Remedies to improve management of agitated ICU patients

Agitated adult patients in hospital Intensive Care Units pose danger to both clinical staff and patients – but there are solutions other than pharmacological interventions available and applicable around the world, as identified by new research from Flinders Caring Futures Institute. 

Anne Mette Adams, a lecturer in nursing at Flinders University’s College of Nursing and Health Sciences, is an intensive care nurse, teacher and researcher at Flinders CFI with clinical experience in Danish, Norwegian and Australian healthcare settings. Her international perspective has added valuable insights to help remedy a problem that exists in many countries. 

Anne Mette Adams

“Before I commenced this project, I studied staff wellbeing in ICU and realised that one reason why clinicians burn out is when they are unable to provide optimised care,” says Mrs Adams. “I therefore wanted to develop a tool that could support organisations, leadership groups and ICU clinicians to provide better care. 

“As a clinician in Danish, Australian and Norwegian health care settings, I have observed broad practice variations in the way patient agitation is managed. 

“Approaches differ between clinicians, institutions and individuals, and the strategies clinicians use to reduce agitation in the ICU seem to be heavily influenced by personal viewpoints and experiences rather than on evidence”  

Existing guidelines for agitation in ICU mainly focus on medical treatments, but Mrs Adams’ thesis instead examined the use of non-pharmacological strategies to prevent, minimise and manage agitation in critically ill adult patients.  

“Agitation has a detrimental impact on the patient, the family and health providers. While it is tempting to first reach out for pharmacological solutions, it is important to be aware that these are often associated with adverse effects,” says Mrs Adams. 

“Although pharmacological agents can be essential for safety, the use of non-pharmacological strategies in the first instance can be cheaper, safer, led by nurses and are more likely to be patient- and family-centred, focusing on the needs of patients and causes of agitation.” 

Mrs Adams’ project involved stakeholders in all research phases, and has a strong focus on how stakeholders can be engaged in ethical and meaningful ways.   

“I discovered that very little guidance existed on how all the stakeholders can be engaged in guideline development, so we developed a practical seven-step framework. This is significant, because stakeholder engagement is often not done well, which is why the uptake of guidelines is often poor. Recommendations simply don’t reflect the needs of those who will use them”.    

Her research quizzed previous ICU patients, ICU family members, physicians, nurses, physiotherapists, occupational therapists and others who work in the ICU setting, to fully understand ICU problems and shortcomings.  

She received overwhelming support from stakeholders because managing patient agitation in ICU is an area that clinicians are very interested in and want to know more about. 

The research developed a range of preliminary Danish and Australian clinical practice guidelines to help clinicians identify non-pharmacological strategies that reduce patient agitation.  

“Patient-centred non-pharmacological strategies are essential and strongly impact patient experiences and outcomes. Offering staff alternatives to physical restraints and sedation, also impact staff and family outcomes.” 

Mrs Adams’ work to develop international guidelines avoids duplication of work and promotes better patient care globally. The study also created an awareness of different cultures and how these affect patient care – such as physical restraints being widely accepted in Australian ICUs, but not commonly used in Danish ICUs.  

She hopes that knowledge and evidence from these different sources can create more comprehensive guidelines. 

“In the long term, I would like to implement and evaluate the guidelines across many countries,” says Mrs Adams. “My hope is that these guidelines will support clinicians in their decision-making processes to ensure optimised patient-centred care worldwide, and to promote a more holistic approach to guideline development.  

“The best result will be if my work encourages clinicians worldwide to reflect upon and use patient centred non-pharmacological strategies when possible – and that this will significantly improve patient experiences.” 

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Intensive Care