Interventions to Minimize or Reduce Patient-Initiated Device Removal

Determining Underlying Cause for Agitation/Cognitive Impairment

Device Removal

Immediate Assessment

If abrupt change in perception, attention, or level of consciousness:

-Assess for life-threatening physiologic impairments:

respiratory, neurologic, fever/sepsis, hypo/hyperglycemia, alcohol/substance withdrawal, fluid and electrolyte imbalance.

-Notify physician of change in mental status & compromised physiologic status

Differential assessment (Interdisciplinary)

-Obtain baseline or pre-morbid cognitive function from family caregivers

-Establish whether the patient has history of dementia or depression

-Review medications to identify drug–drug interactions, adverse effects

-Review current laboratory values

Treatment (Interdisciplinary)

-Treat underlying disorder(s)

-Judicious, low dose use of medication if warranted for agitation

-Communication techniques: low voice, simple commands, reorientation

-Frequent reassurance and orientation

-Surveillance/observation: Determine whether family member(s) willing to stay with patient; move patient closer to nurses’ station; perform safety checks more frequently; redeploy staff to provide one-on-one observation if other measures ineffective.

Disruption of Any Device

-Determine if medically possible to discontinue device; try alternative mode of therapy

-For mild-to-moderate cognitive impairment, explain device and allow patient to feel under nurse’s guidance

Attempted or actual disruption: ventilator

-Determine underlying cause of behavior for appropriate medical and/or pharmacologic approach

-More secure anchoring

Start with less restrictive means: mitts, elbow extenders

Attempted or actual disruption: Nasogastric tube

-If for feeding purposes, consult with nutritionist, speech or occupational therapist for swallow evaluation

-Consider gastrostomy tube for feeding as appropriate

if other measures ineffective

-Anchoring of tube, either by taping techniques or commercial tube holder

-If restraints needed, start with least restrictive restraints: mitts, elbow extenders

Attempted or actual disruption: IV lines

-Commercial tube holder for anchoring

-Long-sleeved robes, commercial sleeves for arms

-Consider Hep-Lock and cover with gauze

-Taping, securement of IV line under gown, sleeves

-Keep IV bag out of visual field

-Consider alternative therapy: oral fluids, drugs

Attempted or actual disruption: Bladder catheter

-Consider intermittent catheterization if appropriate

-Proper securement, anchoring to leg; commercial tube holders available

If patient has underlying dementia:
Consider using Therapeutic Activity Kit

Although there is no strong evidence to support each interventions, they have been used in a multicomponent quality improvement study that demonstrated reduced rates of therapy disruption (Mion, Fogel, Sandhu et al., 2001 [Level III]).