Episode 125: Responding to Agitation in the ICU

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As Dr. Swamy said in episode 61, “You can’t sedate away delirium”. Yet, when patients are delirious and agitated, how can we keep patients and clinicians safe? How do we avoid and even discontinue sedation while keeping lines and tubes intact? What role do restraints play in agitation and trauma for patients? Are soft wrist restraints our best and only options? Dr. Marie Pavini, intensivist, and innovator of Exersides shares with us more tools and insights for approaching sedation and delirium management in the ICU through updated restraint technology.

Episode Transcription

Kali Dayton 0:00
Last episode we talked about alcohol withdrawal and the difficulties with dealing with agitation and hyperactive delirium. This presents a challenging predicament familiar to anyone that has worked in the ICU. The situation in which you have a patient battling delirium, which we know is a life-threatening condition, but they may have a RASS of +2 or higher and posing a risk of harm to themselves or clinicians.

We have legitimate concerns for line and tube removals, unplanned extubations, falls, or violence against healthcare providers. Cultural norm is to automatically restart sedation- and usually deeply. Is that most beneficial to the patient?

Are our teams and especially nurses supported and trained with tools to appropriately assess and address the agitation- or is our autopilot to mask the agitation and make the movement stop? Yet, if the agitation is from delirium- which it so often is—what sense does it make to start or restart deliriogenic medications?

Dr. Swamy said in episode 61- “You can’t sedate away delirium.– Do we give betablockers for tachycardia?“

Such situtations and high RASSes are when we face this predicament- sedate or resedate the patient knowing that this could significantly increase their risks of mortality and life-long disability…. Or what?

What tools do we have to keep the patients and staff safe and with all life-saving equipment in tact in that moment- without exacerbating and prolonging delirium and impeding mobility?

Dexmetamodine is a great medication in response to that agitation. It can and should be used for a RASS as close to 0 as possible- but a RASS +1 should be fine too as we implement the real treatments for agitation and delirium which are family, communication, and mobility.

Yet, I’m realizing as I am working with teams at the bedside that nurses still feel a lot of fear and liability in allowing a delirious patient be close to a 0 while intubated. They are terrified of unplanned extubations. This is a main driver of resedating patients during awakening trials.

One study showed that awakening trials actually resulted in a higher cumulative dose of midazolam as sedation was usually restarted and often at a HIGHER dose after the awakening trial- in response to agitation- I would assume from DELIRIUM.

We also tie patients tighter when they are agitated or not trust worthy. I understand it. I’ve done it! But… how does that not fuel the fire of agitation and trauma for patients?

What if we had a better support system for nurses? This would include better training, mobility practices, open visitation hours so family can really be there to help the patients, and even… better restraints?

Do we really trust our standard soft wrist restraints? What if there was a better way to titrate our restraints to ensure more security for patients that are at higher risk of unplanned extubations/line and tube removals… but more liberty and still security for those that are less agitation but still not reliable? Could such improvements help nurses feel more secure and confident about avoiding sedation?

This podcast is all about laying out the problems, sifting through the complicated realities we face, and bringing real tools to the table.

Dr. Marie Pavini- and intensivist and innovator joins us this episode to bring a great solution to the podcast.

Dr. Marie Pavini 0:08
Hi, Kali, thanks so much for having me. My name is Marie Pavani. I’m an intensive care unit physician in Vermont. I’ve been practicing since 2001. And in that time, I’ve been mostly at a community hospital except for my earlier training.

And during that time, I’ve done a lot of rounds with the nurses and, and assessed patients, and trying to figure out what the best way was that I could help everybody, help the patients help the staff really, you know, help the community. And in doing so I ended up becoming an innovator. And so I’ve been on lots of interesting journeys.

Kali Dayton 0:58
And I think you just fit into this club of revolutionists, and even with leaders of the revolutionists so perfectly, I had the pleasure of being with Dr. provine on site she came met with up with me at a with a team in Washington. When Heidi Engel physical therapist, Geoff Corey and I went to work with the team in Washington and Marie met us there. And Marie has really powerful insights as an intensivist. Considering that you’ve How long have you been an intensivist.

Dr. Marie Pavini 1:30
So I guess I started medical school in 1992. And so I believe 2001 was starting to practice, which was in a surgical ICU and then bumped to a mixed ICU shortly after.

Kali Dayton 1:44
And I consider 20 years, the timeline, the history of this research that we have about delirium, mobility, sedation, right, you came out when it was normal, kind of like now but even worse, back in the 90s, early 2000s, when everyone’s deeply sedated, but we didn’t have back then the evidence that screams that this is harmful.

Yet, listening to you share your experiences and talk about your practice was really inspiring to me, I could tell that you really practiced the true form of the ADF bundle, far before it ever existed. You followed instinct and humanity compassion, before the evidence, even validated that share with us.

Dr. Marie Pavini 2:26
I think, that’s a great point. Because research, of course, is wonderful, right? I mean, where would we be without research. But before research, there’s common sense, you have to test the common sense and make sure that it’s that it’s okay, but some common sense is so obvious.

And, like you said, there’s there’s natural humanity, feelings, and the ability to see what we might be doing wrong, and to question it early on, and then to try to do what’s right. And in my case, I was in a community hospital, so I was not near research.

So I can remember going to SCCM lectures and the leaders there, JP cress, resi, lay down even more, you know, we’re all there. And there were probably only five to 10 people in the lectures. And we were talking about early mobilization, delirium prevention, this is in the early 2000s. And, you know, they went on to do all this wonderful research, but I didn’t have that. So I tried to build things and to, you know, form groups where we would treat patients with humanity, kindness, and things that make sense. And as you were saying, when I started, it was just commonplace to sedate and immobilize patients.

And when you think about it, that makes sense with, we had better technology when I started, then for my predecessors, who didn’t really have much, and the only thing they really had was, let’s get the patient up and moving, and make them look more like they would be at home and maybe they’ll get home, you know, it’s really the only thing we had, and we’d relied on it.

But then technology came in place, and we needed to keep patients immobilized in order to, to tolerate what we were doing to them and all the new tubes and lines and, you know, implantables that we needed to protect, to try to make them better, we needed to immobilize them and not have anything dislodge. And and imagine now being immobilized and sick and in a strange place, you’re going to be agitated. And so the only humane thing to do at that point is to really sedate you. And maybe you won’t remember what happened to you. And things just snowballed after that but but right the research was going on, but before there was research, there was common sense.

Kali Dayton 4:49
And I think about that era, the kind of ventilators they had or not like the ventilators we have now they were not customizable. They didn’t have the sensors. They didn’t have the advanced technology we have now to be able to be more comfortable, the endotracheal tubes were stiff. They were smaller. Right? We were using large volumes high peeps. I mean, it was a completely different scenario. So of course, patients could not be comfortable.

And everything else that has advanced, but our sedation practices didn’t really and yet, you questioned these things. You used common sense. And how did you lead your team? What did what, what was your approach at the bedside as an intensivist, to solicit these changes that were new to everyone?

Dr. Marie Pavini 5:34
Well, that’s the benefit of then being in a small community hospital, we didn’t change shifts a lot. And there were not so many people, that everybody had to separate and go do their own jobs, we could all work as a team. So I was able to be at the bedside a lot. And since the the culture was already in place to restrain and sedate patients, I needed to be there, because I needed to show everybody else that I was truly involved, and that it wasn’t just telling them what to do, I was there doing it with them.

And they need, they need to know that you really believe it, that you’re serious about it, that you really are going to make sure that it’s going to happen. And then they’ll, you know, if they believe in you, and they believe in what you’re saying, they’ll join in. And so it’s, it’s you know, better to know, to, to be friends with your team and to know them and to be, you know, a small community.

And in that respect, in fact, in my situation we did one week off, and when we gone for service, so I was on day and night, for an entire week. And that meant that I didn’t come in in the morning, with a big surprise of something that somebody left me, I was able to plan the night before about sedation and mobilization. So that I was with a patient of for an entire week. So that that was really helpful. But the culture is ingrained. And if we were not a small group, it would have been nearly impossible to try to change this practice.

And then we started to with the electronic health record. And documentation became crazy for nurses. So now they’re spending 40 to 50% of their time at a computer instead of with their patient. And imagine what this does, over the years, the bedside nurse being out of the computer more, doesn’t get the sense of which patients need what thing they don’t, they don’t get that feeling of what they could probably do with the patient. It’s just a matter of fulfilling the orders and then going to document by the way about things that are not nurse level, critical things to document about secretarial and LMA things to document, but they’re being made to do it. So patient care is less.

And you have to think that that plays into the nursing shortage, it’s it’s only, I mean, I suppose it’s a it’s a factor and maybe not the total cause. But imagine how much more nursing time at the bedside we would have. If they weren’t 40 to 50%. At the computer, we’d have much less of a nursing shortage, nurses would not be nearly as burnt out, they would feel like they were doing what they got into nursing to do, which is to evaluate and and have some say in what happens to the patient day by day, hour to hour. So I’m not I can’t even remember what the question.

Kali Dayton 8:42
You bring so many good points. I feel like sedation and immobility, it just places patients onto this conveyor belt. But you make a good point of how the time dedicated to staring at a computer allows the patient just just continue on the conveyor belt with no further assessment analysis. Because that disconnect from the patient is perpetuated by the physical disconnect. They’re often outside the room, they’re not looking at the patient or not touching the patient.

So you have them sedated and immobilized where you don’t expect to have human connection. And now you have this obligation to dedicate so much of your time to a computer, which further disconnects you from the patient. And that creates a huge barrier. Absolutely, you make a really good point. And so you also bring up a good point about continuity of care, your ability to be with that patient throughout the days and nights. You didn’t come on realizing that night shift increased or started sedation without need you were there to help support them and keep it off those kind of team dynamics.

And I think that is what we still need even now to 2023 Especially to have physicians that are invested in that process and are willing to utilize those tools. I think sometimes as we’ve seen physicians don’t necessarily know what to do when a patient is agitated. They too, have been taught to just sedate them, right? So we’re turning to physicians with the expectation that they’re supposed to lead this out. But how do you lead something you’ve never done? So theoretical question, but really, you did it, you lead something that was so new?

Dr. Marie Pavini 10:19
My research colleagues used to call me “attending resi-intern”. Because being in a community hospital, I had to do everything. So and they don’t get to do that, you know. And so sure, a lot of physicians are disconnected. And they’re going off shift and they’re listening to a nurse who was telling them what’s happening. And, and they just, you know, some of them just came out of school, too. So everybody’s coming in with their different levels of education and their different levels of experience and listening to the people before them. And that’s how this culture gets started.

Kali Dayton 10:50
Yep, and get stuck, right? And then, yeah, as a resident, as a new doctor, I think I would have a really hard time even as a nurse practitioner, I think I would have a hard time telling very seasoned nurses that probably know more than me. “No, here’s what we’re gonna do, we’re not gonna sedate the patient”, right? To question that pillar of their practice.

It is a scary endeavor. So I have really enjoyed learning from your journey, the history and the insight that you give to this little community hospital in Vermont, and the incredible things that you were able to do that defy the practices of that time, and even today, and let’s zoom back out into the history and let’s talk about restraints. I think, obviously, restraints has been around for hundreds of years. But how do restraints become such a key part of Critical Care Medicine?

Dr. Marie Pavini 11:42
Well, I think again, it goes back to I believe it had roots in psychiatric care. But then, as we required, you know, we had more and more technology, and we required more tubes and lines to be kept in place. And as you said, our equipment was not that good. And all of a sudden, we said, well, we have this thing, you know, we have restraints, and that will keep the patient still, so that we can make them better.

And we have these sedation and sedation started getting better. Right? We had, you know, started out with just benzos. And then we we had got propofol and even later we got precedex. And so you know, and they were antipsychotics, and, of course, all the research that was going on, and which was good and which was bad.

But we were thinking about it anyway. And we were improving. So we felt like we were doing the right thing, and we were doing the best thing. But people were not realizing that the patient, although they look pretty calm and relaxed and comfortable. And we’re doing all these high tech things to them that, you know, we’re patting ourselves on the back for.

But that patient is slowly devolving and losing their quality of life and their chance for their own future. And when we when we see a patient leave the ICU alive, and maybe without the disease or the disorder that they came in with. We all think this is great. This was a success, our technology works. Our efforts are working, and they’re doing great, they’re they’re gone to step down. Now they’ve gone to rehab, they’re on their way to getting back. But it’s not happening this this isn’t this isn’t what’s really happening.

Patients are quietly delirious, and they’re quietly muscle wasting. And they’re quietly becoming a victim for the rest of their lives. They’re there and trained to be a victim to, to lie there and let all the people who know what they’re doing, do what they have to do to them. And so they they leave thinking that they need to always be that and that they’re, they can’t be independent anymore, that that they shouldn’t move. And they shouldn’t do this. And, and so I think that it was quiet for so long.

And just before COVID I don’t know, maybe a few years before COVID. The research was getting done, and data were coming out. And we started to realize that this was not a good thing for patients to be restrained and sedated. That delirium was happening, that early mobilization couldn’t happen. Because sedation was there. And even when you take sedation off, it’s really still there for a while. It’s still affecting the body and it’s still affecting the mind, even when it’s been off for a while, especially depending on which type of sedation it was.

And so, you know, I think that those efforts were underway, and maybe we could talk about it later. But then you know, COVID hit and everything sort of stopped, but as far as restraints, that never changed. So everybody was talking to about early mobilization. And from early mobilization, everybody started talking about sedation. And so the two big phrases were early mobilization and sedation minimization. But if your boots on the ground, what you’re going to see is that, sure, really early mobilization can’t get done when someone’s sedated.

But you can’t not sedate someone who’s tied down to the bed, it’s not going to work. And a nurse is not going to untie somebody from the bed and leave them alone. Now, that said, there’s examples, there’s few examples of where this happens, there’s little tiny pockets of where this is happening. And that’s when the entire team is motivated and, and on top of this, and they’re going to all join in and all stay doing the same thing, and keeping the patient at the center of attention. But 99.9% of places are just not going to do that.

Not everybody’s on the same page. Not everybody believes in it, not everybody knows about it. So so when you think about why is a patient sedated? Sure. It’s partly because they’re so sick, that it’s uncomfortable. A lot of it is the perception of the bedside caregiver about how uncomfortable that patient is. Because we’ve seen patients who have every right to be as uncomfortable as another patient, but are not. There. They’re kept awake. And they’re not nearly as as upset by things as we think they should be.

Kali Dayton 16:46
I’ve actually walked patients on a peep of 18 and 100%. Who they’re not doing cartwheels, but they’re not riding, they’re not languishing, they can tell me that they’re not in pain, or if they are in pain, we can treat it we can treat the air hunger. But they’re compliant. They’re they’re unrestrained, they’re safe. But then other patients that are on a peep of eight 40, 50% are strapped down to the bed, and we’re terrified about them pulling their lines out. It’s not just the ventilator.

Dr. Marie Pavini 17:19
Right, right. And don’t forget about the patient who has withdrawal, or is dangerous. Yep. Because that’s the example that a lot of bedside staff want to bring up when when we talk about not restraining somebody or not sedating them, well, I’m not going to get hit, you know, I’m not going to put myself in danger. You know, it’s not worth it. I’m running around like and not taking care of people. I’m not going to you know, put my my physicality in danger. And we’re seeing a lot, a lot more nurse endangerment these days because of other issues, because of other safety precautions that are not there for them.

Kali Dayton 17:54
What and a lot of that is rooted in delirium.

Dr. Marie Pavini 17:57
Yes, yes, of course. And so people are just rotten people, you know, what the percentage is so small, we can’t use them as as what we now are going to punish everybody else because of the very, very few. And like you said, the ones who are not just mean people are probably delirious. And we see all those people who were not in their right mind later on in their right mind apologizing. That’s not to say that we can, you know, let them beat up on us.

Well, when they were in that state, we have to do the right thing. But we and then I guess that’s where my involvement started with is that we didn’t have the right tools. So the restraints that we have the options, our wrist restraints, mit restraints, the elbow immobilizers. And then there’s the creative ones, like a loosely tied mit or a loosely tied wrist restraint, or a bedside sitter. And then, of course, chemical restraint. And chemical restraint can come in lots of forms.

So every time you know, we get guidance that tells us to reduce sedation, or to use better sedation that comes with loopholes that, sure you need to minimize sedation. But if the patient has a diagnosis that requires sedation, then you can use it, and nobody’s going to question you. And so now you can say there’s anxiety, or, you know, the patient has pain because they have an endotracheal tube in and they felt lines—“It must be painful. I think I saw their brow move. And you know, now I can use opiates.” And, you know, so there’s just lots of ways to to get around the guidelines that are trying to help people,

Kali Dayton 19:45
We can rationalize it any which way.

Dr. Marie Pavini 19:47
Yep.

Kali Dayton 19:48
And I think a lot of sedation that’s used is for quote agitation, especially when we’ve started sedation and then at this objective point later, we know that we have to do an “awakening trial”. You know, their ventilator settings are minimal. And now it’s harder to rationalize having them sedated because we know they probably should be working towards getting extubated, we want to do breathing trial.

But we have to that, that stinkin awakening trial everyone hates, you turn it down, boom, they come out with thrashing, kicking, we interpret that as “It is inhumane to have them off of sedation, they’re agitated, they’re uncomfortable” so we turn sedation back on, and now we’ve treated them now they’re more humane. But now that we’ve seen them be agitated and thrashing, we’re terrified. We don’t want to get hit as nurses, we don’t want to be assaulted.

We also feel a sense of obligation to keep them safe, which is rational, but, but we’re not considering the risks that harm of sedation. Our focus is keeping those tubes and lines in place. So we’re in a hard point where now we created delirium. We have to get sedation off, but we also have to keep them safe. How do we do it?

And I was working with him hospital system that was saying, “Okay, but yeah, we were going to have educated patients and even in the soft wrist restraints, they can get down, they can get it out.” Which is true. I’ve seen people almost self extubate.

Dr. Marie Pavini 21:20
Yes.

Kali Dayton 21:21
So but but just because they’re delirious, they’re confused and agitated. What sense does it make to turn back on a deliriogenic medication? It’s like, why would you treat delirium with something that causes delirium, we would never treat sepsis with bacteria. So with its hard point where the restraints can precipitate and exacerbate delirium, agitation, and all those things, it’s terrifying to be strapped down when you have no idea what’s going on. But you asked this important question is, but is that the best thing for someone that’s experiencing that to have them strapped down? Is that really safe? Is that really beneficial?

Dr. Marie Pavini 21:59
Well, that’s it so but the answer is that the nurse has to go document or the nurse has to go take care of another patient? Are they going to leave this person who was like agitated, because we just turned off the sedation alone and put a lot of effort into being there? No, you know, and then the other harm that’s being put upon these patients, is the thought that they’re just not ready yet. They’re not ready yet. You know, they could be perfectly ready to wean. And but but you know, when they wake up, and they’re agitated, that delirious, oh, they’re not ready yet. Put them back in the oven. And we’ll try again in a day or two.

Kali Dayton 22:38
You know, we have a good example of that with a survivor that I interviewed in episode 92. She was intubated for just airway protection. She had Ludwig’s angina. And so her, her airway was swollen, full of infections and she had an abscess. That was it. Just airway protection. Of course, they said and sedated her, I think about six days after intubation. She probably had an cufflink she probably would have been acquitted, extubated. They turn on sedation, she had traumatizing, horrific delirium came out thrashing. She heard them say, “Oh, she’s not ready yet. They turn it back on.” She ended up intubated for, I think, 17- 18 days.

Dr. Marie Pavini 22:39
Yeah, this is not that unusual. No, it’s It’s all because of our own perception and not what’s really going on with the patient. And another thing that happens in situations like that, especially with older adults, is when they’re sedated. Or if they look really agitated, when you finally wake them up, the consensus is that, “We are harming we’re doing more harm than good. We’re having to hurt them so much, by trying to make them better, we should just go to palliative care. This is inhumane, and we should stop doing what we’re doing. We’re torturing these people to make them better. Let’s call palliative care in and stop this madness.”

When really it just needed a different pathway and things would have gone much differently. So I think we’re calling palliative care a lot more than we normally would have, if we would give it a lot, a lot of effort upfront, to do everything that we could to reduce delirium to figure out what’s causing the delirium to to mitigate it, and to allow the patient to be awake and not look like they’re dead so that we think they should be dead.

Kali Dayton 24:26
Woohoo. That’s profound. Yeah, absolutely. I think we, we set expectations by what we see. And yes, if we make them look like they’re dying, and are dead, we dehumanize them, we have no idea what their potential could be. We’re also giving them lethal treatment. So we are determining their destiny and saying they’re going to die because I mean, I’m just because we’re giving them lethal treatment. I don’t know how to tactfully say that. But, and again, this is my podcast. I can ruffle feathers. You can turn it off if you’re offended, but we cannot fix what we can’t control. Right?

And when you look at PTSD, it would be very traumatizing to be strapped down to the bed. But I’ve had patients asked to be restrained, like loosely restrained at night, because they’re, I would probably ask the same. I don’t trust myself to wake up and not be a little disoriented. I’m asleep-walker sometimes. So I would. That’s different. That’s not traumatizing to them, versus when you have delirium.

Now, you’re strapped down. So some teams that I’ve consulted with, they say, “Well, we, don’t allow restraints, because that causes PTSD.” Which blows my mind if you’re not using physical restraints, that is or your chemical restraints, and that’s a consistently, teams that do not allow physical restraints have on average arrests of -3 to -5. And oftentimes, their negative fives are not charted as negative fives, which is a whole nother discussion, right.

Dr. Marie Pavini 25:58
But you just Yeah, but that discussion maybe should almost be in this discussion, because you can’t measure it, just like you said, if you don’t know about it, you can’t fix it. And those inaccurate RASS scores are not letting us see the true picture. And so our research data is skewed. Yep. And our response is skewed.

Kali Dayton 26:18
Absolutely. And, yes, I’ve had people say, well, we don’t deeply sedated patients. But when we work with the nurses, they don’t even they don’t see the difference between the voice response and physical response right there. They’re just not trained, which is, again, this is not against nurses, this is just a systemic problem that nurses are subjected to, they’re put into this process.

Dr. Marie Pavini 26:40
They don’t have anything to do if they can’t get the patient to be what the order says. What else do they have? They don’t have anything else they can do. And they’re short staffed, or time in the day.

Kali Dayton 26:52
Yep, I think people assume that in the Awake and Walking ICU that patients are one to one. With nurses, which is not true. I worked as an RN in that unit for about five years, I almost always had two to one and oftentimes 200 patients, right? You try to mix them up. But nonetheless, they were safer, because they didn’t have same rates of delirium, right, which is key.

We were not chemically restraining these patients, but we did use restraints when it was needed. But I love your device, because I see this gap that I didn’t really question beforehand. I do remember having patients restrained that I still didn’t feel comfortable turning my back on, I didn’t feel confident that with a RASS of plus two plus one, that they weren’t going to get into trouble when my back was turned.

Dr. Marie Pavini 27:38
Imagine- and your ICU which is like premium, right? You know, if that’s still a concern, then you you don’t like the only devices that you have available now go to all the other ICUs, you know, except for a handful that are trying to fix a problem with without any kind of the right tool. So everything is not standardized, everybody’s trying something different. And they’re trying something different at different times during the day. And they’re trying something different depending on when somebody’s coming around to do with therapy.

And so everything’s happened in such a random fashion, it’s such such different times of the day, there’s no way to do a research study, that’s going to get the results in any kind of a large study fashion anyway, it’s going to get results that are meaningful, because everybody’s doing something different. They can use the same terms. And it sounds like they’re doing the same thing. But they’re not.

And so I feel like the device that I came up with, which by the way, you know, had a lot of input from other nurses, mostly nurses, and also other physicians, other clinical staff. So that if everybody is using a device, the same device that has a lot of variability in it, in other words, you can titrate it, you can titrate it from being very conservative, to very liberal, then you have the safety that you need. And you have the mobility that you need. And you can titrate it to go along with whatever is going on with the patient.

So usually, it’s one of those three things that’s missing, and everybody’s reaching for a different device to try to fix it. So if we had the same device that can do everything. And I’ll say there are some caveats. We don’t want an unapproved patient, we don’t want it on somebody who could otherwise lift a Volkswagen, you know, because they’re withdrawing or something. So there’s a few patients but again, we’re not going to talk about the very, very few patients and punish everybody else for that. So I think what we want is a safe device that allows mobility and titration. So that’s what we came up with.

Kali Dayton 29:46
And listeners check out on the transcription for this episode. I’ll have links to videos so you can see Marie’s device it’s called “Refraint”. So it’s not just restraint. It’s a Refraint, which I think that is obviously very thoughtful to use that terminology. But even in the video watched a few times, I think when nurses first see it, even when they see it in person, they completely misinterpret it. I experienced it’s one of those things where you have to try it on yourself, you have to try it on someone else, really understand the technology behind it. Otherwise, you see something new, and that shock factor blinds you from being open to understanding the actual application of it. So my even just over podcast, audio explained to us what features your Refraint has.

Dr. Marie Pavini 30:37
So just like you said, it’s bigger, you know, just like the stand assist device devices are bigger than gait belts, you know, there are some things that are bigger because they’re more comfortable that way, and they’re more ergonomic and they’re more safe for the person using it. So it is bigger. And it’s basically comprised of a clear two that goes alongside outside the arm and doesn’t touch the arm. And then there’s a clear, soft shield, that goes over the hand, that the patient is attached to this device, by a soft strap at the wrist and a soft strap at the shoulder, the axilla.

And those are the only two places that it touches the patient, except that the hand is resting on soft neoprene so basically whatever is under that fabric is what the patient is on. The the wrist strap that attaches the patient to the device is a sort of a slip loop so that if the patient gets a Deema, this wrist area will automatically regulate to that edema. So it won’t constrict the wrist. The way other restraints constrict, the rest of the patient gets edema. And we’re all taught to look for that. But it happens in between the checks. That’s just you know, that’s when it happens you two hours and boom, the patient has neurovascular injury.

Kali Dayton 31:58
But you know, with that edema. Yes, we look for it, we see it, but what can we do about it? Right, if you have a patient that really needs to be restrained, and yes, they’re fluid overloaded, but you’re trying to minimize sedation, you’re weighing out all these risks. So yeah, you’re gonna be a little bit more accepting of pressure on edematous extremity restraints, you probably realize, Wow, this is an there’s an implant in their wrist from the restraints. But again, when we don’t have any other options, we kind of normalize and accept it.

Dr. Marie Pavini 32:33
Absolutely, absolutely. And then some of the other features are, so you get a patient who’s going to be variable within their course. So they may be just so sick, that they can barely move anyway. And then they start to wake up, and maybe they don’t know where they are, or pain starts to become an issue. Because they were so out of it before that they didn’t realize they had pain or, or whatever it is, and they change and they become agitated, and then they become sedated, and then they become sicker. And they and then something else happens. So there are two optional bed straps to this device.

So the goal is to just have the device on the patient, so they can move around with full range of motion at the shoulder. So we’re going to try to reduce rotator cuff injuries and frozen shoulder. And they have mobility at the elbow. So again, cutting down and frozen joints and the the auto regulating restrap cutting down on neurovascular injury. And I say those things, not that they’ve been proven, but they are tools that the person using the device can enact if they use the device properly, depending on how they want to use it. So if the patient let’s say is not maybe so much agitated, but let’s say that they’re really confused and sort of swinging wildly, not because they’re trying to hit anybody, but just because they’re so confused and swinging.

There’s a there’s a restraint strap that you can use and there’s a an exercise bed strap. So for that patient, you might want to use the exercise resistance bed strap. So it’s always on the bed frame. And you can just within 10 seconds, attach it to the device. And then you can titrate that resistance band to allow a lot of movement or a little bit of movement and it’s against resistance so the nurse can stay safe and titrate how far the patient can move and how much effort it will take the patient to move that distance so they can adjust the resistance. And then if a patient is just temporarily needs restraint until you can fix the situation, then there’s a restraint strap that you can just put along the device immediately.

And even when it’s in that restraint position. It’s still a better restraint because it’s only tugging on the device. It’s not tugging on the patient. So the patient can actually still move their wrist in all directions. And under that At clear shield, and the the restraint strap will only keep keep the arm in the vicinity right next to the bed, but the risk can still move around. So it’s still better even as a restraint.

Kali Dayton 35:14
And having seen the straps that you’re talking about, there’s velcro all throughout that strap, it’s, in my mind so much more secure than a variable tie of the restraint. I think we’ve all experienced it, those restraints can get loosened with enough pressure, or we all tie them somewhat differently.

I’ve shared on an unplanned extubation episode, that one of my unplanned expansions was because there was a floor nurse watching a kind of a boarding patient on the unit during the night shift. I didn’t realize that they didn’t have ICU experience. I had them come in and help me boost a patient up, I tied down my restraint, I didn’t check his and he wasn’t tied properly in the patient was delirious and got to his tube. He was okay, everything was fine. But it was one of those things where seeing your strap, that would have been a totally different scenario, because he would have just been able to just tie just Velcro, it’s so simple, and so much more secure. That tight, that is sturdy fabric that you’re using for the velcro is that is so much in my mind better and not going to stretch as much as some of the restricted soft wrist restraints. But in a standardized.

Dr. Marie Pavini 36:26
Yeah, it’s standardized.

Kali Dayton 36:27
Yes, everyone’s gonna do it the same, and it’s reliable. But I also appreciate that that doesn’t have to be used for every patient. If we think about delirium, confusion, sundowning dementia, we have such a spectrum of reasons for patients to be confused, different Encephalopathies. Their presentations are variable, not every patient is a plus four on the wrath scale. But they still they can be a plus one still need restraint. You can just have the pickers that are just going to get busy with their fingers and get into stuff.

Dr. Marie Pavini 37:00
And they’re gonna get antipsychotics and they’re gonna get him by psychotic, right?

Kali Dayton 37:04
Or they’re going to get deeply restrained or deeply sedated and tied down. But did they have to be tied down? Or did they just need something like a mitt, but I think we’ve, I don’t I want to everyone. So maybe if you’ve worked in the unit where everyone’s deeply sedated, you haven’t really encountered these problems.

But when you’re working towards lightening sedation, you’re going to find that patients are unique. They’re all different. They’re variable. That’s the, that is the trend amongst humans. So when you allow patients to be human, you’re going to have different scenarios, and you’re going to have to critically think, so I’m thinking of patients that are pickers. But if you tie them down, they’re gonna get more agitated, they’re gonna get more panicked, but mitts are not always the best option.

If they’re edemetous, it’s hot, it’s sweaty, that alone can cause panic when they feel like something is really compressing their hands, that’s not normal. So I love that this device, their hands are free, their wrists aren’t even be being pulled on. If they’re just pickers. They can just move their arms around.

But that’s what actually panicked nurses, I think, in your video, when I shared it, is I saw that the patients could raise their arms and they panicked, which made me panic, I thought, “Wow, if we’re that damaged, have a visceral response to seeing a patient move their arms. The problem is that you’re refrained. The problem is the culture of the ICU.”

We have to recognize that there are patients that yes, will need to be highly restrained. They if you have a RASS of three or four, yes, you need to have immediate action to keep everyone safe while you recalibrate and figure out how it has to be available. And I’m thinking about let’s use a scenario of um, maybe a patient with the comes in for pneumonia, they’re an alcoholic, they start to withdrawal, right?

I historically have now I’d probably use phenobarbital. But I think in the past, I really liked librium. So maybe we’re having limb librium. We’re trying to figure out the right dose for it. Maybe they have some breakthrough. They’re having some agitation. So maybe we’ve had this intubated patient. we’ve mobilized them. They’ve walked around the unit, they’re in bed, they’re fine, right? But they’re still confused or having some withdrawal. So they are restrained.

Or they have some restraints on let’s say you’re refrained. And then they come out of their nap. And they’re disoriented, they’re confused, they’re needing some more librium or another phenobarbital push. But in that moment, what do you do? I’ve been in that situation where the restrictions are not enough. And I’m yelling out to the hall, “Hey, someone grab elbows, some or I can even get to the corner of my room to grab the elbows and binders in the cart because I’m trying to keep the patient down. I need an extra hand.”

It’s stressful. It’s dangerous. It’s dangerous to me. It’s dangerous to the patient. But with your device when I was holding my hands or you had it on I’m like, “Oh my gosh, in that scenario, boom, I’ve got an elbow. Oh binder right there built into it, I can just reinforce the elbows, I can tighten it down with the Velcro, it’s already there.” If I had this patient where they could move their arms, I don’t have to then try to get the restraints tied down underneath the bed. I’ve got velcro right there, boom, I’ve got them velcroed I’ve got some security.

Dr. Marie Pavini 40:16
On device, the arm is flailing, you have a bent elbow and fists, and everything’s coming up.

Kali Dayton 40:21
Yes! How, when you already have bending elbows and you need….. when you recognize that you need elbows–c cit’s too late. It’s hard to get the elbows on that whereas the elbows are already there, and you can titrate how much the elbows can move. I just, it just seems so much more humane. You don’t have to punish the patients that are just pickers. And treat them like they aren’t a thrasher yet. But they changed. There’s mixed delirium, like 22.2% of delirium is mixed delirium, meaning that it’s not reliable, they’re not going to be comatose all the time, they’re not going to be hyperactive all the time.

So it makes sense to have some that you can titrate to go with what they need in that moment and be prepared if something changes. So nurses freaked out like it was something less secure and more dangerous to them, when in my mind, and now they use an experienced it, it’s the opposite, it is so much safer for the patient, more humane for the patient, safer and easier for the team, you don’t have to have three people come in and try to wrangle this patient and get all these devices on because everything you need is right there.

Dr. Marie Pavini 41:24
Right, and whatever device that they reach for is going to have an issue because it’s not always going to be the right thing. It’s only the right thing for one moment in time. And so the wrist restraint is great until somebody figures out that they can slither their head down and pull the tube out anyway. Or because you know when they get so agitated, they’re going to get you know, chemical restraint on top of that anyway,

Kali Dayton 41:45
and wet underneath it. And it affects the dressing for the PICC line. Are there a demo has like there’s so many problems to that. And you can do elbows and then what we give that PRN Josephina Barbara tall, now they’re fine, but they’re gonna end up with those elbow restraints for the next week straight.

Dr. Marie Pavini 42:03
:ike you said, they cover the elbow, the watering type ones cover the skin, they can emmacerate it. It’s warm and moist under there. And you don’t know what’s going on in there with your tubes and your lines. And patients even bite them up. And they can still reach for catheters and things and they can reach over to the other one on the opposite side. So that’s only good for one point in time, it’s not going to be good for the the patient’s whole state and MIT restraints. I don’t know if you’ve seen it.

But I’ve seen where patients like to squeeze the mitts around the endotracheal tube and pull that pull the tube out. And those MIT restraints restrict finger activity. So the patient can’t hold anything. They can’t do a call button, they can’t do a remote, they can’t hold hands. You can’t write to be filled checks, you can’t do fingerstick glucose checks. And, you know, the so the refrain deals with that in that the hand is free under a shield that’s over the the the hand, that’s what makes it bigger. Because there’s a soft, clear shield over it.

It’s bigger, but the hand is free underneath, it’s much more comfortable. And we also have another feature of the devices therapy sheet. And therapy. It is a little human shaped, squeezy mechanism that the patient can be doing digital exercise, so dexterity strength, and comfort, because lots of patients feel like, Oh, I’ve got what I need in my hand, this is fine, I’m going to be okay. We used to just try to give patients face cloths or something to hold on to because they felt more secure if they were holding something. So in the device, the patient is still doing occupational therapy. And that’s not going to happen in any other device.

Kali Dayton 43:50
And I’m having flashbacks to taking mitts off of people. And you see them open and close their hand like it right to the movies when they get the shackles taken off. And they’re like, “Oh, thank goodness, I can finally move my wrist, I can move my hands.”— That is probably what they’re experiencing. And when they’ve been in the MIT for so long. They haven’t been able to open and close their hand. How often do we have our hands flat and restrained like that?

And I really honestly, I did not think about mitts that way. But I now I’m thinking about how patients respond and you take them off. And it makes sense. I did not think about patient perspective. And they do they can they’re very creative. If they want to get the tube out, they will use them it’s to do that. And I know that if someone’s just tuning into this episode, and they haven’t listened to the episodes beforehand, they’re gonna say this is insane— just sedate that patient!

Dr. Marie Pavini 44:42
Exactly.

Kali Dayton 44:43
What are you doing? Like don’t don’t even bother, right? They don’t have the context and understanding how lethal sedation is there gonna say why would you even bother with that, but the objective is to master the A to F bundle to minimize sedation and avoid at all costs, but you have to have the tools to enable that when you hit these circumstances.

So when we think about the financial side of it, go back to Episode 95, talking about the financial sinkhole of sedation and immobility, when you’re increasing complications, length of stay, workload all the things just because you’ve used sedation because you didn’t have a way to keep them safe while they had delirium, and allow them to deliberate it with from delirium over a few days, because you didn’t have the right devices to keep them.

Dr. Marie Pavini 45:28
Right. So you can minimize delirium by minimizing sedation by minimizing restraint. And then when you have a more awake and mobile patient, don’t be afraid of moving arms, I actually have a lecture on seduction, which is the you know, the sweet spot of minimal sedation and maximum action, maximum mobility that is safe.

And so you cannot be afraid of the moving arm, the moving arm is good, it clear secretions, it helps gut motility. It reduces stasis ulcers, it reduces DVTs. It allows patients to participate in their own care to tell you that they need to be suctioned, even if they’re writing it to be able to nod, you know, “yes, I want to keep going.”, “No, I don’t want to be intubated anymore.” Whatever it is, there’s so much that affects the financial bottom line of a hospital. Nevermind just that, you know, the humanity of it can affect costs in a significant way.

Kali Dayton 46:29
And I’m now thinking back to the survivors that I’ve interviewed on the podcast, even those that did not have delirium. So I’m thinking of one of our area survivors, she didn’t have any experiences under sedation, but her trauma and her panic came from coming out of sedation and not being able to lift a finger just being trapped in her own body working so hard to will her finger to touch the remote, or the call button, and then falling asleep out of exhaustion trying to lift her finger. Would that have been the case, if she had something that would have allowed her to lift her arms move her fingers stay mobile during that time, it would have been a completely different experience for her.

Dr. Marie Pavini 47:10
And as you were saying before, some patients don’t need to be restrained at all, they need nothing. But the nurse doesn’t know that. So it’s not going to happen. Oh, so you want the device to let the bedside staff feel safe, and then it will happen. And then the bonding will be able to take place.

One of the things I found, as I was trying to you know, so I had I did a pilot study. And then we had such good results with less sedation, less agitation, more mobility, greater interaction, better patient satisfaction, Nurse satisfaction, because they started to bond with their patient, better family satisfaction. So we ended up getting about, I think, three NIH grants to develop and commercialize the device to get it out there.

And we hoped to get it out during COVID- in time for COVID.

Kali Dayton 48:02
Yep.

Dr. Marie Pavini 48:03
But what I found when I was trying to tell people, “Look! I’ve got this thing now it’s great, you’re gonna you know, it’s gonna be so good, especially during COVID! “–you know, the, the Delerium factory. You know, “I’ve got an answer!” And no.

So I mean, of course, we were worried about just survival, you know, just ourselves as caregivers. I can remember, you know, showering after a shift and, and doing like the most comprehensive cleaning I’ve ever done in a shower. Facial area…

Kali Dayton 48:34
Burning your clothes.

Dr. Marie Pavini 48:36
yeah, Exactly, you know, before going home, you don’t want to give it to you. So we were scared. We wanted to survive ourselves. We needed enough ventilators. That’s all we were focused on. And then when when that sort of we felt like, “okay, we’ve got a handle on this COVID thing. It’s not over yet, but we have a handle on it.”

That that’s a couple of years of education and momentum for moving patients and understanding what happens to them when they’re sedated– that was lost. And so we’re trying to get that ball rolling again. And it’s really difficult. And so nobody was interested in my restraint alternative, which to me was just almost criminal. And so I said, “What am I going to do?” And so I said, “You know what, I have to let these people experience what the patient is experiencing.” What is the patient is experiencing.

So we ended up developing a virtual reality delirium experience. So, you know, when you put the headset on, you enter in the body of the patient, and you experience what it’s like to to be in the hospital to be in an ICU room. Intubated, restrained, and the doctor and the nurse coming in to talk to you and telling you things and then the sedation is started for for what is seemingly good reasons. And then what happens to you from all of that. And you experience the delirium, the hallucinations, the fear, anxiety, hopelessness, helplessness.

And after that, then you enter you that episode, that part of the module ends and you enter in the body of the caregiver. And you’re asked to perform certain tasks like turn the patient, suction the patient within this module. And so if you do it incorrectly say you don’t tell the patient what you’re doing, or you don’t introduce yourself, and you don’t tell the patient what’s going on. Their hallucination enters the picture, again, you can see it. And so you have to back up and do the right thing for that hallucination to go away.

And then you also are run through how to assess delirium. So you’re run through those cam questions, those cam ICU questions, so that you, you understand what you need to do and sedation agitation and, and, you know, sort of get the whole comprehensive idea of how those questions are linked to what the patient is experiencing and experiencing. And so when you put the headset on and you become that patient, it is a memory for you.

Now, it wasn’t just a lecture, you heard, you didn’t just have to get the answer, right on a quiz, you experienced it. And it is now a memory just in the same way that when those people experienced those hallucinations, and they’re not real, they’re actually memories for them, they entered their brain as memories. And so the education now can enter the bedside caregiver as a memory so that when they go to their next patient, and they start to maybe say things that could be turned into a hallucination for the patient, or they do things to the patient that’s going to start those those hallucinations and delirium happening.

They they get a visceral response, to not do it. And they remember their training of how that relates to the, to the questions that they’re supposed to ask the patient. And then they remember what can alleviate those symptoms, what what that delivery could mean, maybe they do need to be sectioned, maybe they do have a little pain, maybe they’re just afraid maybe they’re worried about the bills at home or their pet. You know, there’s lots of things that that can cause those those reactions from a patient. And until you eliminate those, you should not be just adding the sedation back and tying them down.

Kali Dayton 52:16
Your virtual reality program is so vivid. And I’m sure it’s nothing in comparison to what delirium was really like how vivid survivors portrayed as explained to me how real it is to them. They said it’s more real than what you and I are experiencing right now. Nonetheless, putting those goggles on was just just startling. So I wouldn’t I we offered it to one of the physicians at the on site, but he had already experienced delirium. And we backed off and said, “You know what? That’s probably going to be triggering.”

And I really think that it would be because it’s not realistic. And I wonder that is, that tool probably does more than I could do in like five podcast episodes, right? As far as giving insight. And there’s no way I just can’t imagine that there’s any way that any nurse, or any clinician that does those scenarios with your goggles, your virtual reality goggles, can approach awakening trials in the same way, or approach sedation period in the same way, but especially wakening trials, because we believed just hold on to this belief that patients come out agitated because of the ventilator.

But once they’ve seen it from the patient’s perspective, how will that impact how they respond to that agitation, right? And what it’s like for them when installation was resumed, and they’re shoved back in deeper to those hallucinations. Thank you so much for developing that thank you for getting it, thank you for listening to survivors and understanding their perspective and providing a way for us to teach that when I saw that I just knew you’re my woman, you were you are by kind of revolutionist because you’re really out there to make a change and bring in the why.

Dr. Marie Pavini 54:05
Well right back at you, Kali because when I experienced your week long seminar that you did in Washington, I was blown away the case studies that you used and the interaction that you had with everybody they were they were riveted, they were glued and they were listening to everything and they did their homework before you came and they really learned a lot.

I heard them reciting back all the risks that that particular patient in that case scenario had and how they could mitigate those factors and and how they could try to diagnose and and you know what different things that they would tools that they had. So I was blown away by by you, and by this effort that you’ve put forth in the Awake and Walking ICU was totally revolutionary. And I think that we need a few more people like you to be out there and training people?

Kali Dayton 55:03
Well, I, I have already people on the waiting list right people that are adapting this into their practice people in these ICUs that I’ve worked with, that are getting that experience and the expertise to then go out and train others because that’s this is going to take….. it does, it takes hands on, real interactions and experience and understanding “the why”.

I think you and I had similar experiences during COVID were here we are watching this unfold experiencing it firsthand. And we have so many tools for the how we see the problem, we have so much for the solution. But the community didn’t understand “the why”. So then it didn’t mean anything, no matter how many tools you have, unless you see the problem and feel an urgency about it. You don’t care about the solution.

So that’s what your virtual reality goggles do is, here’s the problem. Here’s the why. And here, here’s the how here are my Refraints. Having you on site, bless your heart, I have to tell everyone that Dr. Pavini came on site to help us use a virtual reality goggles to train on the refrain to test it out to show this team. And the first night I thought, “Well, while you’re here, do you want to play the patient?” She ended up playing the patient the entire week, which was a lot of work for her.

But she was such a good actress, you were so good. No, I could tell that you, you had experienced this right you had practiced in your career in a way in which you’ve really worked with patients that had delirium. That you really tried to avoid sedation, you understood the different RASSes, you understood the terror, the anxiety that they experience, like you just got it and you portrayed it beautifully. What was it like for you to play the patient during all that simulation training?

Dr. Marie Pavini 56:48
Well, it was a little bit triggering, you know? So, I mean, I can, I could see that for a couple of decades, right? And you don’t really, I didn’t understand how much I really empathize with those patients. I, I was glad that I could understand the patient, I always had that little wall so that I could keep on going, that I didn’t let anything get so far inside of me that it would it would stop me from being able to perform my duties.

And so there’s always that wall. But I always felt like if anybody did I really could understand and be compassionate. And and but when I had to play the patient, and act out some of the things I remember seeing, I mean, the terror, and the fear just could come inside of me. And I was I was those patients that I was portraying. And I thought, man, if if anybody knew how terrorizing This is, they would never do it to even one person. Ever, ever.

Kali Dayton 57:56
Yeah, this has been Yes, I worked in the Awake and Walking ICU, I’ve seen an experience and even provided incredible care. But this journey of interacting and really diving in with survivors in with teams into the research like it is just so much more real to me.

And yes, I regret during my travel nurse times sedating patients, I recognize that I did probably more harm than I could have ever imagined at that time. And I feel twinges of guilt, but at the same time, that empowers me, it’s like bringing these two perspectives together, helps me understand what needs to happen the future.

And that’s what I hope we do with this information as we experience your Virtual Reality goggles as we listen to survivors, that we use that with an empowerment and excitement for the future. And I experienced that I think we both enjoyed that about being on site with a team in Washington, is that they’d had an awakening. were

Dr. Marie Pavini 58:58
They were wonderful, by the way. Those people were far ahead of the curve. And they work together as a team. From from everywhere, the therapists, the respiratory therapists, the physical therapists, occupational speech, the nurses, the nurse leaders,

Kali Dayton 59:14
The chaplain!

Dr. Marie Pavini 59:15
The marketing people, the CEO had the goggles on and was and totally got the the idea of the refraint. The whole hospital was in on this and what an amazing group they were.

Kali Dayton 59:30
Absolutely, I mean, we showed up and almost everyone had participated in the webinars. Even they weren’t when we showed up, they are already were reporting a 40% reduction in restraint use, which is clearly a manifestation of the difference in their sedation practices and the delirium rates, right?

But we also saw it during that time, one or two patients that really could have benefited from the Refraint. They were scared to leave in a chair, but they would have benefited And from being in the chair, they needed to sit in the chair during the day, but it was scared to turn your back on them. But if they’d had the refrained, they the nurse everyone would have been felt better about it and the patient would have been safer. So it was a great experience.

Dr. Marie Pavini 1:00:11
it wasn’t happening while the nurses off doing other things.

Kali Dayton 1:00:15
Yes,

Dr. Marie Pavini 1:00:15
Right? So there were frank design and the patient, the patient’s awake and moving, they’re moving those arms that are so scary, in a safe way, because the refrain has a, an IV and cord containment system. So as the patient moves their arms, they can’t get tangled up in anything. That’s, that’s part of the beauty of the of the safety of the device.

And so the nurse will have the patient in the Refraint. So that’s delirium prevention, that’s mobilization, that sedation minimization, it’s freedom for the patient. It’s allowing the family to come in and actually interact with the patient all while they’re off, taking care of another patient, or documenting. So it checks a lot of boxes without any extra effort.

Kali Dayton 1:00:56
And it was so neat to be on site to see a team that, like you say were thought was far ahead of the curve. They had already done so many things to become more of an awakened walking ICU, and now they’re really mastering the mobility section of it. I think they’re on the map. I think they’re Awake and Walking ICU. And I see that even with that population, even with improved sedation practices that there were patients while we were there before eyes that could have really benefited from a titratable refraint device.

So check out the transcription. You have to see Dr. Pavini’s videos, any citations that you want to include Dr. provine, I would love to have that on their lectures, whatever you have, let’s put it on there. Everyone go do their your homework pitches to your teams if you need more help. We’ll have Dr. Pavini’s contact information on there as well.

Dr. Marie Pavini 1:01:43
Thank you, Kali.

Kali Dayton 1:01:44
Thank you so much.

Transcribed by https://otter.ai

References

Episode 92: “Intubated Because She’s Sedated and Sedated Because She’s Intubated”

Contact

Marie Pavini MD FCCM FCCP

marie@exersides.com

802-821-1002

https://calendly.com/healthy-design

https://www.facebook.com/Exersides

https://www.instagram.com/exersidesicu/

https://twitter.com/ExersidesICU

https://www.linkedin.com/company/exersidesicu/

Call to Action

Caregiver champions and administrators need to recognize that current education, resources and tools are insufficient to uniformly deliver meaningful improvement in the current milieu of over-restraint, over-sedation and delirium given the safety needs of patients and staff. They must actively seek restraint alternatives to reduce agitation, sedation and delirium risk, and decrease risk of immobility and sedative complications. Restraints and restraint alternatives should be titratable from conservative to liberal, be free from tension/pressure on the limb, be able to remain safely untied to a bed/chair, and allow finger dexterity, visibility and access to the limb, active range of motion without risk of entanglement in tubes/lines, and standardized best practice. Administrators need to incent non-restraint by allowing reduced documentation through CMS language of non-restraint.

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