Prevalence and Influencing Factors of Physical Restraints in Intensive Care Units: A Retrospective Cohort Study

Prevalence and variability in use of physical restraints in intensive care units: A systematic review and meta-analysis

BACKGROUND

Given the varying perspectives on the use of physical restraint (PR) over the past decades and the provided protocols to minimise its occurrence in intensive care units (ICUs), a comprehensive study was deemed necessary to examine the prevalence and variation of PR use in ICUs.

OBJECTIVE

The aim of this study was to estimate the overall proportions of PR utilised in adult ICUs whilst examining the various factors contributing to the variability of these estimates.

METHODS

A search of five databases (PubMed, Cochrane Library, Scopus, Embase, and Web of Science) was performed. Studies published in English and available online from inception to December 18, 2024, were included. A pooled estimate with a 95% confidence interval was calculated, and the data were represented by the random-effect model. Analysis was performed using the STATA statistical software (version 17).

RESULTS

The meta-analysis included 39 studies, with a sample size of 21 665 patients. The overall prevalence of patients exposed to PRs was 41.6% (95% confidence interval: 33.8%-49.5%). The heterogeneity was significantly high (I2 = 99.61%), and the Q Cochrane test for homogeneity was significant (p value < 0.001), indicating substantial variability between studies. Subgroup analysis regarding the continent and restraint method contributed to a lowered heterogeneity.

CONCLUSIONS

There was considerable variation in reported estimates of PR prevalence in adult ICUs. Despite valid guidelines and recommendations supporting the reduction of PR, the results of our study show its significant prevalence. Additionally, our study demonstrated a relationship between PR use and delirium, sedation use, and mechanical ventilation. This study emphasises the importance of managing and focussing on PRs in ICUs. Also, it is crucial to evaluate barriers to guideline implementation.

REGISTRATION

The systematic review protocol has been prospectively registered in the International Prospective Register of Systematic Reviews: CRD42024566480.

Physical Restraint Use in Hospitalized Patients: A Study of Routinely Collected Health Records Data

BACKGROUND

The use of restraints in hospitalized patients is associated with physical and psychological adversity for patients and staff. The minimization of restraint use is a key goal in the hospital setting. Reaching this goal requires an accurate assessment of existing patterns of use across clinical settings.

OBJECTIVE

This study reports the rate of physical restraints among patients hospitalized within a multi-entity healthcare network along with stratification by care context, diagnostic, and demographic factors, and examines the sensitivity and specificity of ICD-10 code Z78.1 "physical restraint status" for defining physical restraints relative to electronic health record (EHR) documentation.

DESIGN

The EHR was used for a retrospective analysis of all adults hospitalized between 2017 and 2022.

PARTICIPANTS

Hospitalized adults.

MAIN MEASURES

Patient demographics, structured diagnostic information, care area, length of stay, and in-hospital mortality, Z78.1 coding for physical restraints, restraint documentation in orders and flowsheets.

KEY RESULTS

Among 742,607 hospitalizations, 6.3% (n=47,041) involved the use of physical restraint based on coding or EHR documentation. Treatment in the intensive care unit (ICU) included restraint in 39% of encounters whereas treatment outside the ICU included restraint use in 1.3% of encounters. Besides critical illness, demographic factors including increasing age (adjusted odds ratio (aOR)=1.21 [1.19-1.23]), male gender (aOR=1.56, [1.52-1.60]), unknown race (aOR=1.27 [1.19-1.35]), and preferred language other than English (aOR=1.24, [1.18-1.29]) were associated with higher odds of restraint utilization. As compared to EHR orders or documentation of restraint, the ICD-10 code for physical restraint had a sensitivity of 1.5% and a specificity of 99.99%.

CONCLUSION

Among adults admitted to acute care hospitals, clinical, demographic, and operational factors were associated with increased odds of restraint, with care in the ICU associated with greatly increased odds of restraint. Research into restraint utilization using coded administrative claims data is likely limited by the sensitivity of physical restraint coding.

Study of Psychomotor Agitation Constraint Method: A Systematic Review

BACKGROUND

Psychomotor agitation is a common psychiatric disorder that often requires physical restraint, consuming significant healthcare resources. Assessing the clinical importance of the correct method of physical restraint for patients with psychomotor agitation presents a challenge for physicians and researchers. This review aims to assess the use of physical restraints in Intensive Care Units (ICUs) and other departments, identifying potential factors influencing their use.

METHODS

Two independent researchers conducted a computerized search of PubMed, Embase, Web of Science, and Cochrane databases for literature related to methods of psychomotor agitation restraint. The review focused on the methods of inhibiting psychomotor agitation in the ICU.

RESULTS

A total of seven papers met the inclusion criteria for this systematic review. The restraint rates among patients ranged from 8.7% to 59.07%. Factors influencing patient restraint included gender, marital status, mental and behavioral disorders, emergency referrals, and the use of mechanical ventilation.

CONCLUSIONS

Restraint is frequently used among patients, particularly among the elderly, males, and those with disorders of consciousness or social relationship issues. This review identifies several factors influencing restraint rates in patients with psychomotor agitation, highlighting the need for further research to develop targeted interventions aimed at reducing the necessity for physical restraints.

Vascular complications in extremities of physically restrained intensive care unit patients: A prospective, observational study

BACKGROUND

Physical restraint is used to prevent agitation, to continue treatments and to ensure safety in intensive care patients. Physical restraint has negative effects on physical and psychological health, and physical restraint should not be used unless necessary.

AIMS

The purpose of this study was to evaluate the development of vascular complications in extremities of physically restrained patients hospitalized in the intensive care unit (ICU) and the associated factors.

STUDY DESIGN

A prospective, observational study. The study was conducted between September 1, 2022, and March 31, 2023 in eight ICUs of a hospital located in the inner regions of Türkiye. The development of vascular complications (discolouration, distemperature, variations in capillary refill time, fluctuations in peripheral pulse, skin ulceration and oedema in the area of physical restraint) rate in patients hospitalized in the ICUs who were physically restrained. Independent sample t test, Mann-Whitney U test and Pearson-χ2 test were used to analyse the data.

RESULTS

During the study, 2409 patients were admitted to ICUs. Physical restraint was applied to 209 of these patients. Of the 209 patients, 112 patients who met the inclusion criteria were included in the study. The physical restraint site of the patients was evaluated an average of 230.12 times and physical restraint was terminated in 9.8% of the patients (n = 112) because of vascular complications that developed in the physical restraint site. The rate of vascular complications at the site of physical restraint was higher in patients with endotracheal tubes (p < .05), lower GCS scores (p < .05) and higher INR values (p < .05). Patients with skin ulceration at the restraint site received more massages and cream applications (%95CL = 1. 1.692-34.734, OR = 7.667, p = .032). It was determined that more massage was applied to patients with changes in skin temperature at the restraint site (%95Cl = 1.062-11.599, OR = 3.510, p = .032).

CONCLUSIONS

Vascular complications may develop at the restraint site in patients hospitalized in the ICU. This may be more common in ICU patients with endotracheal tube, lower GCS score and higher INR values.

RELEVANCE TO CLINICAL PRACTICE

Nurses should closely monitor ICUs patients with endotracheal tube, lower GCS score and higher INR values, and implement care interventions to prevent the development of vascular complications.

Influence of Surgery Preparation Time on Patient Outcomes

Aims

This study aimed to analyze the effects of the surgery preparation time on patient outcomes.

Background

Postoperative complications have a decisive effect on postoperative survival. The anesthesia time is a crucial determinant of such complications. Competent operating room nurses can shorten the surgery preparation time, which is the time from when anesthesia is first administered to the making of the surgical incision. The shortening of this preparation time can shorten the anesthesia time and may reduce postoperative complications. However, discussion of this preparation time is insufficient. Therefore, this study analyzed the effect of the surgery preparation time on patient outcomes.

Methods

From electronic health records data, this retrospective cohort study used the data of 1,944 patients who had been immediately admitted to the ICU after their surgery between 2017 and 2020. The patients were divided into two groups: ≥30 minutes preparation time and <30 minutes preparation time groups. We performed chi-squared tests and t-tests to determine differences in preoperation, intraoperation, and postoperation characteristics of the patients and patient outcomes based on the surgery preparation time. Furthermore, we performed a multiple logistic regression by including 12 adjusted variables to determine the influence of the surgery preparation time on patient outcomes.

Results

Among the 1,944 patients, 820 were in the ≥30 minutes preparation time group and 1,124 in the <30 minutes preparation time group. The multiple logistic regression analysis showed that the surgery preparation time affects alertness (OR = 1.44; 95% CI: [1.09, 1.90]), ventilator application (OR = 1.32; 95% CI: [1.03, 1.70]), and length of stay in the ICU (OR = 1.69; 95% CI [1.16, 2.47]).

Conclusions

The surgery preparation time affects postoperative patient outcomes. The competence of operating room nurses is the most essential aspect of the surgery preparation time. Implications for Nursing Management. It is important to analyze operating room nurses' tasks, standardize the tasks, and educate nurses according to their experience level to reduce the surgery preparation time and improve patient outcomes.

Non-pharmacological interventions to reduce physical restraints in critical care units

Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.