Using the evidence to decision frameworks to formulate the direction and strength of recommendations for adapted guidelines of physical restraints in critical care: A Delphi study

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.

Development and validation of nurse's assessment ability questionnaire in delirium subtypes: Based on Delphi expert consensus

BACKGROUND

Delirium, a common occurrence in clinical work, can be divided into three subtypes according to Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5). Each subtype has its special significance and focus. As the primary caregivers and observer of delirious patients, nurses should be able to quickly and accurately indentify each subtype. Therefore, it is necessary to clarify nurses' assessment ability of delirium subtypes. However, there is currently no suitable questionnaire available for investigating nurses' assessment ability of delirium subtypes.

OBJECTIVE

To develop a scientifically validated questionnaire for assessing nursing assessment ability of delirium subtypes based on Knowledge-Attitude-Practice(KAP) Model.

METHODS

The questionnaire was conducted from October 2021 to February 2022 to assess the KAP status of nurses the regarding delirium subtype. A two-round Delphi Method was employed to revise the draft questionnaire, ensuring the importance and rationality of each item. Ten experts specializing in critically ill patients, clinical nursing, and nursing management were invited from seven provinces in China for the Delphi process. Additionally, we validated the reliability and validity of the questionnaire.

RESULTS

The return rate in the first and second rounds were 83% and 100%, respectively. The individual authority coefficients for the two rounds of correspondence ranged from 0.787 to 0.987, while the overall authority coefficient of experts was 0.866. Kendall's coefficient of coordination for the importance scores were found to be 0.192 and 0.156, respectively, whereas those for rationality scores were calculated as 0.149 and 0.141, respectively. Notably, all mean values of importance and rationality scores in the two rounds were exceeded a threshold of 4.10 across both rounds of assessment with coefficient variations (CV) ranging from 0.00 to 0.19 for importance ratings and 0.00 to 0.16 for rationality ratings, both of which were <0.25. Experts proposed modifications to eleven items while introducing four new ones into consideration during this process; thus ensuring that reliability and validity standards were met by the final questionnaire design which consists of a total of thirty-seven items distributed across four dimensions: delirium subtype-related knowledge, assessment attitude, assessment practice, and knowledge source-thereby establishing its clinical relevance as a reliable scientific instrument.

CONCLUSION

The development process is both scientific and theoretical, encompassing reliable expert correspondence results and a diverse range of question formats. As thus, effectively captures the current landscape of delirium subtypes assessment among clinical nurses from multiple perspectives, including knowledge level and source, attitude, assessment behavior, and assessment barriers. It offers comprehensive and detailed insights.

Values and preferences of health care professionals, policy-makers, patients and family members regarding recommendations of adapted physical restraint guidelines in critical care: A survey research

BACKGROUND

The values and preferences of stakeholders are crucial in the development of guidelines.

AIM

The aim of this study was to investigate stakeholders' values and preferences regarding draft recommendations for adapted physical restraint guidelines in China.

STUDY DESIGN

This survey research was carried out at four university-affiliated comprehensive hospitals based in the eastern, central, western, and north eastern zones of China from January 5-30, 2022. A 48-item self-report questionnaire was distributed, and values and preferences were assessed on a 10-point Likert scale. One-way ANOVA was used to compare values and preference scores among stakeholders. As effect-size measures, partial η2 and Cohen's f values are reported for ANOVA results.

RESULTS

A total of 1155 stakeholders were enrolled in the study. The mean value and preference scores were higher than seven for 46 draft recommendations. There was either no significant difference in the values and preferences of the stakeholders for the draft recommendations or there was a significant difference (p values ranged from <0.001 ∼ .048), but the effect size was small or very small (partial η2 value ranged from 0.011 ∼ .044; Cohen's f value ranged from 0.101 ∼ .214). The mean scores of patients for items related to cyber therapy and early tracheotomy were 6.84 and 6.60, respectively, which were lower than those of family members, policy-makers, and health care professionals and were statistically significant (p < 0.001). The partial η2 and Cohen's f values of the effect size were 0.083/0.062 and 0.302/0.256, respectively, which indicated that the differences were moderate.

CONCLUSION

These recommendations were in line with the values and preferences of stakeholders. Patients were more supportive of implementing cyber therapy or hypnosis for pain management but did not support early tracheotomy to reduce the duration of mechanical ventilation. Guideline panels could use value and preference information to revise and endorse recommendations of adapted physical restraint guidelines in critical care.

RELEVANCE TO CLINICAL PRACTICE

Practitioners should implement recommendations based on the values and preferences of stakeholders.

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

Purpose

Physical restraints are used routinely in intensive care units (ICUs) and have negative effects. It is critical to identify the impact factors of physical restraints on critically ill patients. The present study investigated the prevalence of physical restraints and impact factors associated with their use in a large cohort of critically ill patients over one year.

Patients and Methods

A retrospective cohort study was performed in multiple ICUs at a tertiary hospital in China in 2019 using observational data from electronic medical records. The data consisted of demographics and clinical variables. Logistic regression was used to assess the independent impact factors for the use of physical restraint.

Results

The analysis consisted of 3776 critically ill patients with a prevalence of physical restraint use of 48.8%. The logistic regression analysis indicated that physical restraint use was associated with independent risk factors, including surgical ICU admission, pain, tracheal tube placement, and abdominal drainage tube placement. Physical restraint use was associated with independent protective factors, including male sex, light sedation, muscle strength, and ICU length of stay.

Conclusion

The prevalence of physical restraint use in critically ill patients was high. Tracheal tubes, surgical ICU, pain, abdominal drainage tubes, light sedation, and muscle strength were independent variables associated with the use of physical restraint. These results will assist health professionals in identifying high-risk physical restraint patients based on their impact factors. Early removal of the tracheal tube and abdominal drainage tube, pain relief, light sedation, and improvements in muscle strength may help reduce the use of physical restraints.