Using Healthcare Failure Mode And Effect Analysis To Reduce The Incidence Of Unplanned Extubations Of The Patients With Physical Restraints

BackgroundPhysical restraints is a common traditional means of medical personnel to preventing unplanned extubations (UEX), however, the effect on preventing UEX is still controversial. With the deepening of the research on physical constraints, the use of physical restraints has been curbed in foreign, but, due to the lack of nursing staff, its utilization rate is much higher than abroad. Currently, our country have not promulgated the unified process of using physical constraints in general hospital, what’s more, a large proportion of nurses haven’t realized physical restraints can bring a series of harm to patients. There is a certain empirical judgment and randomness in the using of physical restraints because of the above reasons. In recent years, the research both at home and abroad related to physical restraints mainly focus on the rehabilitation in institutions, there are less research about the use of physical restraints in general hospitals. The latter mainly focuses on the investigation of present situation, the regarding to improve the preventive effect to UEX of physical restraints are few. Therefore, it is necessary to carry out the related research to formulate the appropriate management measures with improving the effect of prevention for UEX of physical restraints, to reduce patients’ economic burden, ensure the safety of patients and promote patients recovery. Objectives1. To investigate the present situation of the patients in neurosurgery Intensive Care Unit and find the characteristics and problems of physical restraints.2. To use the mothod of Healthcare Failure Mode and Effects Analysis building the management model of physical restraints, and to study its effects in preventing UEX in the patients with physical restraints.Methods1.164critically ill patients with indwelling pipeline in the neurosurgery ICU in a general hospital in Nanjing were enrolled into the prospective cohort study. The self-designed record sheets about the characteristics of physical restraints and the nurses’behaviors on physical restraints implementation were used to invest the incidence of UEX of the patients with restraints, the present situation of the physical restraints and the characteristics of nurses’ behaviors of using physical restraints.2. The management team about the nursing of physical restraints was set up according to Healthcare Failure Mode and Effects Analysis, to revise the nursing process by the Work Breakdown Structure, and then take the hazards analysis to all the links of the nursing process to identify the key links influencing the effects. Finally, build the management mode for physical restraints by analyzing the failure modes of the key links.3. The management model of HFMEA was applied to clinical practice, compared the incidence of UEX and the characteristics of the patients with physical restraints before and after the implementation of HFMEA. Study the effect of HFMEA in strengthening physical restraints to prevent UEX by the statistical analysis results. Results1. The study showed that among the164patients in neurosurgery ICU,99patients (60.4%) experienced physical restraints, they experienced physical restraints averagely continuing (140.15±132.61) h, including81(81.8%) patients started to experience physical restraints,52(52.5%) patients have been under restraint along in hospital. The patients experienced physical restraints have higher incidence of UEX (P<0.05) compared with patients without restraint. The GCS score, diagnosis, and whether they are conscious may affect the use of physical restraints (P<0.05). At the same time, the clinical observation showed that "relaxing to patients timely","the shift for the patients with restraints" and "choice the best tools for patients needing restrainted" are the three projects with the lowest rate of using.2. The nursing procedure of physical restraints was revised by applying HFMEA. Eleven key links were identified and management measures were formulated for these key links. Finally, build a management model of HFMEA for physical restraints.3. The nurses’ level of knowledge and behaviors about physical restraints both were improved (P<0.05) by training, applying visual management and example motivation method. The patients’incidence of UEX reduced after applying HFMEA was lower than the patients before applying HFMEA (P<0.05). The rate of utilization and the duration of physical restraints for patients in lucid interval were both reduced (P<0.05), however, the average restraints’ duration of overall patients under restraints has no difference (P>0.05). What’s more, the risk number of nine key links was reduced (P<0.05) expect the best choice of tools and the fixation on the edge of bed.Conclusions1. The incidence of UEX of patients with physical restraints in neurosurgery ICU, and the present situation of physical restraints is not optimistic, which is reflected in high-rate utilization, long-time restraints, high-rate utilization in conscious patients and nurses’ behaviors are lack of standardization.2. HFMEA theory is an effective screening out the key links of physical constraints, and building effective safety management model for physical restraints.3. The management model of HFMEA can reduce the incidence of UEX with physical restraints, the rate of utilization and the duration of physical restraints for patients in lucid interval, can decrease the patient’s risk of UEX, and change the present situation of physical constraints.