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Berger S, Grzonka P, Amacher SA, Hunziker S, Frei AI, Sutter R. Adverse events related to physical restraint use in intensive care units: A review of the literature. JOURNAL OF INTENSIVE MEDICINE 2024; 4:318-325. [PMID: 39035621 PMCID: PMC11258505 DOI: 10.1016/j.jointm.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 07/23/2024]
Abstract
Physical restraints are widely used and accepted as protective measures during treatment in intensive care unit (ICU). This review of the literature summarizes the adverse events and outcomes associated with physical restraint use, and the risk factors associated with their use during treatment in the ICU. The PubMed, Scopus, and Google Scholar databases were screened using predefined search terms to identify studies pertaining to adverse events and/or outcomes associated with physical restraint use, and the factors associated with their use in adult patients admitted to the ICU. A total of 24 articles (including 6126 patients) that were published between 2006 and 2022 were identified. The described adverse events associated with physical restraint use included skin injuries, subsequent delirium, neurofunctional impairment, and a higher rate of post-traumatic stress disorder. Subsequent delirium was the most frequent adverse event to be reported. No alternative measures to physical restraints were discussed, and only one study reported a standardized protocol for their use. Although physical restraint use has been reported to be associated with adverse events (including neurofunctional impairment) in the literature, the available evidence is limited. Although causality cannot be confirmed, a definite association appears to exist. Our findings suggest that it is essential to improve awareness regarding their adverse impact and optimize approaches for their detection, management, and prevention using protocols or checklists.
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Affiliation(s)
- Sebastian Berger
- Clinic for Intensive Care, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Clinic for Intensive Care, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Simon A. Amacher
- Clinic for Intensive Care, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical faculty, University of Basel, Basel, Switzerland
| | - Anja I. Frei
- Clinic for Intensive Care, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Chary A, Torres B, Brickhouse E, Charles D, Thomas Y, Suh M. Gender and emergency physicians' experiences of leading decision making about restraint use: A qualitative study. Acad Emerg Med 2024; 31:707-709. [PMID: 38097859 DOI: 10.1111/acem.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Anita Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Beatrice Torres
- School of Public Health, University of Texas Health Science Center Houston, Houston, Texas, USA
| | - Elise Brickhouse
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Datonye Charles
- Department of Psychiatry, Baylor College of Medicine, Houston, Texas, USA
| | - Ynhi Thomas
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Michelle Suh
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, USA
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Paul FA, Ganie AUR, Dar DR, Saikia P, Banerjee I. Exploring psychiatric patient restraints: Balancing safety, ethics, and patient rights in mental healthcare. Asian J Psychiatr 2024; 96:104051. [PMID: 38643681 DOI: 10.1016/j.ajp.2024.104051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/26/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024]
Abstract
Restraint, often linked with limiting an individual's freedom of movement, has become a focal point of extensive discussion and evaluation within the realm of mental healthcare. Striking a delicate balance between ensuring individual safety and minimizing reliance on restraint methods poses a significant challenge. In mental health inpatient settings, the prevalent forms of restraint encompass physical, chemical, environmental, and psychological methods. Paradoxically, the consequences of employing restraint can be severe, ranging from injuries and cognitive decline to sedation and, in extreme cases, fatalities. This paper seeks to offer a nuanced exploration of the landscape surrounding psychiatric patient restraints, considering both global perspectives and specific insights from the Indian context. The guidelines outlined in India's Mental Healthcare Act of 2017, which governs the use of restraint on individuals suffering with mental illnesses, are also examined in detail.
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Affiliation(s)
- Fayaz Ahmad Paul
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Aasim Ur Rehman Ganie
- Sharda School of Humanities and Social Sciences, Sharda University, Knowledge Park-3, Greater Noida 201310, India.
| | - Danishwar Rasool Dar
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Priyanka Saikia
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Indrajeet Banerjee
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
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Abstract
The practice of medicine frequently involves the unconsented restriction of liberty. The reasons for unilateral liberty restrictions are typically that being confined, strapped down, or sedated are necessary to prevent the person from harming themselves or others. In this paper, we target the ethics of chemical restraints, which are medications that are used to intentionally restrict the mental states associated with the unwanted behaviors, and are typically not specifically indicated for the condition for which the patient is being treated. Specifically, we aim to identify the conditions under which chemical restraints are ethically permissible. It is wrong to assume that what is morally true of physical restraints is also true of chemical restraints. Our aim is thus to identify the conditions under which chemical restraints are permissible while distinguishing these conditions from those of the application of physical restraints.
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Affiliation(s)
| | - Michael Redinger
- Western Michigan University Homer Stryker M.D. School of Medicine
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Masserano B, Hall M, Wolf R, Diedrich A, Gupta A, Yu AG, Johnson K, Mittal V. Pharmacologic Restraint Use During Mental Health Admissions to Children's Hospitals. Pediatrics 2024; 153:e2023062784. [PMID: 38073316 DOI: 10.1542/peds.2023-062784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 01/02/2024] Open
Abstract
OBJECTIVES Primary mental health admissions are increasing across US children's hospitals. These patients may experience agitation requiring pharmacologic restraint. This study characterized pharmacologic restraint use in medical inpatient units by primary mental health diagnosis. METHODS This retrospective, cross-sectional study used the Pediatric Health Information System database. The study included children aged 5 to 17 years admitted with a primary mental health diagnosis between 2016 and 2021. Rates of pharmacologic restraint use per 1000 patient days were determined for 13 mental health diagnoses and trended over time with Poisson regression. RESULTS Of 91 898 hospitalizations across 43 hospitals, 3% of admissions and 1.3% of patient days involved pharmacologic restraint. Trends in the rate of pharmacologic restraint use remained stable (95% confidence interval [CI], 0.7-2.1), whereas the incidence increased by 141%. Diagnoses with the highest rates of pharmacologic restraint days per 1000 patient days included autism (79.4; 95% CI, 56.2-112.3), substance-related disorders (45.0; 95% CI, 35.9-56.4), and disruptive disorders (44.8; 95% CI, 25.1-79.8). The restraint rate significantly increased in disruptive disorders (rate ratio [RR], 1.4; 95% CI, 1.1-1.6), bipolar disorders (RR, 2.0; 95% CI, 1.4-3.0), eating disorders (RR, 2.4; 95% CI, 1.5-3.9), and somatic disorders (RR, 4.2; 95% CI, 1.9-9.1). The rate significantly decreased for autism (RR, 0.8; 95% CI, 0.6-1.0) and anxiety disorders (RR, 0.3; 95% CI, 0.2-0.6). CONCLUSIONS Pharmacologic restraint use among children hospitalized with a primary mental health diagnosis increased in incidence and varied by diagnosis. Characterizing restraint rates and trends by diagnosis may help identify at-risk patients and guide targeted interventions to improve pharmacologic restraint utilization.
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Affiliation(s)
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ryan Wolf
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Andrew Diedrich
- Child and Adolescent Psychiatry, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
- Children's Medical Center, Dallas, Texas
| | - Ankita Gupta
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Andrew G Yu
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Katherine Johnson
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Vineeta Mittal
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
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Soto J, Mitchell TO, Masters KJ, Millard H. The Role of Psychiatrists in Seclusion and Restraint Episodes: a Curriculum for Psychiatric Trainees. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2023; 47:676-679. [PMID: 36952217 DOI: 10.1007/s40596-023-01767-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Jessica Soto
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Kim J Masters
- College of Health Professions Medical University of South Carolina, Charleston, SC, USA
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Harris CM, Gupta I, Beydoun H, Wright SM. Outcomes for Hospitalized Aggressive and Violent Patients When Physical Restraints Are Introduced. J Patient Saf 2023; 19:216-219. [PMID: 36715978 DOI: 10.1097/pts.0000000000001109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hospital outcomes among patients acting aggressively or violently have not been extensively studied in the United States. OBJECTIVES The aims of the study are to determine rates of physical restraint use among hospitalized patients who are aggressive/violent and to characterize associations with mortality and utilization metrics. DESIGN/SETTING/PARTICIPANTS National Inpatient Sample databases from 2016 to 2019 were analyzed with multivariable regression to compare aggressive/violent patients in whom physical restraints were or were not used. MEASURES Prevalence of physical restraint use, in-hospital mortality, length of stay, and total hospital charges were measures. RESULTS A total of 40,309 hospitalized patients were coded as having aggressive/violent behavior, of whom 4475 (11.1%) were physically restrained. Physically restrained patients were younger (mean age ± standard error, 42.6 ± 0.64 versus 45.7± 0.41; P < 0.01), more frequently male (71.0% versus 65.4%; P < 0.01), and had less comorbidity (Charlson Index score >3: 7.9% versus 12.5%; P < 0.01) than unrestrained patients. Patients with physical restraints had higher odds of in-hospital mortality (adjusted odds ratio, 2.4, confidence interval [CI], 1.0-5.7; P = 0.04) and lower odds of being discharged to home (adjusted odds ratio, 0.46; CI, 0.38-0.56; P < 0.01) compared with unrestrained patients. Longer hospital stays (adjusted mean difference, 4.1 days CI, 2.1-6.0; P < 0.01) and higher hospitalization charges (adjusted mean difference, $16,996; CI, 6883-27,110; P < 0.01) were observed for those who were physically restrained. CONCLUSIONS Physically restrained aggressive/violent patients had worse in-hospital outcomes compared with their unrestrained counterparts. Avoiding physical restraints whenever possible should be considered when managing this confrontational yet vulnerable patient population. When restraints are needed, providers must thoughtfully bear in mind heightened risks for worse outcomes.
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Affiliation(s)
- Ché Matthew Harris
- From the Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Ishaan Gupta
- From the Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Hind Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Scott Mitchell Wright
- From the Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Qualitative Analysis of Workplace Assault Outcomes from the Perspectives of Emergency Nurses. J Emerg Nurs 2022; 49:450-460. [PMID: 36273930 DOI: 10.1016/j.jen.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Emergency nurses experience a myriad of negative consequences associated with workplace assault. The purpose of this study was to explore the experiences of emergency nurses using the Ecological Occupational Health Model of Workplace Assault. METHODS A descriptive qualitative design was used for this study. Data from 167 emergency nurse participants who described an episode of workplace assault were analyzed using a conventional content analysis method. RESULTS Fourteen codes emerged from the qualitative data that related to 4 categories for the theme, Outcomes of Workplace Assault. The category "Consequences of Assault to Patients and Visitors" was supported by the following codes: use of limit setting; being evicted or removed from the emergency department; having charges pressed or being arrested; use of restraints; and retaliation against aggressor. "Effects on the Worker" was supported by the following codes: physical outcomes and response; psychological outcomes and response; physical support from peers; apologies; and debriefing/supportive care. "Effects on the Workplace" was supported by the following codes: calling for and response by police or security; and visitor response, support, or assistance. "Effects on Patient Care" was supported by the following codes: impact to treatment and work productivity. DISCUSSION Workplace assault in the ED setting is associated with consequences of workplace assault to patients and visitors as well as negative effects to emergency nurses, the workplace, and patient care. Emergency nurses need to seek and also offer emotional support after workplace assault. Providing support could serve as a deterrent to retaliation while minimizing potential adverse impacts to nurses' psychological health and work productivity.
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Thomann S, Zwakhalen S, Siegrist-Dreier S, Hahn S. Restraint practice in the somatic acute care hospital: A participant observation study. J Clin Nurs 2022; 32:2603-2615. [PMID: 35451093 DOI: 10.1111/jocn.16322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/09/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective. BACKGROUND A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the 'insider' view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased. DESIGN A qualitative observation study design was employed. METHODS Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR). RESULTS A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak. CONCLUSIONS The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful. RELEVANCE TO CLINICAL PRACTICE The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies.
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Affiliation(s)
- Silvia Thomann
- School of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland
| | - Sandra Zwakhalen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Sandra Siegrist-Dreier
- School of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland
| | - Sabine Hahn
- School of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Hudgins JD. Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments. J Pediatr 2021; 236:276-283.e2. [PMID: 33771581 DOI: 10.1016/j.jpeds.2021.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). STUDY DESIGN We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. RESULTS We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001). CONCLUSIONS Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | | | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Joel D Hudgins
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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