirium and painalthough they did mention a conversion of sedation

directional relationshipbetween delirium and physicalrestraint.

Future observational studies toexplore whether the use ofsedative or analgesic drugscontributed to agitationrequiring physical restrain orvice versa.

25

score from all units to one Sedation Agitation Score.

Unclear if any of the unitshad a policy on restraint usebut did mention Nationallegation to reduce its use.

Recommendations seemedweak in relation to impacton practice.

(Michaud et al., 2014)Early Pharmacological treatment of deliriummay reduce Physicalrestraint Use: Aretrospective study

To assess patientoutcome afterprompt administration ofany clinicallyaccepted delirium medication.

Retrospective cohortanalysis.Consecutively selected byconvenience sample foranalysis

Patients admitted to the22-bed medical/surgicalICU from February 2009to December 2012

Screened for delirium by trained bedside nursesusing the Intensive CareDelirium ScreeningChecklist (ICDSC).

Any patient with at least 1 documented positivedelirium screen (indicated by a score of ≥4 on the ICDSC) was eligible to be included in the study.

Other inclusion criteria Included:≥18 years

Median day in physical restraint (p = <0.001)

Treatment group= 3days (range 1-12 days)

Non-treatment group 6 days (range 1-21 days).

Median time to extubation (p=0.001)

Treatment group 3 days (range 1-21 days)

Non-treatment group 6.5 days (1-99 days).

In hospital death (p=0.008) Treatment groups 8 Non-treatment group 22.

Strengths:

The cohort was recruited in an acceptable way and a power and sample size was performed as priori.Gender, primary admittingdiagnosis, APACHE II score was comparable between the groups

Limitations:

Due to the retrospectivenature of the study therewas limited data collection.

The study did not delineatebetween the deliriumsubtypes.

If the patient receivedtreatment >24 hours after the first positive deliriumscreen or did not receiveany pharmacologicaltreatment during their

Further research of aprospective, placebo-controllednature is needed. Noted thatpharmacological managementwas only one component of a multi modal; approach howeverpharmacological therapy isbeneficial when initiated soonafter a validated positive delirium score.

26

Mechanical ventilation at the time of the firstpositive delirium screen.Patients were excluded if they were pregnant.Quetiapine, olanzapine,risperidone, ziprasidone,haloperidol, anddexmedetomidine werethe medicationsconsidered clinically acceptable for delirium treatment.

If at least 1 dose of apharmacologicaltreatment medication wasadministered to a patient within 24 hours of the first positive delirium screen,the patient was placed inthe “treatment” group.

delirium course, they wereplaced in the “no-treatment” group.

Promotion of sleep/wakecycle, daily sedation breaks, reorientation of the patients was deemed to be ‘standard’ practice however notdocumented and therefore impact not assessed.

The treatment for delirium was not standardised across the group.

Duration and resolution of delirium not noted.

Kandeel N.A. and Attia A.K., 2012Physical Restraint Practice in Adult Intensive Care Units in Egypt

To investigate thepractice of physicalrestraint amongcritical care nursesin one city in Egypt

Descriptive cross sectionalDesign

Convenience sample

patent group one –patients exclude in they were in the ICU less than 12 hours

Group two nurses-excluded if less than12mths experience

Physical restraint is commonplacein the ICU accessed.

The study indicated:Poor observation/document/assessment of the restraint siteA lack of documentation andeducationLack of family/patientinvolvement

Strengths:

There was a clear statement of the aims of the study and a clear observation tool devised and pilot prior to the study.All research staffinvolved were educatedabout this.There was a clear statement of findings and ethical standards maintained.

Highlighted the need forstandard practice guidelinesand policy for physical restraintuse and the further researchwas required.

27

Limitations:

The findings are limited as to their generalisability due to the one region of Egypt

Noted by the authors that nursing staff in Egypt do not question practice but follow instruction from medical staff impacting on the practice observed

(De Jonghe et al., 2013)Physical restraint inmechanically ventilated ICUpatients: A survey of French Practice

To characterise the perceived utilisationof physical restraintin mechanicallyventilated ICUpatients and toidentify clinical andstructural factorsinfluencing PR use

Cross sectional survey

A questionnaire was hand delivered to one intensivist within all of the 130 ACCU across France

In 82% of ACCU physical restraintis used at least once duringmechanical ventilation in morethan 50% of patients.

Physical restraint used most frequently during awakening from sedation.

Physical restraint commenced without written instruction in 50%.

Only 21% of ACCU have awritten local policy on physicalrestraint use.

Strengths:

This was a large nationalsurvey with a response rateof 93%. The questionnairewas purposefully designedby three intensivist, pilotedand refined beforedistribution.

Limitations:

Possible difference betweenreported and actualpractice due to self-reporting bias.Completed by physicianwith the suggestion todiscuss with nursing staffbut this was not formalizedand not documented if itoccurred.Recruiter hand deliveredthe survey and approached

Physical restraint use could beimproved by increasingphysician awareness of thepositive and drawback of it use.

Physical restraint requires awritten order for it to becommenced and discontinued.

The study should be used as abase for developing andimplementation physicalrestraint use policy on a local ornational scale.

28

the first intensivist theymet on arrival at the unit.

The recruiter were salesrepresentatives from thepharmaceutical companyGlaxoSmithKline.

To what degree thisimpacted on response isnot clear and whatdiscussion therepresentative had inrelation to the survey not noted.

(Tate et al., 2012)Anxiety andagitationin mechanicallyventilated patients

To gain a more indepth understanding of the manifestations,interpretations and management of anxiety andagitation in themechanically ventilated patient.

Ethnographic study usingprevious generateddataset.

Data from 30 purposivelyselected patient and their family members and clinician who cared for them.

All patient had reported or experienced anxiety and/or agitation.

Data generated from Happ et al (2007) justified secondary analysis as:

The phenomena of interest frequent in data setData set extensiveMaximise the participation

The study developed an Anxiety,agitation in mechanical ventilatedpatient model, which they feltclinical staff could use to targettheir interventions. The study’sfinding support the value of‘knowing the patient’, whichenables clinical staff to interpretresponses.

Strength:

Audit trail ofmethodological memo andnotes. Multiple data sourcewere cross checked ortriangulated to confirmfinding. Credibility wasestablished via memberchecks with 5clinical participants.

Member of the researchteam were also involved inthe original study the date were generated.

Limitations:

Limited transferability to other ACCU patients.

Inclusion criteria were only

Further work is needed inrefining operational definitionsand clinical language toimprove the discriminationbetween agitation and anxiety.

Research is needed to explainthe effects of the nurse andfamily presence and clarify the effects of specific support strategies.

29

of a vulnerable population patient in the weaningphase.Study was carried out insingle center, singleinstitution.Accessing an existing dataset may affect the reliabilityof interpretations.Practice may havedeveloped over the timelapse

(van den Boogaard et al., 2011)

Incidences and short term consequences of delirium incriticallyill patients: aprospective observational cohort study

To determine theoverall incidenceand duration ofdelirium, perdelirium subtypeand per ICUadmission diagnosis.

To determine theShort-termconsequences ofdelirium

Prospective observational study.All consecutive patientsadmitted to the ICUincluded and systemicallyscreen for delirium usingCAM-ICU.

Diagnosed with one positive screen duringadmission.Delirium divided into three subtypes (hyperactive/hypoactive/mixed)

Excluded patients:Admitted for less than one daySerous visual or auditory disordersUnable to understandDutchHad a mental disabilitySuffered from serousreceptive aphasiaWere the compliance rate

1613 patients included26% (n=411) developed delirium.

The mixed subtype delirium occurring most frequently (53%).

Delirious patients were:

Mechanically ventilated for longerMore likely to remove their tubes and cathetersStayed in ICU and hospital for longer6 times higher chance of dying compared to non- delirium group

Strengths:

They used a validated screening tool to establish delirium.Well defined outcome measure and noted all variables.Had a data checker check 15% of data randomly.

Limitations:

Limited generalisability due to single site in one country.

Large number of cardiac surgery patients included which may have reduced the occurrence of delirium as these patents generally have a short ICU stay.

As a prospective cohortstudy it determineddelirium’s association withseveral outcomes but not

Nurses should be encouraged totake preventative measuressuch as:

cognitive stimulation music therapy prophylactic

haloperidol early mobilisation.

30

of delirium screening was<80% during the patients stay

necessary established acausal link.

Number of patients died andthe data for these patientswas removed from thedelirium durationcalculation

(L. C. Chang et al., 2011a)Risk factorsassociated withUnplanned Endotracheal Self-Extubation ofhospitalised intubated patients: a 3 year retrospectivecase control study

To identify the riskfactors associatedwith UnplannedEndotracheal Self-Extubation (UESE)and to comparecertain characteristics between UESE and a control group

Three year retrospective study carried out in one teaching center, which had 11 units.

Exclude patients who:

Had planned or accidental extubation (possibletypographical error inpaper)Died during hospitalizationPatient with a psychiatric historyPatient with suicidaltendencyPatient with dementiaPatient with a lifethreatening illness.

Compared thecharacteristics of patients,nurses, vital signs,duration of intubation,serum laboratory results, Glasgow Coma score (GCS)Acute Physiology and Chronis Health Evaluation

Most UPSE occurred: during the evening night shift shift with less

experienced nurses.

80% of the self-extubated patientswere physically restrainedhowever all patient in the controlgroup had physical restraintapplied.

Pulse rate and APACHE II scores were significant indicators of UESE

Strengths:Clear analysis of the data.Used a recognised outcomemeasure tool.

Case recruited and controlselected in an appropriateway.

Limitations:

Small sample size in a single site.The APACHE II scores were assessed on admission rather than at the time of UESE. Therefore these may have been different.Unable to attribute causality due to the retrospective nature of the study.

Sedative management and assessment included and unsure if consistent across the two groups.

Nurse to patient ratio also appear to be inconsistent

Recommended that nurses should reassess patient continually and routinely measure APACHE II and pulse rates.

Recommended providing continual education for nurses, increasing the number of nurses, increasing the number of nurses on duty and providing more frequent bedside visits during the evening and night shift if needed.

31

II (APACHE II) scores andthe use of physicalrestraints and sedatives.

across the care delivered.

(de Groot et al.,2011)Risk factors andoutcomes afterunplanned extubation(UE) on the ICU: aCase control study

To study theincidence, determinants andoutcomes of UE andto assess the riskfactors for re-intubation

Case control studyIncluded:All patient requiringartificial airways at threeICU were monitored for UE. From Dec 2005-June 2008

Excluded: patient who hadaccidental extubation due to nursing or medicalintervention.

For every UE four control patient were randomly selected from the total population of mechanically ventilated patient across the units.

Within the study period 74 UE in 69 patient ( 5 patients UE x2)

Determinant of UE were: male, higher BMI one unit with increased

population of surgical patients,

elevated serum sodium, reduced Ramsay

Sedation Score (anxious/agitated-awake/calm),

use of haloperidol and methadone.

47% required re-intubation with 53% not.

Those without re-intubation had significantly shorter length of stay in ICU and in hospital.

Strengths:

Pre- study support provided for staff.Had clear criteria for weaning across the three sites.Staffing, securing the ETT and sedation appear to be consistent across the three units.Control group was recruited randomly.

Limitations:

Generalisability to other region/countries as this was three centers in on region of the Netherlands

Data gathered up to 12hours after UE and thenurse interview, which mayimpact, on the re-call ofdetails.

The study has introduced additional risk factors for UE.

Introduction of weaning and/orextubation protocol and dailyevaluation of the need for MVcould reduce the length of MV and in turn reduce UE

Langley G.,Schomollgruber S.and Egan A 2010Restraints in Intensive Care Units-A Mixed Method Study

To provide a detailed description of restraint practice across three ICUs.

Quantitative datacollected:Number of patientsrestrainedType of restraint usedAverage duration ofRestraint time

Quantitative results:

219 patients were recruited48.4% (n=106) were physicallyrestrained.Patients were restrained on average for 9 days and in the case

Strengths:

It had a clear study aim andobjectives with appropriate research methodology forthe question.The paper highlights points

Further research is needed especially around patient and family opinion of restraint use.

Institutions need to have apolicy regarding the use ofrestraint and restraints

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If the department had a policyIf so was it adhered to?

Qualitative data wasgathered around medicaland nursing staff views onthe use of restraint viaindividual interviews.

of one patient only 53 days.

In 9 cases they were inadequately or ineffectually applied.In 5 cases restraint were applied but not secured.

Qualitative findings:physical restraint had a place,balancing act re: benefit anddisadvantages; poorcommunication across the team represcription and legal directivesand with patient and families

raised in other work andadds to the overall body ofknowledge on whichfurther research could be based.

Limitations:

Limited to the generalisability of the finding due to the fact this is a small mixed method study conducted in on region within three sites. Clinical staff were purposively recruited to the qualitative phase possibly introducing bias

prescribed in line with this with a minimal duration set.

(Benbenbishty, Adam, & Endacott, 2010)Physical Restraint usin intensive careunits across Europe: The PRICE study

To explore theincidence of physicalrestraint in adult ICUacross Europe and explore the association with other factors such as staffing

Point prevalence survey used in 34 ACCU in nine countries.

Bed numbers ranged from 6-24.All patient on the unit on the observed day were included.

Exclusion criteria applied at unit rather than patient level.Specialist neurologicalsurgical unit exclude inrecognition of specificchallenges.Paediatric units excluded.

34 ACCU in nine countries providedstudy data regarding 669 patientsregarding details of physical and chemical restraint.

39% (n=219/566) were physically restrained.

Use of restraint was not related to the time of the week.

Restraint was more likely to beapplied to ventilated, sedatedpatients in a unit with a lowerdaytime nurse: patient ratio.

Commercial wrist restraint andpolicy for use was evident in the

Strengths:

This was the first study of its kind and was Europe wide.A structured data collection tool was used and translated into the relevant languages.

Limitations:

The case mix of patient was not included and therefore some patient may have been ready for discharge or high dependency patients rather than ICU.

The paper recommends the development of evidence based guidelines and educational packages to underpin restraint practice.

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larger units.

Physical restraint use was less in unit with a policy regardingphysical restraint.

The primary reason for use was to prevent unplanned extubation or removal of infusion lines.

Data was collected by a range of collectors across 34 sites and the authors did not include if these data collectors had had any training.

Inter-country reliability testing would have ensured consistency of the data collected.

The extent to which the unit within the study are representative of others in the same country is unknown.

(Tanios et al., 2010)Can we identifypatients at high riskfor unplannedextubation? A largemultidisciplinary study

To define high riskpatient for unplanned extubation and determine clinician beliefs on perceived risk for unplanned extubation

Cross sectional survey

All critical care members of:The American Association for Respiratory CareThe America Association of Critical Care nursesThe Society of Critical Care Medicine

Total of 1976 respondents(419 respiratory therapist, 870 nurses and 605 physicians all from ACCU).

87% considered a patient tuggingat the endotracheal tube (ETT) riskof self-extubation.

71% removal of nasogastric tube increased risk.

Definition of a ‘near miss’ less clear with half the respondent believing it was dependent on the patient’s medical condition.

Strengths:Clear and transparent account of survey development with involvement of clinical experts, content validity checking and pre-testing carried out.

Clear an appropriate statistical analysis of findings.

Limitations:

The survey focus was on perceived risk, which may not equate to actual risk.

Due to the survey design

The study provided a working definition of an airway ‘near miss’ as ‘outward ETT migration of 2cm if measured at the lips or 3cm in measured at the incisor’

The relationship between unplanned extubation an the risk factor highlighted require further study via direct observational study

34

95% viewed near missed a threat to patient safety.

44% considered unplannedextubation to be a medical error.

Situations which posed a high risk of self extubation:72% felt absence of physicalrestraint.60% nurses/patient ratio59% trip out of ICU43% light sedation29% bedside portable x-ray

there may be bias in the question posed.

Recruitment was via three large organisations.

Accessing a convenience sample such as this may not represent the view held by clinical colleagues therefore limits the transferability of the findings.Those who responded may have had more interest or experience in the topic areas than non-responders skewing the results.

(Huang, 2009)Factors leading toself-extubation ofendotracheal tubesin the intensive careunit

To discuss thefactors leading toself extubation ofendotracheal tubes (ETT) and explorethe difference between the group of patient who did and who did not self remove their ETT

Case control study

Purposive sampling patient data either with a planned extubation or who self-extubated. No exclusion criteria offered

708 patients included

44 self extubated (6.4%).

63.9% of those who self extubated had been restrained

MDT stating the reason forrestraint was to prevent selfextubation.

66.7% of patients did not have sedative post operatively.

Among the 44 patients who self-extubated 28 patients met the criteria for extubation.

Strengths:

The case and control were recruited in an acceptable way with independent and controlled variable accounted for.

The paper reported a robust statistical analysis.

Limitations:

The total sample was obtained from one surgical ACCU in one region of Taiwan, reducing the generalisability of the results.

The paper recommends that the knowledge of the MDT should be improved in relation to the use of physical restraint.The psychological support and orientation of a conscious patient is vital.

Patients need to be assessed and extubated once they are ready and this should not be delayed.

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Sedation and analgesic practice was not noted which may impact on the results.

It was noted that a significant number of patient who self extubated had been restrainedbut it was not made clear if this was at the time ofextubation and how long the patient had been in restraints.

Did not include the nurse topatient ratio, which maydiffer to UK ACCU and havea possible influence on the rate of self-extubation.

(Reade et al., 2009)Dexmedetomidine vs. haloperidol indelirious, agitated,intubated patients: a randomised openlabel trial

To establish ifdexmedetomidine would be moreeffective thanhaloperidol in thetreatment of ICUassociated deliriousagitation inmechanically ventilated patient

Pilot randomisedOpen label, parallel groupcontrolled trial.Included patientconsidered by thephysician to require ventilation only becausetheir degree of agitationrequire high dose ofsedative that extubationwas not possible.Agitation assessed using the RASS.ExcludedPatient who could not be extubatedPatient with a plannedreturn to theatre

Patients randomise to theDexmedetomidine group wereextubated significantly sooner than the haloperidol group (p=0.016)Time to extubation was shorter in the Dexmedetomidine group (19.9 vs. 49.8 hours p=0.0147)Patient who receivedDexmedetomidine weredischarged from the ICU earlierwith a short length of stay(1.5 median days vs. 6.5 p=0.0039)

Strengths:Used a validatedassessment tool to assessfor agitation which staffwere familiar with.

Limitations:As this was a pilot studythere were a number oflimitations.

Small single centre sample

Staff were not blinded to thegroup allocation and drugdelivery

Dexmedetomidine significantlyshortened time to extubationand decreased ICU length of say.

The authors felt their results justified the conduct of a larger, multi-centred blindedrandomised controlled trial

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Those likely to require on-going airway protectionThose physiologicallyunstablePatients with previousadverse reaction tohaloperidol or a2 agonist

Patients were allocatedusing a random numbersequence 10 allocated todexmedetomidine groupand 10 to haloperidolgroup

No protocol to guide thetitration of medication

Clinicians were free toprescribe any additionalsedation or anxiolytic

The unit had no formalweaning protocol

There was no baseline data in each group regarding presence of delirium, pre-morbid cognitiveimpairment or history ofsubstance abuse

(Turgay et al., 2009)Physical restraintuse in Turkishintensive care units

To determinenurses’ reasons forthe application andremoval of physicalrestraint (PR)

Cross sectional survey

All nursing staff in thechosen sites.

ICUs in 2 universityhospitals and 5 statehospitals in West Turkeyaccessing a on-randomvolunteer sample of 190nurses

84.7% of respondent stated theyuse PR without prescription.Wrist and ankle restraints beingmost commonly used (84.7%).

Common reason for application is:Maintenance of medical devices (86.8%)Restless behaviour (86.3%)Impairment of mental status (79.5%)Performance of medical treatment (53.7%)Convenience (23.3%)Suggesting from family or medical staff (12.1%)

36.8% reported complicationsafter the application of PR withskin breakdown most common.

Strengths:

There was a clear process ofquestionnaire distributionand the relevantparticipants across 7hospitals approached.

Generated some interestingfindings to add to the smallbody of work in this area.

Limitations:Low response rate of 40%

Recruitment from oneregion of Turkey limits thegeneralisability of thefindings.This only sought the nursesview rather than the MDT.

Recommended furthereducation to standardizenursing practice and protocolrelated to the use of PR.

Further research required toidentify alternatives to PR.

Restraint used should only beimplemented when all othertherapeutic methods haveproven ineffective.

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The sedation, analgesic practice as well as the nurse to patient ratio was not outlined which may impact on the frequency and duration of PR use.

(L.-Y. Chang et al., 2008)Influence of PhysicalRestraint onUnplanned Extubation of AdultIntensive CarePatients: A CaseControl Study

To evaluate theeffect of physicalrestraint onunplanned extubation in adultintensive carepatients

Case control study

All patients who had been admitted and intubated in the selected ICU over the 21mth period

Medical records andincident reports wereexplored on 100 patientswho had an unplannedextubation.

The cases compared to a sample of 200 other cases with matched age, sex and diagnosis with no record ofunplanned extubation.

This was to evaluate the effect of physical restraint on unplanned extubation.

Total 300 patient selected

191 had physical restraintsapplied.

This group had a higher rate of:Nosocomial infection (21.5% vs. 9.2% p=0.05)

Unplanned extubation (42.9% vs. 16.5% p=0.01)

Of the 191 patients in physical restraint 82 had unplannedextubation.

Strengths:

Recruitment was clearly stated and conducted in an acceptable way including a power calculation for sample size.

Limitations:

This was a retrospective study collecting data from medical note and incident reports of unplanned extubation.This assumed that the note were an accurate representation of events.

There was noacknowledgment of any missing data.

Some unplanned extubation may not be reported via the incident reporting system particularly if the patient did not require re-intubation.

The study findings concluded that a patient was more likely to have an unplanned extubation when they were physically restrained.

Highlighted the need for effective standard for use of physical restraint and further research of the subject wasrequired.

(Curry et al., 2008)Characteristics

To determine the characteristics of

Retrospective exploratory design in one 10 bedded

All unplanned extubation wereself-extubation.

Strengths: Recommended that the timing of weaning from the ventilator

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associated withunplannedextubation in asurgical ICU

patients and nursesand risk factors that affects extubation

surgical ICU in America

84% (n=26) were men 86% were in PR at the time of self-extubation.

Those who needed re-intubatinghad a significantly higher meanRamsey Sedation Score.

Positive correlation between RSSand the need for re-intubation.

87% in PR mostly soft wristrestraint. 3 patients had morethan one type of restraint in placeat time of self-extubation.

89% of the attending nurses werenot at the bedside at the time ofSE. Most patient had received lowlevels of sedition within the hoursproceeding SE

The paper outlined a clear definition of self and accidental extubation.They used a validated tool for sedation soring (Ramsey Sedation Score).

Limitations:

They did not include severity of illness scoring (APACHE 11) and as this was retrospective assessment of documentation there could have been missing or inaccurate data.

This was a small sample size of surgical patients in one ICU limiting the generalisability of the findings.

support was critical.

Staffing availability duringweaning, medication management in particularly pain management is vital.

(Mion et al., 2007)Patient-InitiatedDevice Removal inIntensive Care Units:A NationalPrevalencestudy

To explore theprevalence of deviceremoval, describethe patient context,examine unit leveladjusted risk factorsand describe theconsequences.

This was a prospectiveprevalence study withdata collected for 49,482patient days by trainednurses.

1097 episodes of device removalwith no significant difference intypes of ICU noted.

181 episodes of self-extubationduring 18,308 ventilation days.

At the time of device removal:45% (n=494) patient were in physical restraints

58% had documented agitation or anxiety at the time of the episode.

Harm or injury occurs in 23%

Strengths:

This was a large multi-sited trial where 49 hospitals were selected at random across several region of the United States.

A standardised data collection tool was used which was validated and tested for inter rater reliability (>95%) before the study commenced.

Additional inter rater

Found that device removal bypatient is not uncommon but theprevalence did vary across theICUs selected.

Resources on the ICU had animpact on the number of devicesremoved by patients and theremoval of device did result insome degree of harm, mostminor in nature.

There was also a variance in there-insertion of devices once

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4% being major (re-intubation, re insertion of central line).

Harm to staff occurred in 10% (N=110), which was mainly,unprotected exposure to bodily fluid.

checks were carried out at each site during the study.

All variables well defined and confounding factors considered with unit adjusts made.

Limitations:

However the study relied on practitioners’ documentation of device removal, which could have led to under reporting of events and the daily surveillance of staff, may have affected practices.

removed.

Further development of staffing and work load measurement is required to understand better how nursing staffing levels affect quality of patient care.

Martin B. andMathisen L., 2005

Use of PhysicalRestraint in AdultCritical Care: ABicultural Study

To examine the traditional use of restraint verses limited or no use ofrestraint.

To describe the relationship between patient characteristics, environment and actual use of physical restraint in selected critical care units in Norway and the United States

This was an observational study with a descriptive correlation design to describe the relationship between patientcharacteristics, theenvironment and the use of physical restraint in two different countries, United States and Norway.

Data collected in 3 ICU in USA and 2 in Norway.

Patient required until predetermined sample size reached.

Inclusion:Patients >18yearsLength of stay >12 hours

The use of physical restraint was associated with patient activity.

Physical restraint uses in 40% ofthe US sample- none in Norway.

US had a greater activity score from the patient observation

US patients received smallervolumes of sedative

Norway had a higher workload score per patient

Norway had a higher nurse to patient ratio (Norway 1.05:1, US 0.65:1)

7 incident of unplanned patient removal of devices all in US

Strengths:

Physical restraint wasclearly defined for theresearcher and oneresearcher collected thedata in both countriesaiding consistency inobservations.

The study had a clear inclusion and exclusion criteria.

Power calculation provided pre-set sample size and recruitment continued until this was met.

Author considered other

Both countries ICU had similarpatient groups and similartechnology yet differed on thenurse patient ratio, levels ofsedative used and restraintpractices.

The study concluded thatrestraint free practice was safefor patients yet highlighted that this was a small study.

Further research was required to assess the effectiveness ofrestraint free care and assessthe use of non-pharmacologicalinterventions, such aseducation of patients, the use ofnon-professional staff orfamilies

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Those not undergoing cardiac surgery

Exclusion:Those awaiting diagnosis to confirm possible brain death

If active ICU treatment had been withdrawn.

sample and all has restraints applied at the time

Only statistical significant difference in across the patient population was race, all Norway sample white US sample more diverse.

confounding factors such as family visiting, ICU environment and admission policy

Limitations:

Documentation and staff response may not reflect actual practice.

Patient characteristic, which may have an impact, not assessed such as metabolic imbalance

Pain management and assessment not noted.

Limited transferability to the UK NHS system as the admission criteria was unclear to each of the departments

(Jaber et al., 2005)A Prospective Study of Agitation in a Medical-surgical ICU

To describe theincidence, riskfactors, characteristics andoutcomes ofagitation

Prospective observation study, which screened all consecutive ICU admission over an eighth month period.

Those excluded from thestudy were patient with aprior diagnosis ofdementia and those whodied before waking 182patient were recruited

52% (n=95) patient experienced at least one episode of agitation during their ICU stay.

Agitation was greater in medical patients rather than surgical.

Multivariate analysis showedseven independent predicators ofagitation.These being:

presence of sepsis

Strengths:

Provided a clear definition of agitation, used a validated tool to assess agitation.

Provided a cleardocumentation trail ofrecruitment and inclusion.

Limitations:

Further research is required to better identify those with an increased risk of agitation.

More research is needed todemonstrate reducing riskfactors will decrease theincident of agitation.

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previous alcohol abuse used of sedation fever dysnatremia psychoactive drugs.

Agitation occurred both day and night and early in the patient ICUadmission (<3-5 days).

Agitation was associated with:

Increased LOS in ICU(16+/- 19 days vs. 6 daysp=0.0001)

Higher unplanned extubation (17% vs. 2% p=0.0003)

Higher CVC removal (16% vs. 1% p=0.001)

This was a single site study in one country limiting the generalisability of the findings.The inclusion of nonventilated patients withinthe study may possiblyunderestimate the agitationwhich occur with theinvasively ventilated ICUpatient

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Figure One: Flow of paper selection based on PRISMA

43

Table Three: A section of the synthesis matrix

Box One:

Study

Country of

Origin

44

Findings Syntactic constructs Synthesised theme Sub themes

All respondents believed that physical restraint had a placeMajority of the view that the reason for its application was to maintain patient safety.87% considered a patient tugging at the endotracheal tube (ETT) riskof self-extubation. 71% removal of nasogastric tube increased risk.Definition of a ‘near miss’ less clear with half the respondent believing it was dependent on the patient’s medical condition.95% viewed near missed a threat to patient safety.44% considered unplanned extubation to be a medical error. Situations which posed a high risk of self extubation: 72% felt absence of physical restraint.60% nurses/patient ratio, 59% trip out of ICU, 43% light sedation29% bedside portable x-ray

Sources: (Freeman et al., 2015, Tanios et al., 2010)

Physical restraint maintains safetyPrevent extubationPrevent line removal

Agitation management

strategies

Effectiveness of Physical

Restraint

Opinions on Physical Restraint

Use

Poor observation/document/ assessment of the restraint siteA lack of documentation and educationLack of family/patient involvement48.4% (n=106) were physically restrained.Patients were restrained on average for 9 days and in the case of one patient only 53 days.In 9 cases they were inadequately or ineffectually applied.In 5 cases restraint were applied but not secured.

Sources: (Kandeel & Attia, 2013; Langley, Schmollgruber, & Egan, 2011)

Physical restraint poses risk

Some expressed discomfort about the use of physical restraint.Nurses were happy to discuss the use of restraint with familiesPerceived need for training and support for nursing staffNeed for medical staff to support the decision-making process

Source: (Freeman et al., 2015, Tanios et al., 2010)

Discomfit with PR useTeam disagreement

Physical restraint had a place, balancing act re: benefit and disadvantages; poor communication across the team re prescription and legal directives and with patient and familiesSource: (Langley et al., 2011)

Physical Restraint has a place

Most UPSE occurred: during the evening, night shift and shift with less experienced nurses.80% of the self-extubated patients were physically restrained however all patient in the control group had physical restraint applied.

Pulse rate and APACHE II scores were significant indicators of UESESource: (Chang et al., 2011)

Physical restraint effective

7 America, 3 Taiwan, 2 Netherlands, 2 France, 1 Canada, 1 Egypt, 1 South Africa1 Turkey study, 1 United Kingdom, 1 Brazil, 1 Australia, 1 jointly conducted between America and Norway and 1 European study.