Predictors of physical restraint use in Canadian intensive care units

Restrictive use of Restraints and Delirium Duration in the Intensive Care Unit (R2D2-ICU): protocol for a French multicentre parallel-group open-label randomised controlled trial

INTRODUCTION

Physical restraint (PR) is prescribed in patients receiving invasive mechanical ventilation in the intensive care unit (ICU) to avoid unplanned removal of medical devices. However, it is associated with an increased risk of delirium. We hypothesise that a restrictive use of PR, as compared with a systematic use, could reduce the duration of delirium in ICU patients receiving invasive mechanical ventilation.

METHODS AND ANALYSIS

The Restrictive use of Restraints and Delirium Duration in ICU (R2D2-ICU) study is a national multicentric, parallel-group, randomised (1:1) open-label, controlled, superiority trial, which will be conducted in 10 ICUs. A total of 422 adult patients requiring invasive mechanical ventilation for an expected duration of at least 48 hours and eligible for prescription of PR will be randomly allocated within 6 hours from intubation to either the restrictive PR use group or the systematic PR use group, until day 14, ICU discharge or death, whichever comes first. In both groups, PR will consist of the use of wrist straps. The primary endpoint will be delirium or coma-free days, defined as the number of days spent alive in the ICU without coma or delirium within the first 14 days after randomisation. Delirium will be assessed using the Confusion Assessment Method-ICU twice daily. Key secondary endpoints will encompass agitation episodes, opioid, propofol, benzodiazepine and antipsychotic drug exposure during the 14-day intervention period, along with a core outcome set of measures evaluated 90 days postrandomisation.

ETHICS AND DISSEMINATION

The R2D2-ICU study has been approved by the Comité de Protection des Personnes (CPP) ILE DE FRANCE III-PARIS (CPP19.09.06.37521) on June 10th, 2019). Participant recruitment started on 25 January 2021. Results will be published in international peer-reviewed medical journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04273360.

Use of physical restraints on older adults in South Korean nursing homes: a multicenter study

In this study, we aimed to examine the current status of physical restraint use and ascertain factors affecting the rate of usage of physical restraints on older adults in South Korean nursing homes. For this purpose, we conducted a secondary analysis of data from 190 registered nurses employed at 62 nursing homes. Logistic regression analysis was used to identify the factors affecting the use of restraints in nursing homes. The rate of using physical restraints was 79.5%. Nursing homes were found to use 90.7% and 91.3% less restraint when the work environment was better (odds ratio [OR]: 0.093, 95% confidence interval [CI]: 0.023-0.368) and mixed (OR: 0.087, 95% CI: 0.087-0.100), respectively. Nursing homes owned by corporations were 9.796 times more likely to use physical restraints than those owned by local governments (OR: 9.796, 95% CI: 1.473-65.158). Therefore, improving nurses' work environment and introducing regulations and education that enable the entrusted doctors or nurses to make decisions regarding restraint use, monitoring, and removal, regardless of nursing home ownership type, are necessary.

Physical restraint practices in an adult intensive care unit: A prospective observational study

AIM AND OBJECTIVES

To conduct a diagnostic evaluation of physical restraint practice using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

BACKGROUND

Evidence indicates that physical restraints are associated with adverse physical, emotional and psychological sequelae and do not consistently prevent intensive care unit (ICU) patient-initiated device removal. Nevertheless, physical restraints continue to be used extensively in ICUs both in Canada and internationally. Implementation science frameworks have not been previously used to diagnose, develop and guide the implementation of restraint minimisation interventions.

DESIGN

A prospective observational study of restrained patients in a 20-bed, academic ICU in Toronto, Canada.

METHODS

Data collection methods included patient observation, electronic medical record review, and verbal check with the point-of-care nurses. Data were collected pertaining to framework domains of unit culture (restraint application/removal), evaluation capacity (documentation) and leadership (rounds discussion). The reporting of this study followed the STROBE guidelines.

RESULTS

A total of 102 restrained patients, 67 (66%) male and mean age 58 years (SD 1.92), were observed. All observed devices were wrist restraints. Restraint application and removal time was verified in 83 and 57 of 102 patients respectively. At application, 96.4% were mechanically ventilated and 71% sedated/unarousable. Nurses confirmed 71% were prophylactically restrained; 7.2% received restraint alternatives. Restraint removal occurred after interprofessional team rounds (87%), during daytime (79%) and following extubation (52.6%). Of the 923 discrete patient observation of physical restraint use, 691 (75%) were not documented. Of the 30 daytime interprofessional team rounds reviewed, physical restraint was discussed at 3 (10%).

CONCLUSION

In this single-centre study, a culture of prophylactic physical restraint was observed. Future facilitation of restraint minimisation warrants theoretically informed implementation strategies including leadership involvement to advance interprofessional collaboration.

RELEVANCE TO CLINICAL PRACTICE

The findings draw attention to the importance of a preliminary diagnostic study of the context prior to designing, and implementing, a physical restraint minimisation intervention.

Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews

AIMS

This study was performed to identify and summarize systematic reviews focusing on the prevention of unplanned endotracheal extubation in the intensive care unit.

DESIGN

Overview of systematic reviews.

METHODS

This overview was conducted according to the Preferred Reporting Items for Overviews of Systematic Reviews, including the harms checklist. A literature search of PubMed, the Cochrane Library, CINAH, Embase, Web of Science, SINOMED and PROSPERO was performed from January 1, 2005-June 1, 2021. A systematic review focusing on unplanned extubation was included, resulting in an evidence summary.

RESULTS

Thirteen systematic reviews were included. A summary of evidence on unplanned endotracheal extubation was developed, and the main contents were risk factors, preventive measures and prognosis. The most important nursing measures were restraint, fixation of the tracheal tube, continuous quality improvement, psychological care and use of a root cause analysis for the occurrence of unplanned endotracheal extubation.

CONCLUSIONS

This overview re-evaluated risk factors and preventive measures for unplanned endotracheal extubation in the intensive care unit, resulting in a summary of evidence for preventing unplanned endotracheal extubation and providing direction for future research.

TRIAL REGISTRATION DETAILS

The study was registered on the PROSPERO website.

A Nomogram for Predicting Physical Restraint of Patients in Intensive Care Unit

Background

Despite its ethical implications, physical restraint (PR) is widely used in the intensive care unit (ICU) to guarantee the safety of patients. This study investigated the frequency and risk factors of PR use for patients in the ICU to establish a predictive nomogram.

Methods

Clinical parameters of patients admitted to the ICU of Jiangsu Province Hospital from January 2021 to July 2021 were retrospectively collected. Independent risk factors of PR were analyzed by univariate and multivariate logistic regression analyses. The R software was used to establish the nomogram. Model performance was validated using the concordance-index (C-index) and calibration curves.

Results

The rate of PR use was 46.32% (233/503 patients). Age (B = 0.036, odds ratio [OR]: 1.037, 95% confidence interval [CI]: 1.022-1.052, P < 0.001), consciousness disorder (B = 0.770, OR: 2.159, 95% CI: 1.216-3.832, P=0.009), coma (B = -1.666, OR: 0.189, 95% CI: 0.101-0.353, P < 0.001), passive activity (B = 1.014, OR: 2.756, 95% CI: 1.644-4.618, P < 0.001), delirium (B = 0.993, OR: 2.699, 95% CI: 1.097-6.642, P=0.031), -3 < Richmond Agitation Sedation Scale (RASS) score <2 (B = 0.698, OR: 2.009, 95% CI: 1.026-3.935, P=0.042), RASS score ≥2 (B = 1.253, OR: 3.499, 95% CI: 1.126-10.875, P=0.030), and mechanical ventilation (B = 1.696, OR: 5.455, 95% CI: 2.804-10.611, P < 0.001) were identified as independent risk factors for PR in the ICU (P < 0.05) and included in the nomogram. The C-index was 0.830, and the calibration curve indicated good discriminatory ability and accuracy (mean absolute error: 0.026).

Conclusion

The prediction nomogram model of PR in ICU was established based on age, mobility, delirium, consciousness, RASS score, and mechanical ventilation. It showed good discrimination and accuracy. This nomogram may predict the probability of PR use in the ICU and guide nurses in developing precise interventions to reduce the rate of PR.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

OBJECTIVES

To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement.

METHOD

Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals).

RESULTS

A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521).

CONCLUSIONS

Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

Physical Restraint in the Critical Care Unit: A Narrative Review

Restraint has been used within health care settings for many centuries. Initially physical restraint (PR) was the method of choice, in present times. Within critical care units PR and chemical restraint are used, frequently in tandem. Restraint is not a benign intervention and PR specifically is associated with physical and psychological trauma towards those receiving it. Healthcare staff also suffer psychological consequences. This paper has reviewed the literature (using the terms 'physical restraint'; 'hospital'; 'care home critical care'; 'intensive care' 'attitudes'; 'knowledge' 'use of'; 'healthcare') to investigate the reasons for the use of restraints, its consequences and the attitudes of healthcare professionals' attitudes towards physical restraint currently present in critical care. Restraint use remains common practice in Critical Care Units (for 'patient safety'), initiated outside of institutional protocols, despite evidence questioning its effectiveness and the resulting harm to patients and staff.

The Use of Physical Restraints in Italian Intensive Care Units: Results From a Multicenter Observational Study

BACKGROUND

The use of physical restraints (PRs) varies across countries and clinical settings, with intensive care units having the highest frequency. Although many investigations on the use of PRs have been conducted worldwide, few studies are reported in the Italian context.

OBJECTIVES

The aims of this study were to describe PR rates and types and to observe the factors associated with PR use.

METHODS

In this observational study, 2 methods were used to collect data: direct observation and review of patients' documentations.

RESULTS

We performed 328 observations on 146 critically ill patients. Physical restraints were applied in 56.7% (n = 186) of these observations. Bilateral wrist ties were used for most PR episodes (n = 135, 72.6%), followed by unilateral wrist ties (12.9%). The most documented reasons were preventing patients from self-extubation (n = 93, 50.0%) and preserving indwelling lines and tubes (n = 60, 32.2%). In the multivariate logistic regression analysis, patients who were cared for during the night shift were almost 4 times more likely to be restrained than patients in the morning shifts (odds ratio, 3.84; P = .001) and patients with endotracheal tube were 3.5 times more likely to be restricted than spontaneously breathing patients (odds ratio, 3.59; P < .001).

DISCUSSIONS

Physical restraints are commonly used among critically ill patients in Italian intensive care units. There is a need to share the metrics for an efficient and accurate measurement of PR usage and trends and to document the reason for restraints, type of restraints, timeframe, and decision-making criteria.

Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran

Background/aim

Patients in the intensive care units (ICUs) are at high risk of developing delirium and agitation. Physical restraint (PR) has increased to control these patients which accompanies by adverse consequences. The aim was to determine the PR use and associated factors in patients hospitalized at the ICUs in the North of Iran.

Materials and methods

In this cross-sectional study, a total of 272 patients in 3 ICUs of 5 Azar referral hospital affiliated to Golestan University of Medical Sciences (Gorgan, Iran) in 2018 were included. Confusion assessment method for the ICU (CAM-ICU), Richmond Agitation-Sedation Scale (RASS), acute physiology and chronic health evaluation II (APACHE II), and Glasgow Coma Scale (GCS) were used to evaluate delirium, sedation level, disease severity, and level of consciousness, respectively. Analysis was done by STATA version 14.2 (StataCorp LP, College Station, Texas), univariate and multiple analyses.

Results

Data from 272 patients were analyzed (mean age of 45.8 ± 21.3 years). PR was used for 74.5% of patients. Restrained patients had more severe disease [mean of APACHE II score, 20.20 (7.5) vs 11.6 (7.1)], longer length of stay [mean of 10 (5.5) vs 5.5 (4.6) days], and lower level of consciousness [mean of GCS score, 8.7 (3.5) vs 13.5 (3.3)] than patients without it. CAM-ICU was positive in majority of patients (79.5 vs 10.4%) and agitation level of RASS score was higher in restrained patients (31.7 vs 3.0%). Associated factors in multiple analysis were use of sedative and psychoactive drugs [odds ratio (OR), 2.85; 95% confidence interval (CI): 1.04–7.82], presence of delirium (OR, 15.13; 95% CI: 4.61–49.65), deep sedation (OR, 0.04; 95% CI: 0.00–0.45), and GCS score (OR, 0.69; 95% CI: 0.53–0.9).

Conclusion

This study revealed the high use of PR in the ICUs, and use of sedative and psychoactive drugs, presence of delirium, deep sedation, and GCS score were such associated factors.

How to cite this article

Nomali M, Ayati A, Yadegari M, Nomali M, Modanloo M. Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran. Indian J Crit Care Med 2022;26(2):192–198.

Prevalence of and factors associated with physical restraint use in the intensive care unit: a multicenter prospective observational study in Japan

Physical restraint is widely used in the intensive care unit (ICU) to ensure patient safety despite its ethical implications. We performed a prospective observational study in six ICUs in Japan to determine the prevalence of and factors associated with physical restraint use in the ICU, a phenomenon that has not yet been reported on in Japan. Data were collected on 10 random days between November 2018 and February 2019. We evaluated physical restraint use in ICU patients aged ≥ 20 years during the data collection days. Among the 787 observations, the prevalence of physical restraint use was 32.9%; however, it was 41.5% in patients receiving invasive mechanical ventilation (IMV). The average age of patients was 68.5 years, and the average Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score was 19.4. Among the included patients, 52.1% received IMV, and 17.2% were diagnosed with delirium. Logistic regression analysis revealed that the independent factors [odds ratio (95% confidence interval)] associated with physical restraint use were age [1.02 (1.00-1.05)], APACHE II score [1.05 (1.01-1.09)], IMV [2.15 (1.16-4.01)], central venous catheter indwelling [2.66 (1.46-4.85)], sedative medication [2.98 (1.72-5.17)], agitation [7.83 (2.96-20.8)], and delirium [4.16 (2.37-7.29)]. Approximately one-third of the ICU patients required physical restraint in Japan. In addition, physical restraint use was influenced by disease severity, mental condition, and the medical apparatus used. Based on these findings, further investigations are imperative to develop strategies to reduce physical restraint use.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Physical Restraints and Post-Traumatic Stress Disorder in Survivors of Critical Illness. A Systematic Review and Meta-analysis

Rationale: Physical restraints are used liberally in some intensive care units (ICUs) to prevent patient harm from device removal or falls. Although the intention of restraint use is patient safety, their application may inadvertently cause physical or psychological harm. Physical restraints may contribute to post-traumatic stress disorder (PTSD), but there is a paucity of supportive data.Objectives: To investigate the association between physical restraint use and PTSD symptoms in ICU survivors. Secondary objectives were to examine the cognitive and physical outcomes associated with physical restraint use and to assess interventions that may be effective in reducing restraint use.Methods: A systematic review of English language studies in PubMed, Medline, Embase, CINAHL, and CENTRAL between January 1, 1990, to February 8, 2020 was performed. Observational or randomized studies that reported on restraint use and associated outcomes, or interventions to reduce restraint use, in critically ill adult patients were identified. Two independent reviewers completed the review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Results: We identified 794 articles, of which 37 met inclusion criteria and were included. Thirty of these studies related to patient outcomes including PTSD, delirium, mechanical ventilation hours, and physical injury. Seven related to interventions to reduce physical restraint use. The quality of studies was not high; only four of the included studies were assessed to have a low risk of bias. Three studies found a significant relationship between restraint use and PTSD, but their results could not be pooled for analysis. Pooled data indicated a significant association between physical restraint use and delirium (odds ratio [OR], 11.54; 95% confidence interval [CI], 6.66-20.01; P < 0.001) and duration of mechanical ventilation (mean difference in days, 3.35; 95% CI, 1.95-4.75; P < 0.001). We also found that interventions, such as nursing education, may effectively reduce restraint use by approximately 50% (OR, 0.48; 95% CI, 0.32-0.73; P < 0.001). The impact that a reduction in restraint use may have on associated outcomes was not examined.Conclusions: Physical restraint use may be associated with PTSD in ICU survivors and is associated with delirium and longer duration of mechanical ventilation. Nurse education is likely effective in reducing rates of physical restraint among ICU patients.

Physical Restraints in Critically Ill Children: A Multicenter Longitudinal Point Prevalence Study

OBJECTIVES

We elucidate to investigate the prevalence of and factors associated with the use of physical restraints among critically ill or injured children in PICUs.

DESIGN

This was a multicenter, longitudinal point prevalence study.

SETTING

We included 26 PICUs in Japan.

PATIENTS

Included children were 1 month to 10 years old. We screened all admitted patients in the PICUs on three study dates (in March, June, and September 2019).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We collected prevalence and demographic characteristics of critically ill or injured children with physical restraints, as well as details of physical restraints, including indications and treatments provided. A total of 398 children were screened in the participating PICUs on the three data collection dates. The prevalence of children with physical restraints was 53% (211/398). Wrist restraint bands were the most frequently used means (55%, 117/211) for potential contingent events. The adjusted odds of using physical restraint in patients 1-2 years old was 2.3 (95% CI, 1.3-4.0) compared with children less than 1 year old. When looking at the individual hospital effect, units without a prespecified practice policy for physical restraints management or those with more than 10 beds were more likely to use physical restraints.

CONCLUSIONS

The prevalence of physical restraints in critically ill or injured children was high, and significant variation was observed among PICUs. Our study findings suggested that patient age, unit size, and practice policy of physical restraint could be associated with more frequent use of physical restraints.

Use of Physical Restraints in Critical Care Units: Nurses' Knowledge, Attitudes, and Practices

BACKGROUND

Various factors affect the use of physical restraints in the intensive care unit, with nurses' knowledge and attitudes being the strongest determinants.

OBJECTIVE

To determine Turkish intensive care unit nurses' knowledge, attitudes, and practices regarding physical restraints and factors influencing them.

METHODS

This cross-sectional, correlational study was conducted in the intensive care units of state and university hospitals. A total of 191 nurses provided information on their sociodemographic and professional characteristics and completed a questionnaire on their knowledge, attitudes, and practices regarding physical restraints.

RESULTS

Statistically significant differences were found between average knowledge scores according to type of intensive care unit, weekly working hours, work shift, and frequency of using physical restraints, with the highest scores found in nurses who worked in the surgical unit, worked 40 hours a week, worked only during the day, and used physical restraints every day. Significant differences were found between average attitude scores according to type of intensive care unit, with the highest scores found in nurses who worked in the cardiology unit. Significant differences were found between average practice scores according to level of education and use of physical restraints without a physician's order, with the highest scores found in nurses with undergraduate and postgraduate degrees and those who did not use physical restraints without a physician's order.

CONCLUSIONS

This study revealed inadequate knowledge about physical restraints and some unsafe practices among participants. Evidence-based guidelines and laws regarding physical restraints are needed, as well as regular training programs for involved personnel.

Decline in Physical Restraint Use Following Implementation of Institutional Guidelines

OBJECTIVE

To investigate the strategies implemented at our institution to reduce medical restraint use.

BACKGROUND

Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients.

METHODS

The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation.

RESULTS

The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark.

CONCLUSIONS

This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

Development and implementation of a novel decision support tool on physical restraint use in critically ill adult patients

AIM

To investigate whether a novel decision support tool would effectively minimize physical restraint use in critically ill adult patients.

DESIGN

A nonequivalent quasi-experimental design combined with a descriptive qualitative approach was used.

METHODS

A Restraint Decision Tree was developed based on a qualitative study that explored the barriers to employ the Restraint Decision Wheel. During the quasi-experimental study, patients admitted to the unit between October 2017 and March 2018 were enrolled as the control group receiving the Restraint Decision Wheel (n = 528), whereas patients between April 2018 and September 2018 were enrolled as the intervention group receiving the Restraint Decision Tree (n = 564). The physical restraint rate, accidental catheter removal rate and nurses' satisfaction were compared.

RESULTS

The Restraint Decision Tree significantly decreased physical restraint use. No significant difference in the rate of accidental catheter removal was found. Nurses reported increased satisfaction with the restraint decision-making.

CONCLUSIONS

The Restraint Decision Tree could minimize physical restraint use. Physicians' involvement in the restraint decision-making and nurses' competence in delirium assessment may be essential for successful implementation of the Restraint Decision Tree.

Factors Influencing the Physical Restraint of Patients in the Neurosurgical Intensive Care Unit

The purpose of this study was to investigate the current status of physical restraint of patients in the neurosurgical intensive care unit (NSICU) and analyze the factors influencing this measure using a cross-sectional study design. A total of 312 patients from four tertiary hospitals in NSICU were investigated in Beijing, China. The rate of physical restraint of patients in the NSICU was 42.9%. In 41.8% of cases, nurses performed physical restraint based on experience, and 45.5% of patients had physical restraint-related nursing records. Binary logistic regression analyses revealed that physical restraint was associated with delirium, mild-to-moderate disturbance of consciousness, history of extubation, surgery, and use of sedatives within 24 hour. Analysis of related factors can provide a reference for nurses and managers to improve physical restraint strategies.

Association between physical restraint requirement and unfavorable neurologic outcomes in subarachnoid hemorrhage

Background

Physical restraint has been commonly indicated to patients with brain dysfunction in neurocritical care. The effect of physical restraints on outcomes of critically ill adults remains controversial as no randomized controlled trials have compared its safety and efficacy, and the association between physical restraint requirement and neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been fully examined. The aim of this study was to examine the association between physical restraint requirement and neurological outcomes in patients with SAH.

Methods

A single-center, retrospective study was conducted on patients with acute phase SAH treated for > 72 h in the intensive care unit from 2014 to 2020. Patients were divided into three groups based on the amount of time required for physical restraint during the first 24–72 h after admission: no, intermittent, and continuous use of physical restraint. Unfavorable neurologic outcome, assessed using the modified Rankin scale upon hospital discharge, has been considered as primary end point.

Results

Overall, 101 patients were included in the study, with 52 patients (51.5%) having unfavorable neurological outcomes. Among them, 46 patients (45.5%) did not use physical restraint, and 55 (54.5%) patients used physical restraint during the first 24–72 h after admission: 26 (25.7%) intermittent and 29 (28.7%) continuous. Multivariable logistic regression analysis showed that continuous use of physical restraint during the first 24–72 h after admission was significantly associated with unfavorable neurological outcomes in patients with SAH (odds ratio, 3.54; 95% confidence interval, 1.05–13.06; p = 0.042) compared with no physical restraint.

Conclusions

Continuous use of physical restraint during the first 24–72 h after admission was more significantly associated with unfavorable neurological outcomes than no physical restraint among patients with SAH during the acute phase.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00541-z.

Predictors of physical restraint use on critical care units: An observational structural equation modeling approach

BACKGROUND

Modifiable unit characteristics, including nurse work environment, education, certification, and staffing have been shown to impact patient safety. Physical restraints are an important patient safety issue, however the relationships between these modifiable unit characteristics and physical restraint use on critical care units has not been explored.

OBJECTIVES

Our objective was to determine the role of nursing work environment, nurse education and certification, and nurse staffing on physical restraint use.

DESIGN

The study was a secondary analysis of 2017-2018 unit-level restraint rates from the National Database of Nursing Quality Indicators linked to Registered Nurse survey and hospital characteristics data.

METHODS

Work environment was examined at the unit-level using total Practice Environment Scale of the Nursing Work Index and subscale scores. Unit-level nurse expertise included the percent of nurses with at least a Bachelor of Science in Nursing degree and percent with certification. Nurse staffing was the unit-level Registered Nurse hours per patient day and skill mix. Analyses included descriptive statistics, bivariate correlations, and Structural Equation Modeling. We used a first order model to estimate predicted restraint use from the five subscales of the Practice Environment Scale of the Nursing Work Index. A higher order model predicted restraint use from a total work environment factor score.

RESULTS

The sample included 408 critical care units from 226 hospitals. Mean restraint rate was 15% (SD 12, range 0-53%). In the first-order model, the Collegial Nurse-Physician Relations subscale had a positive relationship with restraint use (β = 0.167, 95% confidence interval 0.010-0.333). In the higher order model, the total work environment score had a negative relationship with restraint use (β = -0.088, 95% confidence -0.178- -0.014). Registered Nurse hours per patient day had a negative relationship to restraint use in both the first order (β = -0.114, 95% confidence interval -0.222--0.025) and higher order models (β = -0.117, 95% confidence interval -0.223- -0.012).

CONCLUSION

We found that better nurse-physician relationships were associated with higher restraint use. This finding is supported by previous literature and may reflect physician trust in nursing judgement when using restraints. However, a better work environment overall was associated with lower restraint rates. Further, Registered Nurse hours per patient day, but not skill mix, was associated with lower restraint rates. We conclude that improving the overall nurse work environment and nurse staffing, as well as using interprofessional interventions, may be successful in decreasing restraint use on critical care units.

The multidisciplinary team perspectives on agitation management in critical care: A qualitative study

BACKGROUND

People who are experiencing a period of critical illness frequently experience severe agitation. The presence of agitation can pose risks to the patient, family, and clinical team.

AIMS AND OBJECTIVES

To capture the views and opinions of critical care multidisciplinary teams concerning the approaches in the management of agitation, and to understand and identify the perceived risks and benefits of current management strategies.

DESIGN

A descriptive qualitative design.

METHODS

Data were gathered using semi-structured interviews with multidisciplinary teams from adult critical care units from one region in the United Kingdom.

FINDINGS

A total of 19 participants participated between February to September 2017. There were two group interviews (GIs) (n = 12, GI 1 n = 8, GI 2 n = 4) and seven one-to-one interviews, across four hospital organisations with one participant working via an agency. The mean length (± SD) of each interview, one to one or group, was 58.86 minutes (5.81 minutes). Three major themes were generated about the complex clinical decision-making required to manage an agitated patient. These themes represented: the burden of care, continuity of clinical decision-making, and uncertainty and indecision experienced by participants.

CONCLUSION

Participants described caring for an agitated patient as challenging and stressful. Staff sought clarification on what level of restrictive practice is allowed. Feelings of anxiety and stress generated by the decisions made may have an impact on staff, particularly those who are more inexperienced, which in the longer term could lead to fatigue or moral distress.

RELEVANCE TO CLINICAL PRACTICE

The study has emphasised the challenges faced by multidisciplinary teams and how decision-making may impact on individuals within the team.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Association between the use of physical restraint and functional decline among older inpatients admitted with pneumonia in an acute care hospital: A retrospective cohort study

AIM

This study was conducted to investigate the association between the use of physical restraint and functional decline in older inpatients admitted with pneumonia in an acute care setting. Although several adverse effects related to restraint use have been reported, few researchers have examined this subject in acute care settings.

METHODS

This retrospective cohort study was conducted at a 471-bed, acute care hospital in Japan. Patients 65 years old and older who were admitted with pneumonia between April 2015 and September 2017 were included. The use of restraints (belts and/or mittens) was recorded for every 8-hour shift. The number of shifts during which each patient was restrained was used as an explanatory variable. The primary outcome was the Katz ADL score at discharge. We used multiple linear regression analysis to adjust for confounding factors.

RESULTS

Of 403 patients, 94 required physical restraints. The mean age was 84.5 years (standard deviation [SD] 8.2); 44.4% were women. The mean Katz score on admission was 2.7 (SD 2.4). For multiple linear regression analysis, the coefficient of the number of restraints used was -0.024 (95% confidence interval: -0.044, -0.003, p = .022). Consequently, the restraint use for 13.9 days was associated with the decrease in the Katz score by 1.0.

CONCLUSIONS

Results suggest that physical restraint use is associated with functional decline among older inpatients admitted with pneumonia in acute care settings.

Restraint use in the acute-care hospital setting: A cross-sectional multi-centre study

BACKGROUND

Restraints are likely to negatively affect patients' health and therefore a reduction in their usage is recommended for all health-care settings. To date, research on restrictive practices has concentrated on mental health and long-term care settings. In the acute-care hospital setting few studies have been published and these studies mainly focus on physical/mechanical restraints in specific subpopulations and/or on intensive care units. However, to ensure restraints are used as little as possible in the acute-care hospital setting, it seems important to investigate more comprehensively the use of restraints, to include all types of restraints irrespective of ward type or subpopulations and to identify factors associated with restraint use.

OBJECTIVE

The aim of this study was to investigate restraint use regardless of ward type in the acute-care hospital setting, including restraint type, reasons for restraint use, process indicators when using restraints and restraint use-associated patient characteristics.

METHODS

Using a cross-sectional multi-centre design, data were collected by means of an annual international prevalence measurement in acute-care hospitals in Switzerland and Austria. All hospitalised patients aged 18+ who gave informed consent were included. Data were collected at three measurement points between 2016 and 2018. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

A total of 29,477 patients hospitalised in 140 hospitals were included in this study. The prevalence rate for the use of at least one restraint over a 30-day period was 8.7% (n = 2577), with mechanical restraints representing the highest proportion of restraint type used (55.0%, n = 1417). The main reason for restraint use was fall prevention (43.8%, n = 1129), followed by confusion or delirious behaviour (20.4%, n = 525). In 64.3% of the cases (n = 1657), restraint use was documented in the patient file. Regular evaluation occurred in 42.9% of the cases (n = 1105). Care dependency had the strongest association with restraint use (odds ratio [OR] 25.00, 95% confidence interval [CI] 21.01-29.78 for completely dependant patients in comparison to completely independent patients), followed by mental and behavioural disorders (OR 2.36, 95% CI 2.15-2.59).

CONCLUSIONS

Restraints are often utilised in hospitals in complex care situations such as with patients at risk of falling or with delirium. When using restraints the consideration of processes like documentation and evaluation shows great potential for improvement. Standardisation of these processes and education of the interprofessional team could be beneficial for raising awareness and for the sustainable reduction of restraint use. Tweetable abstract: In hospitals restraints are often used in complex care situations. However, their use seems to be insufficiently documented and evaluated.

Burden of Healthcare Utilization among Chronic Obstructive Pulmonary Disease Patients with and without Cancer Receiving Palliative Care: A Population-Based Study in Taiwan

Chronic obstructive pulmonary disease (COPD) is a chronic disease that burdens patients worldwide. This study aims to discover the burdens of health services among COPD patients who received palliative care (PC). Study subjects were identified as COPD patients with ICU and PC records between 2009 and 2013 in Taiwan's National Health Insurance Research Database. The burdens of healthcare utilization were analyzed using logistic regression to estimate the difference between those with and without cancer. Of all 1215 COPD patients receiving PC, patients without cancer were older and had more comorbidities, higher rates of ICU admissions, and longer ICU stays than those with cancer. COPD patients with cancer received significantly more blood transfusions (Odds Ratio, OR: 1.66; 95% C.I.: 1.11-2.49) and computed tomography scans (OR: 1.88; 95% C.I.: 1.10-3.22) compared with those without cancer. Bronchoscopic interventions (OR: 0.26; 95% C.I.: 0.07-0.97) and inpatient physical restraints (OR: 0.24; 95% C.I.: 0.08-0.72) were significantly more utilized in patients without cancer. COPD patients without cancer appeared to receive more invasive healthcare interventions than those without cancer. The unmet needs and preferences of patients in the life-limiting stage should be taken into consideration for the quality of care in the ICU environment.

Iranian nurses' perceptions about using physical restraint for hospitalized elderly people: a cross-sectional descriptive-correlational study

BACKGROUND

Using physical restraint (PR) for hospitalized elderly people is a major nursing challenge. It is associated with different physical and mental complications and ethical dilemmas, though many nurses still use it to ensure patient safety. Nurses' perceptions are one of the most important factors affecting PR use. This study aimed to evaluate Iranian nurses' perceptions about PR use for hospitalized elderly people.

METHODS

This cross-sectional descriptive-correlational study was conducted from July to December 2019. Participants were 270 hospital nurses who were purposively recruited from intensive care units and medical and surgical wards of three teaching hospitals in Kermanshah, Iran. Data were collected using a demographic questionnaire and the Perceptions of Restraint Use Questionnaire (PRUQ). The SPSS software (v. 23.0) was used for data analysis through the independent-sample t test, the one-way analysis of variance, and the multiple regression analysis.

RESULTS

The total mean score of PRUQ was 4.08 ± 0.12 in the possible range of 1-5. The most important reasons for PR use were to prevent patients from falling out of bed and to prevent them from pulling out catheters. The total mean score of PRUQ had significant relationship with participants' age, work experience, and history of receiving PR-related educations (P < 0.05), but had no significant relationship with their gender, educational degree, and affiliated hospital ward (P > 0.05).

CONCLUSION

This study suggests that nurses attach high importance to PR use for hospitalized elderly people. Healthcare policy-makers at national and hospital levels are recommended to provide nurses with PR-related educations in order to reduce the rate of PR-related complications.

Predictors of New-Onset Physical Restraint Use in Critically Ill Adults

BACKGROUND

Physical restraints are frequently used for intensive care patients and are associated with substantial morbidity. The effects of common evidence-based critical care interventions on use of physical restraints remain unclear.

OBJECTIVE

To identify independent predictors of new-onset use of physical restraints in critically ill adults.

METHODS

Secondary analysis of a prospective cohort study involving 5 adult intensive care units in a tertiary care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days.

RESULTS

Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI, 0.80-8.18) or deeply sedated (OR, 2.53; 95% CI, 0.91-7.08) had higher odds of next-day use of physical restraints, and agitated patients (OR, 0.08; 95% CI, 0.00-2.07) were less likely to experience restraint use.

CONCLUSION

Several potentially modifiable risk factors are associated with next-day use of physical restraints.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

Influence of mutual support and a culture of blame among staff in acute care units on the frequency of physical restraint use in patients undergoing mechanical ventilation

Aim

Reducing the use of physical restraint in intensive care units is challenging, and little is known about the influence of culture on physical restraint use in this setting. The present study aims to verify the hypothesis that mutual support and a culture of blame among staff are associated with higher physical restraint use for mechanically ventilated patients.

Methods

We undertook a survey of nurses in intensive care units caring for mechanically ventilated patients in acute care units. The perceived frequency of physical restraint, mutual support, and culture of blame were measured. We predefined a high frequency physical restraint use group and compared the institutional characteristics, human resources, mutual support, and culture of blame between this group and the others (the control).

Results

Three hundred and thirty-three responses were analyzed. The mean number of beds per nurse was not significantly different between the groups; the mean and percentage of positive responses about mutual support and a culture of blame were significantly lower in the high frequency physical restraint use group. After adjusting variables in a multivariable regression analysis, a less positive response about the culture of blame was the only independent factor to predict high frequency physical restraint use.

Conclusion

The study suggests that changing the culture of blame, rather than increasing the number of nurses, is important for reducing physical restraint use.

[Factors associated with physical restraint use in acute care hospitals: A comparison of patient characteristics between patients with and without restraints]

AIM

Physical restraints are defined as limitations on patients' freedom of movement, such as bed/chair belts and/or the use of mittens. Such restraints may be harmful, and the predictors of or factors reducing physical restraint use are unclear. This study investigated the factors determining physical restraint use in patients with stroke admitted to an acute care hospital.

METHODS

This retrospective study analyzed patients' data obtained between August 2014 and September 2015. The variables analyzed were age, sex, physical restraint use, operations performed, presence of tubes, stroke severity, psychotropic medication use, disturbance of consciousness, motor paralysis, cognitive status, independence in activities of daily living, and presence of behavioral disorders. Patient characteristics associated with physical restraints were analyzed using the t-test, Fisher's exact test, and a logistic regression analysis.

RESULTS

The analysis included 253 patients (179 in the non-restraint group and 74 in the restraint group). The prevalence of physical restraint use was 29.2%. The age, cognitive status, stroke severity, operations performed, presence of tubes, disturbance of consciousness, motor paralysis, independence in the activities of daily living, presence of behavioral disorders, and psychotropic medication use significantly differed between the two groups. A logistic regression analysis showed that the age, cognitive status, stroke severity, and presence of behavioral disorders were risk factors.

CONCLUSION

Physical restraint use is more likely in elderly patients and those with cognitive impairment, behavioral disorders, or serious strokes. Physical restraints are also more likely to be applied in patients with cognitive impairment than in those with merely physical impairment.

The management of agitation in adult critical care: Views and opinions from the multi-disciplinary team using a survey approach

OBJECTIVES

To better understand the current strategies employed to manage patient agitation by capturing the views and opinions of the multi-disciplinary team within general Adult Critical Care Units in the UK.

RESEARCH METHODOLOGY

Web-based questionnaire survey.

SETTING

General Adult Critical Care Units in one region of the United Kingdom MAIN OUTCOME: The online survey was circulated to approximately 900 members of staff at eight sites in the UK. The online survey was accessed by 239 (26.5%) clinicians, 163 (18.1%) completed the first two screening questions rendering them valid for inclusion. For those who responded, 98.5% acknowledge the increased risk of harm in the presence of agitation. Additionally, 76.3% felt the management of agitated patients could be improved. Many participants felt equipped in the recognition of delirium and agitation but did not feel they had the knowledge to support decision-making around acute agitation management. There is concern about the use of physical restraint and the over-reliance on sedation. There appears to be inconsistent care delivery exacerbated by staff rotational changes.

CONCLUSION

There are valid concerns raised surrounding the legality of physical restraint and what level of restrictive action is permissible. Currently, we have no robust evidence to determine the effectiveness of one intervention to prevent treatment interruption over another. There is a need to explore the clinical decision-making process that underpins the care of a patient experiencing agitation in Adult Critical Care.

Physical restraints in intensive care units: a national questionnaire survey of physical restraint use for critically ill patients undergoing invasive mechanical ventilation in Japan

Aims

Physical restraints are often used for patients undergoing mechanical ventilation to protect important medical equipment. However, they have adverse physical and psychological effects and could pose ethical hazards. Physical restraint use varies by country, but so far there is little understanding of the frequency of physical restraint use among intensive care unit (ICU) patients in Japan. The present study aims to describe the frequency of physical restraint use among Japanese patients undergoing mechanical ventilation. Additionally, it attempts to verify the hypothesis that insufficient human resources have increased the frequency of physical restraints.

Methods

We undertook a cross-sectional online open anonymous survey of ICU nurses using a self-administered questionnaire to examine the use of physical restraints for patients undergoing invasive mechanical ventilation in Japan.

Results

We obtained 175 responses, of which 46 were excluded. Of the respondents, 43% reported that physical restraints were used for more than 75% of mechanically ventilated patients. Intensive care units with a higher frequency of physical restraint use had a significantly greater number of beds per nurse compared to those with a lower frequency; however, after adjusting for the number of beds in the ICU and hospital type in a logistic regression analysis, the number of beds per nurse was no longer significantly related to the use of physical restraints.

Conclusions

Physical restraints are commonly used among patients undergoing mechanical ventilation in Japan. A systematic approach to reducing physical restraint use among mechanically ventilated patients is needed.

Investigating influencing factors of physical restraint use in China intensive care units: A prospective, cross-sectional, observational study

OBJECTIVE

In this study, we characterised the use of physical restraints in three intensive care units (ICUs) in a general hospital in Nantong, China. Additionally, we explored risk factors potentially related to physical restraint use.

BACKGROUND

Despite their numerous harmful effects, physical restraints are frequently used in ICUs worldwide. Few studies have investigated the factors that contribute to physical restraint use in Chinese hospitals.

METHODS

We conducted a prospective, cross-sectional, observational study of 312 patients in three ICUs at a general hospital in China. The quantitative data were collected during a 5-month period using a physical restraint observation form and patient records. The data obtained were analysed using descriptive statistics. The independent risk factors for physical restraint use were assessed using a logistic regression model.

RESULTS

Of the 312 patients in the three ICUs, 191 (61.2%) were restrained, and physical restraints were used more than once for 46 (24.1%) patients during their ICU stay. The median length of physical restrain use was 20 shifts (interquartile range = 10-36 shifts). Physical restraints were applied in 6664 of 12374 (53.9%) nurse shifts. The most common time at which physical restraints were applied was the beginning of the evening shift. According to the forward stepwise logistic regression analysis, delirium (P < 0.001), mechanical ventilation (P < 0.001), and age (P < 0.001) were independent risk factors for physical restraint use. The use of analgesics (P = 0.001) exerted an independent protective effect against physical restraint use.

CONCLUSIONS

The overall prevalence of physical restraint use in Chinese ICUs was higher than that reported in previous investigations. The patients' nursing notes lacked complete physical restraint records, reflecting a need for standard guidelines and policies for physical restraint use in hospital ICUs in China. In addition, in this study, we explored the risk factors related to physical restraint use and found that age, delirium, mechanical ventilation, and analgesic use are associated with physical restraint use.

Nurses' Information, Attıtude and Practices towards Use of Physical Restraint in Intensive Care Units

Introduction: Physical restraint may seem to be a useful and simple procedure to help the treatment but is a complex practice including physical, psychological, judicial, ethical and moral issues. Research was made on description basis in order to determine the knowledge, attitude and application levels of nurses working in critical care units about physical restraint applied on patients. Methods: The study was performed as a descriptive and correlation study. Working in ICUs, 158 nurses constituted the sampling. "Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire" was used to collect data. Results: For information, attitude and practice scores, participants' scores were 7.1(1.7), 31.8 (4.6) and 36.6 (3.2), respectively. No association was found between information subscale, and age, professional years, working time in ICUs and weekly working hours. However, for attitude subscale, a negative and weak association was found between age (r=-0.229) and professional years (r=-0.174), and increasing these variables decreased attitude score. No association was found between attitude score, and working time in ICUs and weekly working hours. While there was no association between practice score, and age, professional years and working time in ICUs, the increase in weekly working hours (r=-0.243) was found to decrease practice score, and this association was found weak. Conclusion: In conclusion, we consider nurses' level of information is sufficient, but attitudes and practice were not at a positive level. It is recommendable that out of such conditions, novel approaches should be developed to decrease the use of physical restraint.

Impact of a Restraint Management Bundle on Restraint Use in an Intensive Care Unit

Restraint use has been linked to longer lengths of stay and other undesirable outcomes. This evidence-based project explored the impact of a restraint management bundle on restraint use, quality, and safety outcomes. Results indicated that the proportion of intensive care unit patients restrained decreased significantly (24.3% vs 20.9%) following program implementation. Project results suggest that the restraint management bundle may provide a framework for guiding the process to reduce restraint use, minimize harm, and improve patient safety.

Patient agitation and its management in adult critical care: A integrative review and narrative synthesis

AIMS AND OBJECTIVE

To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies.

BACKGROUND

Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness.

STUDY DESIGN

Integrative review and narrative synthesis.

METHODS

A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach.

RESULTS

A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management.

CONCLUSIONS

Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance.

RELEVANCE TO CLINICAL PRACTICE

The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.

Physical Restraint Use With Elderly Patients: Perceptions of Nurses and Nursing Assistants in Spanish Acute Care Hospitals

BACKGROUND

Physical restraint is often used during the hospitalization of elderly people. However, this procedure is associated with adverse outcomes; therefore, it is necessary to be aware of the circumstances that promote restraint use, such as the perceptions of professionals who use it.

OBJECTIVES

The purpose of the research was to determine the situations in which nursing staff considered the use of physical restraint as most important and to evaluate the possible associations with the sociodemographic and professional variables.

METHODS

A descriptive cross-sectional multicenter study was carried out in 52 units of eight Spanish acute hospitals. A survey of registered nurses and nursing assistants was used to collect data related to sociodemographic characteristics, experience, training in restraint use, and the Perception of Restraint Use Questionnaire (PRUQ)-which assesses the perceived importance of reasons frequently given for the use of physical restraint.

RESULTS

The sample comprised 508 registered nurses and 347 nursing assistants. Almost all (98%) had used physical restraint, and 82% thought their training in the use of physical restraint was insufficient. Nursing assistants scored higher than registered nurses (p < .005, d = .68) on PRUQ total score and individual item scores, suggesting they thought the factors were more important in restraint use. Both registered nurses and nursing assistants considered restraint as most important in the prevention of falls and in the removal of medical devices such as intravenous lines and urinary catheters. Associations between PRUQ total score and other variables (unit type, sociodemographic factors, hospital) were nonsignificant.

DISCUSSION

The professionals considered restraint as very important in preventing safety problems. In order to improve the quality of care, it is essential to identify the factors that can have an effect on the application of physical restraint. Educational programs are of fundamental importance, but to be more effective in reducing the use of physical restraint, they should address commonly held views on rationale for restraint use and be accompanied by institutional policies promoting a restraint-free environment.

Use of physical restraints among patients with bipolar disorder in Ethiopian Mental Specialized Hospital, outpatient department: cross-sectional study

BACKGROUND

Even though United Nation announced that all persons with a mental illness shall be treated with humanity and respect for the inherent dignity of the human being, up to now, the use of coercion (physical restrain) is still considered as unavoidable in managing abnormal behavior of psychiatric patients. But, there is no information regarding the magnitude and contributing factors of physical restrain among bipolar patients in low-income countries like Ethiopia.

METHODS

A cross-sectional study was conducted at Amanuel Mental Specialized Hospital from May 1 to June 1, 2015 among 400 participants who were selected by systematic random sampling technique. Data were collected by interviewing; adjusted odd ratios (AOR) with 95% confidence intervals (CI) were used and p value <0.05 was considered as statistically significant.

RESULTS

The prevalence of physical restrain was 65%. Factors like, having two or more episodes [AOR = 1.84 95% CI (1.16, 2.93)], history of aggression [AOR = 2.14, 95% CI (1.26, 3.63)], comorbid illness [AOR = 1.76, 95% CI (1.26, 3.63)], use of antipsychotic [AOR = 1.79, 95% CI (1.08, 2.95)] and current use of Khat [AOR = 1.83, 95% CI (1.10, 3.04)] were associated significantly.

CONCLUSIONS

The prevalence of physical restraint is found high among bipolar patients and it needs public health attention.

Risk factors for the incidence of delirium in cerebrovascular patients in a Neurosurgery Intensive Care Unit: A prospective study

AIMS AND OBJECTIVES

To explore the incidence of delirium in cerebrovascular patients admitted in our Neurosurgery Intensive Care Unit and analyse the risk factors leading to delirium.

BACKGROUND

Delirium is one of the most common mental disorders in general hospitals, but the incidence of different kinds of diseases and studies varies. Cerebrovascular patients in our Neurosurgery Intensive Care Unit are high-risk groups for delirium; identifying risk factors for delirium and taking early interventions are crucial for patient prognosis.

DESIGN

A prospective study.

METHODS

A convenience sampling method was used to collect data from 128 patients in the Neurosurgery Intensive Care Unit of Xuanwu Hospital, Capital Medical University, Beijing, China, between May 2016-January 2017. Researchers used Confusion Assessment Method for the Intensive Care Unit (Chinese version) to assess each patient's delirium statement twice a day at regular times. We also collected other independent data variables and followed up the short-term clinical outcomes daily.

RESULTS

On the basis of Confusion Assessment Method for the Intensive Care Unit evaluation, patients were divided into a delirium group and a nondelirium group. The prevalence of delirium among the 128 patients was 42.2%. Multivariate analysis showed that severity of illness, fever, the use of physical restraints and sleep deprivation were independent predictors of delirium in cerebrovascular patients in the Neurosurgery Intensive Care Unit.

CONCLUSIONS

Cerebrovascular patients in the Neurosurgery Intensive Care Unit with a critical condition, fever or use of physical restraints or experiencing sleep deprivation were more prone to delirium.

RELEVANCE TO CLINICAL PRACTICE

Cerebrovascular patients in the Neurosurgery Intensive Care Unit showed a high incidence of delirium. There are many risk factors leading to delirium, some of which are independent predictors of intensive care delirium. Patients with delirium will suffer various adverse effects upon their short-term clinical outcomes. Therefore, nurses should pay close attention to changes in a patient's mental state and learn about the risk factors associated with delirium, in order to be able to take early measures to prevent delirium.

Determinants of Nurses' Use of Physical Restraints in Surgical Intensive Care Unit Patients

BACKGROUND

Physical restraints are used in intensive care units, particularly among patients at risk for self-terminating necessary treatment interventions, including endotracheal tubes and invasive catheters. Assessments conducted by intensive care unit nurses often influence the collaborative decision to initiate and discontinue restraints in critical care patients. However, little is known about factors that influence the critical thought processes of intensive care unit nurses in determining use of restraints.

OBJECTIVES

To describe nurses' determinants of initiation and discontinuation of restraints in surgical intensive care unit patients.

METHODS

Semistructured interviews were conducted to identify and describe determinants of initiation and discontinuation of physical restraints. Demographic and employment data were collected via questionnaire. Interviews were recorded, transcribed, and analyzed by using conventional content analysis to establish categories and identify themes.

RESULTS

A total of 13 nurses (mean age 43 [SD, 12] years, 92% female, mean of 18 [SD, 12] years of practice as a registered nurse, 69% bachelor of science in nursing) participated in the study. Content analysis revealed 3 general categories and 8 themes that indicated the thoughtful reflection processes nurses in a surgical intensive care unit use to determine use of restraints.

CONCLUSIONS

Top priorities were ensuring patient safety and comfort. Nurses synthesized factors including practice experience, patient-specific behaviors and risk, and patients' need for devices in determining use of restraints.

Risk factors for agitation in critically ill patients

OBJECTIVE:

To evaluate the incidence of agitation in the first 7 days after intensive care unit admission, its risk factors and its associations with clinical outcomes.

METHODS:

This single-center prospective cohort study included all patients older than 18 years with a predicted stay > 48 hours within the first 24 hours of intensive care unit admission. Agitation was defined as a Richmond Agitation Sedation Scale score ≥ +2, an episode of agitation or the use of a specific medication recorded in patient charts.

RESULTS:

Agitation occurred in 31.8% of the 113 patients. Multivariate analysis showed that delirium [OR = 24.14; CI95% 5.15 - 113.14; p < 0.001], moderate or severe pain [OR = 5.74; CI95% 1.73 - 19.10; p = 0.004], mechanical ventilation [OR = 10.14; CI95% 2.93 - 35.10; p < 0.001], and smoking habits [OR = 4.49; CI95% 1.33 - 15.17; p = 0.015] were independent factors for agitation, while hyperlactatemia was associated with a lower risk [OR = 0.169; CI95% 0.04 - 0.77; p = 0.021]. Agitated patients had fewer mechanical ventilation-free days at day 7 (p = 0.003).

CONCLUSION:

The incidence of agitation in the first 7 days after admission to the intensive care unit was high. Delirium, moderate/severe pain, mechanical ventilation, and smoking habits were independent risk factors. Agitated patients had fewer ventilator-free days in the first 7 days.

Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study

BACKGROUND

Critically ill patients frequently experience delirium, and antipsychotic drugs are often used to manage symptoms.

OBJECTIVES

To describe the use of antipsychotic drugs and delirium screening tools in mechanically ventilated, critically ill adult patients in Canadian intensive care units (ICUs) and to identify factors associated with the use of antipsychotic drugs.

METHODS

Pharmacists from 51 Canadian ICUs prospectively collected data on antipsychotic use and delirium screening in all patients for whom invasive mechanical ventilation was initiated during a chosen 2-week period occurring sometime in 2008 or 2009.

RESULTS

Data were collected for a total of 712 patients, of whom 115 (16.2%) received at least one dose of an antipsychotic. The antipsychotic prescribed, the total daily dose, and the administration schedule varied across sites. Delirium screening tools, validated for use in mechanically ventilated patients and endorsed by professional society guidelines, were part of routine care in a minority of ICUs (7/51 [13.7%]), and delirium screening was documented for few patients overall (41/712 patients [5.8%]). In a multivariable analysis, administration of antipsychotics was independently associated with longer duration of mechanical ventilation (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.07-1.17), daily interruption of sedation (OR 1.71, 95% CI 1.01-2.90), and use of physical restraints (OR 2.15, 95% CI 1.27-3.65).

CONCLUSION

A minority of mechanically ventilated patients in Canadian ICUs received antipsychotic drugs, and screening for delirium with validated tools was rare. Antipsychotic drug use was independently associated with longer duration of mechanical ventilation, daily interruption of sedation, and use of physical restraints.