Allen Diane E, Fetzer Susan J, Cummings Kathleen S
Diane E. Allen, DNP, PMHRN-BC, NEA-BC, FACHE, New Hampshire Hospital, Manchester, NH, USA.
Susan J. Fetzer, PhD, RN, MBA, University of New Hampshire, Durham, NH, USA.
J Am Psychiatr Nurses Assoc. 2020 May/Jun;26(3):245-249. doi: 10.1177/1078390319878776. Epub 2019 Oct 8.
The application of mechanical restraints is a high-risk emergency measure that requires psychiatric intensive care to assure patient safety and expedite release at the earliest opportunity. While current Centers for Medicare & Medicaid Services regulations require trained staff to continuously observe restrained individuals, assessment by a registered nurse is required only once an hour. The experience of an acute psychiatric hospital demonstrates that more frequent registered nurse assessments can decrease duration of mechanical restraint episodes. The aim of this three-part quality improvement project was to decrease duration of mechanical restraint episodes by increasing the frequency of registered nurse assessment and surveillance. First, the requirement for frequency of face-to-face registered nurse assessment during episodes of mechanical restraint was increased from once every hour to once every 30 minutes. Second, the frequency of assessment was increased on half the hospital's units, from every 30 minutes to continuous registered nurse presence during restraint. Finally, the remaining units adopted 1:1 registered nurses during restraint. Mean hours of restraint per episode were measured and compared before and after each practice change. Mean duration of restraint episodes decreased 23% in the first change cycle, 12% in the second, and 44% in the third. Overall, there was a statistically significant 30% decrease in mean duration of restraint episodes. Increased frequency of registered nurse assessment and surveillance can significantly decrease duration of mechanical restraint episodes. Nurses are encouraged to adopt mechanical restraint practice standards that provide continuous psychiatric intensive care by a registered nurse.
使用机械约束是一项高风险的紧急措施，需要精神科重症护理以确保患者安全并尽早解除约束。虽然目前医疗保险和医疗补助服务中心的规定要求经过培训的工作人员持续观察被约束的个体，但仅要求注册护士每小时进行一次评估。一家急性精神病医院的经验表明，更频繁的注册护士评估可以缩短机械约束的时长。这个分为三个部分的质量改进项目的目的是通过增加注册护士评估和监测的频率来缩短机械约束的时长。首先，将机械约束期间注册护士面对面评估的频率要求从每小时一次提高到每30分钟一次。其次，医院一半的科室将评估频率提高，从每30分钟一次变为在约束期间有注册护士持续在场。最后，其余科室在约束期间采用一对一的注册护士配置。在每次做法改变前后测量并比较每次约束的平均小时数。在第一个改变周期中，约束的平均时长减少了23%，第二个周期减少了12%，第三个周期减少了44%。总体而言，约束的平均时长在统计学上显著减少了30%。增加注册护士评估和监测的频率可以显著缩短机械约束的时长。鼓励护士采用由注册护士提供持续精神科重症护理的机械约束实践标准。
