Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units

Kydonaki, Kalliopi; Hanley, Janet; Huby, Guro; Antonelli, Jean; Walsh, Timothy

doi:10.1136/bmjopen-2018-024549

Cited by 22 publications

(31 citation statements)

References 27 publications

(23 reference statements)

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“…There was also a lack of standardisation of chemical restraint, with a variety of drugs administered, including Haloperidol (Luk et al, ; MacSweeney et al, ), opiates (Fraser et al, ) and benzodiazepines (van der Kooi et al, ; Luk et al, ). Participants in multidisciplinary focus groups held by Palacios‐Cena et al () and Kydonaki, Hanley, Huby, Antonelli, and Walsh () described the lack of standardised and evidence‐based agents for the management of agitated or delirious patients. This led to variation in dose and confusion amongst nursing staff (Palacios‐Cena et al, ) and reliance on doctors' clinical preferences and a “trial and error” approach (Kydonaki et al, ).…”

Section: Resultsmentioning

confidence: 99%

“…Participants in multidisciplinary focus groups held by Palacios‐Cena et al () and Kydonaki, Hanley, Huby, Antonelli, and Walsh () described the lack of standardised and evidence‐based agents for the management of agitated or delirious patients. This led to variation in dose and confusion amongst nursing staff (Palacios‐Cena et al, ) and reliance on doctors' clinical preferences and a “trial and error” approach (Kydonaki et al, ).…”

Section: Resultsmentioning

confidence: 99%

“…Shift‐by‐shift, or rotational, practice variations were identified (Kydonaki et al, ; Luk et al, ; Palacios‐Cena et al, ; Turgay, Sari, & Genc, ). Nurses involved in the focus groups held by Palacios‐Cena et al () noted that agitated or delirious patients received a different chemical treatment each shift according to the doctor's preference.…”

Section: Resultsmentioning

confidence: 99%

“…This led to variation in dose and confusion amongst nursing staff (Palacios-Cena et al, 2016) and reliance on doctors' clinical preferences and a "trial and error" approach (Kydonaki et al, 2019).…”

Section: Practice Variationsmentioning

confidence: 99%

“…A minority of nurses cited "poor behaviour" (Choi & Song, 2003) as a rationale for physical restraint. Previous drug use and psychosis were associated with difficult sedation, and a reluctance amongst staff to lighten continuous sedation without support from colleagues (Kydonaki et al, 2019).…”

Section: Behaviourmentioning

confidence: 99%

See 4 more Smart Citations

Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit

Teece

Baker

Smith

2019

Journal of Clinical Nursing

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Aims and objectives To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit. Background Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence‐based practice or custom and culture. Study design Integrative review. Method Seven health sciences databases were searched to identify published and grey literature (1995–2019), with additional hand‐searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken. Results A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint. Conclusions There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision‐makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated. Relevance to clinical practice Delirium and agitation pose a potential threat to patient safety and the maintenance of life‐preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence‐based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.

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