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Patient Safety and Use of Restraints

Despite constant awareness on patient safety, patients are unfortunately still suffering unnecessary consequential harm. As healthcare providers we need to ensure that the services we offer to our patients are safe, effective, caring, responsive, and well led. We need to communicate efficiently and lead by example in all areas of patient care.

Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events…
Patient safety is fundamental to delivering quality essential health services…
To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.
WHO, 2019.

Patient Safety Issues

Healthcare-Associated Infections

Each year, about 1 in 25 U.S. hospital patients is diagnosed with at least one infection related to hospital care alone; additional infections occur in other healthcare settings.
CDC, 2017.

Hand hygiene, antimicrobial stewardship, and other protocols, seem to be directly related to the rate and prevalence of healthcare-associated infections, including surgical site infections.

Antibiotic Resistance and Stewardship

Each year in the United States, at least 2.8 million people get an antibiotic-resistant infection, and at least 35,000 people die.
CDC, 2019.

We seem to be headed towards a situation in which antibiotics are rendered useless – a situation which we may be encountering sooner than we expect. This is due to current antibiotic prescription practices, lack of new antibiotic development, and the speed with which pathogens are developing resistance to currently available antibiotics.

Hand Hygiene

Whilst hand hygiene has been proven as the first line of defence against infection, it is still one of the least used tactics, as clearly shown in compliance rates.

Personal Protective Equipment

Lately, in 2020, due to the outbreak of COVID-19, nursing unions worldwide have pushed towards better protective gear and safety precautions, along with increased education and training about treating patients in a safe, effective manner.

Workforce Safety

Adequate nurse-to-patient staffing ratios protect our patients’ right to nursing care and safety. Problem is, in many clinical areas, there is no adequate nurse-to-patient staffing ratio, and this is leading to physical and psychological issues amongst healthcare employees. Ensuring safety of the workforce and within the workplace itself is crucial in ensuring patient safety.

Medication Errors

Medication errors are among the most common medical errors, harming at least 1.5 million people every year.
Institute of Medicine of the National Academies, 2007.

Medication errors to not just jeopardise patient safety; they also lead to unnecessary increased costs. Most medication errors can be avoided through better communication between the patient and the healthcare provider, or between the pharmacist and the patient, as well as adequately following medication-related protocols.

Transition of Care

Transitions of care happen with every physical transfer of patient and change of physician or nurse handover. For optimum transition of care, communication is critical. Information needs to be provided accurately with each transition in a way so that patient care can start right away without the need to read through documentation prior to physically assessing and communicating with the patient.

Patient Engagement

Patients need to be involved in their treatment plans and processes. As healthcare professionals we need to empower our patients so that they become allies in their own care, serving as another layer of defence against safety issues.

For this to happen, one needs to consider the patient’s health literacy so the information given by the healthcare professional is both understood and followed as required.

Pressure Injuries

Pressure injuries can be avoided through multiple efforts. Adequate nursing assessments need to be carried out as per recommendations, especially during bathing time. Thorough patient assessments can help determine risks for pressure injuries, and in such case, ulcer relief equipment needs to be available and sought to avoid unnecessary issues.

Through education on the prevention of pressure injuries along with providing patient-centered care, unnecessary complications can be avoided.

Patient Falls

More than one-third of in-hospital falls result in injury, including serious injuries such as fractures and head trauma.
Agency for Healthcare Research & Quality, 2019.

Through patient-centered care, the needs of each patient can be identified, noted, and met. Optimum communication in transition of care ensures that patient falls are reduced to a minimum.

Information Technology issues

Whilst health IT aims to quicken processes, aggregate and analyse data efficiently and improve outcomes, actual implementation has shown that the scope of technology’s reach has been much shorter than anticipated. This has led to a situation conducive to human error, jeopardising patient safety in the process.

To avoid such situation, technology should be enhanced so it can be used to improve communication within and between multidisciplinary teams, promote timely care, and provide data in a way which enhances monitoring and evaluation of patient care.

Use of Restraints

Use of restraints may seem to be unnecessary measures which take a patient’s personal freedom away. However, in certain situations, restraining a patient is the only way in which the patient’s safety can be ensured.

Use of restraints include:

Physical Restraints: interventions or devices which prevent the patient from moving freely, restricting normal access to his/her own body
Chemical Restraints: use of drugs to restrict patient movement or behaviour (drug or dosage in such case isn’t an approved standard of treatment for the patient’s condition).

patient safety and use of restraints — Retrieved from https://www.myamericannurse.com/use-restraints/ on 12th June 2022

NOTE: The following are NOT considered as restraints, but as safety interventions: orthopaedic supportive devices, age-appropriate protective equipment eg. strollers and helmets, keeping bed side-rails up as a precautionary measure in case of a seizure, and devices used to temporarily immobilise a patient for a diagnostic procedure.

Ethical Issues

Obligations & Duties – as healthcare professionals, identifying our moral obligations to others can help us determine our course of action in any given situation
Avoiding Harm – as healthcare professionals, our main aim and basis for good practice should always be that of avoiding harm to our patients
Assessing Consequences of Action – prior to use of restraints we should always assess the balance between benefits vs harm
Autonomy & Rights – we need to respect the individual’s rights to make their own decisions (if having the mental capacity to do so) and respect for the rights of others

Legal Issues

Does the patient lack capacity in relation to the matter in question?
Is it truly necessary to restrain the patient in order to prevent harm to the patient?
Have you considered the likelihood of the patient being harmed and the seriousness of that harm?

Risks related to Use of Restraints

A supine restrained position may increase the risk of aspiration
A prone restrained position may increase the risk of suffocation
An improperly secured above-the-neck vest may increase the risk of strangulation (if patient slips through the side rails)
Restraints may cause psychological trauma or resurface traumatic memories
Restraints can cause serious injuries and even death

Reducing the Risks…

ensure that a physical restraint is applied safely and appropriately
frequently monitor patients with any type of restraint
provide reassurance, support, and frequent contact to relieve a restrained patient’s fear and anxiety
monitor vital signs to determine how the patient is responding to the restraint
nurses need to receive hands-on training on the use and appropriate application of all types of restraints prior to being required to apply them, which training should be reinforced periodically

NOTE: Use of restraints should not be made part of a routine protocol, but an exceptional event!

The Role of the Nurse in Use of Restraints

Nurses must weigh the risks of using a restraint – restraints may cause physical or psychological trauma. Which is the best option? Is there a possibility of addressing the issue at hand without restraints and in a different way eg. through communication leading to reduction of anxiety?
Restraints should be used as a last resort. Nurses should explore alternatives such as having staff or family members to sit with the patient, using distractions or de-escalation strategies, and reassurance.
If use of restraints is necessary, a provider order must be obtained. However, this will not determine future need for restraints. Nurses should update and revise the patient’s care plan with the aim of reducing restraining measures and episodes.

Elevated Supervision ~ Constant Watch

ELEVATED SUPERVISION IN PSYCHIATRIC NURSING

In psychiatric nursing, constant watch by a professional staff member is recommended when the patient is at risk of harming self or others, as well as to observe the patient’s behaviour.

ELEVATED SUPERVISION IN NURSING (SPECIALLING NURSING)

Nursing care may be required on a one-to-one basis if the patient has so many needs that nursing assistance is required at all times. One-to-one nursing a.k.a. specialling nursing in such cases requires that the patient is kept within sight at all times of the day and night. This helps in reducing the risk and incidence of patient harm.

Whilst specialling nursing can feel intrusive and restrictive, it can be a therapeutic intervention through patient-centered care.

To ensure patient safety as well as your own…

ensure a good handover from the nurse in charge, including the reason why 1:1 nursing has been implemented
inform yourself about your patient’s recent days at the hospital through patient notes and documentation
participate in discussions with the patient’s family, carers, and other healthcare staff
liaise with the multi-disciplinary team and ensure the patient attends all due appointments and required tasks
ensure clarification about break time and who is to provide cover whilst on break
document in detail, including patient speech content, behaviour, risks, and attitude to being under constant watch

Specialling Nursing Patient Care

communicate with the patient and provide reassurance
assist with personal hygiene and other personal needs such as wearing of hearing aids, glasses, dentures, as well as toileting
promote mobilisation where possible so as to maintain daytime activity and stimulation, leading to better nights where the patient can sleep better
liaise with other personnel where need be so as to provide the patient with any cultural and spiritual needs
communicate with carers about the patient’s needs and assist them with any concerns
always keep in mind the patient’s preferences to activities of daily living; What is their normal routine like? Does the patient have any preferences with regards to bathing and dressing up? What are the patient’s food preferences? How is the patient’s usual bowel routine? Does the patient ask for painkillers? How is the patient’s mobility? Any activities of interest that the patient can continue to practice whilst hospitalised? In case of inappropriate or difficult behaviour, how is this usually managed?

constant watch Hospital Policies

most clinical areas have their own SOPs – Standard Operational Procedures; always ask if they exist, and if they do, read them, understand them, and if unclear, ask for clarifications
challenge related malpractice
provide daily patient review on the need for constant watch and the different levels of elevated supervision as should be explained in the SOP; get the GP or consultant to sign and review patient on a daily basis

References

Agency for Healthcare Research & Quality (2019). Patient Safety 101. Retrieved from https://psnet.ahrq.gov/primer/falls on 12th June 2022.

Centers for Disease Control and Prevention (2019). Antibiotic Resistance. Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.

Centers for Disease Control and Prevention (2017). Healthcare-Associated Infections (HAIs). Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.

Institute of Medicine of the National Academies (2007). Preventing Medication Errors. DOI: https://doi.org/10.17226/11623

World Health Organization (2019). Patient Safety. Assessed from https://www.who.int/news-room/fact-sheets/detail/patient-safety on 11th June 2022.

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Infection Control Measures in Immunosuppressed Patients

Infection complications are most often predictable and possibly preventable through adequate infection control measures. In immunosuppressed patients this is of high importance, especially since the greater the impairment, the higher the risk of infection. Recognising patients with increased risk, identifying and correcting risk factors in advance, and reducing sources of infection are important aspects related to prevention of infection.

Immunosuppressed Patients

Immunosuppressed patients typically are those patients who have:

extensive burns
organ transplants
particular genetic disorders eg. immunoglobulin A deficiency
HIV infections
leukaemias (cancer of white blood cells)
lymphomas (cancer of the lymphatic system)
high-dose chemotherapy
haematological malignancies (cancers originating in blood-forming tissue eg. bone marrow, or in immune system cells)
neutropenia (lack of neutrophils)

Neutropenia

Neutropenia is characterised by lack of neutrophils – white blood cells that help fight infections, especially those caused by bacteria. Normal range for neutrophils is 2.5-7.5 x 10⁹/L. The lower the neutrophil count, the steeper the fall or the longer the duration of neutropenia, the higher the risk of infection.

immunosuppressed patients — Retrieved from https://www.haematologica.org/article/view/7075 on 2nd April 2022

Protective Precautions vs Protective Isolation

COMMENSAL MICRO-ORGANISMS – can be found on body surfaces which are covered by epithelial cells and exposed to the external environment (GI tract, respiration tract, vagina, skin, etc).

COMMENSAL BACTERIA – although co-evolved with their hosts, in specific circumstances can overcome protective responses in the host, causing pathologic effects.

NOSOCOMIAL INFECTIONS – eg. healthcare associated infections & MRSA.

OPPORTUNISTIC INFECTIONS – infections affecting solely the immunosuppressed patient eg. Kaposi’s sarcoma.

Infection-causing micro-organisms in immunosuppressed patients may be acquired through:

the presence of the individual’s normal flora
hospital staff hands
hospital equipment
food

Protective isolation components include:

physical separation from the main population through the use of a single room
restriction on movement, visitors and diet
antimicrobial prophylaxis and selective decontamination of the digestive system
care for the maintenance of skin and mucous membrane integrity
application of hand hygiene to prevent exogenous acquisition of micro-organisms

NOTE: Signs & symptoms of infection are most commonly absent in immunosuppressed patients.

Transferring an immunosuppressed patient in Protective Isolation may not be enough to prevent subsequent development of infection.

Infection Control Measures

Infection control measures help prevent infection in immunosuppressed patients. Standard precautions should be applied when caring for neutropenic patients as well as severely immunosuppressed patients.

Component	Recommendations
Hand hygiene	after contact with body fluids (including contaminated items), after glove removal, and between one patient and another
Gloves	use when touching body fluids (including contaminated items), when touching mucous membranes, and non-intact skin
Gown	use during procedures and patient care which require contact with clothing and exposed skin with anticipated exposure to body fluid
Face protection (eg. masks, goggles, visors)	use during procedures and patient care which are likely to generate splashes of body fluids, including aerosol-generating procedures with suspected or proven infections that transmit by respiratory aerosols (in which case wear an N95 or higher respirator along with gloves, gown, face and eye protection)
Soiled equipment	handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment; perform hand hygiene and wear gloves when handling visibly contaminated items
Environmental control	support/advocate for routine care, cleaning and disinfection of surroundings, especially surroundings close to patient-care areas

Standard Precautions

Textiles and laundry	handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment
Sharps	avoid recapping, bending, breaking or manipulating used needles; if recapping is needed, use one-hand scoop technique; use safety features if available; use appropriate sharps disposal containers
Patient resuscitation	use mouthpiece, resuscitation bag, or other ventilation devices to prevent oral contact and contact with oral secretions
Patient placement	use single-patient room if patient is at increased risk of transmission, contamination, lacking hygiene maintenance, or if patient is at increased risk of becoming infected or developing adverse outcomes following infection
Hygiene etiquiette	teach symptomatic patients to cover mouth and nose when sneezing and coughing, correct use and disposal of tissues, wearing of surgical mask if tolerated, or maintaining spatial separation (if possible more than 3 feet)

Patient Placement

SINGLE ROOM – promotes reinforcement of infection control measures; should be prioritised for isolating individuals with communicable diseases or epidemiologically important organisms, to avoid exposing immunosuppressed patients to such organisms. A patient placed in a single room should:

have an isolation notice displayed on the door
have an ensuite bathroom
have its door closed at all times
have limited staff entering the room
be provided with psychological support and reassurance whilst in isolation
not have staff with infections to provide patient care
not have staff to provide patient care whilst providing care to infectious patients in the same duty shift

SINGLE ROOM + HIGH EFFICIENCY PARTICULATE AIR (HEPA) FILTERS – promote reduction of risk to healthcare associated infections due to airborne fungi such as Aspergillus Genus (especially where construction-related work is in progress).

Patient Hygiene

FATIGUE – Immunosuppressed patients are often fatigued. Thus, patient hygiene must be assessed on a daily basis, and assistance must be provided where necessary.

PERINEAL CARE – Immunosuppressed patients frequently suffer from irritation or infection in the perineal area – an area which would be heavily colonised with bacteria. Thus, particular attention to this area is a must to maintain patient hygiene. Note that the use of soap may irritate the mucous membranes, leading to irritation exacerbation.

STAFF ILLNESS – immunosuppressed patients should not be nursed by staff with known or suspected infections or communicable diseases eg. oral-facial herpes simplex and upper respiratory tract infections; contact between such individuals should be reported to the infection control team and to the patient’s medical consultant.

Hand Hygiene

Environment and Equipment

Removal of dust from surfaces may help prevent infection (routine use of chemical disinfectant has not yet been proven to reduce infection) – surfaces need to be damp-dusted daily with single use cleaning cloths and neutral detergent; mop head needs to be laundered daily
Isolation rooms require cleaning with the use of gloves and aprons, followed by hand hygiene prior to leaving the room
Vacated rooms must be cleaned thoroughly before they are reoccupied
Medical equipment should be decontaminated after each use
Single-use items must be discarded and not re-used
Toys of immunosuppressed children should be decontaminated
Flowers and plants have not been directly linked to infection in immunosuppressed patients, however, are usually not permitted since they may act as a reservoir for Gram Negative bacteria or fungal spores like Aspergillus

Personal protective equipment

Use of face masks is not known to prevent infection in immunosuppressed patients, but can help protect healthcare staff from body fluid splashing
Routine use of non-sterile gloves and aprons/gowns may help in preventing acquisition of micro-organisms
PPEs must be minimally used to prevent contact with body fluids or contaminated items, and when in contact with non-intact skin and mucous membranes
Must be removed and discarded of as clinical waste after use, followed by application of hand hygiene
Sterile gloves are only required in certain aseptic or invasive procedures, or when in contact with sterile sites

Nutrition

Immunosuppressed patients have an increased risk of acquiring food-borne illnesses and harmful micro-organisms, and so, should be advised to avoid high-risk foods such as shellfish, pate’, soft cheeses and foods that are made with raw eggs
Neutropenic individuals have an increased risk of acquiring infection from Gram-Negative bacteria which is commonly found in sink plugholes and overflow outlets

Immunosuppressed Patient Visitors

Visitors should:

report to a staff member prior to entering the patient’s room so precautions can be explained, and infections that may pose danger for the patient may be identified
not visit if they have any transmissible infection
not bring any pets, and plants or flowers (fresh or dried)

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