Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US

Characteristics and correlates of seclusion and mechanical restraint measures in a Parisian psychiatric hospital group

Introduction

Seclusion or restraint (S/R) are last-resort measures used in psychiatry to ensure the safety of the patient and the staff. However, they have harmful physical and psychological effects on patients, and efforts to limit their use are needed. We describe the characteristics and correlates of S/R events in four Parisian psychiatric centers.

Methods

Within a 3-month period, November 5, 2018 to February 3, 2019, we recorded data for patients experiencing an S/R measure as well as characteristics of the measures. We studied the mean duration of a S/R event, the time between hospital admission and the occurrence of the event, as well as correlates of these durations. We also examined factors associated with use of a restraint versus a seclusion measure.

Results

For the 233 patients included, we recorded 217 seclusion measures and 64 mechanical restraints. Seclusion measures mostly occurred after the patient's transfer from the emergency department. The duration of a seclusion measure was about 10 days. Patients considered resistant to psychotropic treatments more frequently had a longer seclusion duration than others. The mean duration of a mechanical restraint measure was 4 days. Male sex and younger age were associated with experiencing mechanical restraint.

Discussion

S/R measures mostly occur among patients perceived as resistant to psychotropic drugs who are arriving from the emergency department. Developing specific emergency department protocols might be useful in limiting the use of coercive measures.

Restraint in somatic healthcare: how should it be regulated?

Restraint is regularly used in somatic healthcare settings, and countries have chosen different paths to regulate restraint in somatic healthcare. One overarching problem when regulating restraint is to ensure that patients with reduced decision-making capacity receive the care they need and at the same time ensure that patients with a sufficient degree of decision-making capacity are not forced into care that they do not want. Here, arguments of justice, trust in the healthcare system, minimising harm and respecting autonomy are contrasted with different national regulations. We conclude that a regulation that incorporates an assessment of patients' decision-making capacity and considers the patient's best interests is preferable, in contrast to regulations based on psychiatric diagnoses or regulations where there are no legal possibilities to exercise restraint at all in somatic care.

Physical Restraint Usage in Hospitals Across the United States: 2011-2019

Objective

To determine the change in rates of physical restraint (PR) use and associated outcomes among hospitalized adults.

Patients and Methods

Using national inpatient sample databases, we analyzed years 2011-2014 and 2016-2019 to determine trends of PR usage. We also compared the years 2011-2012 and 2018-2019 to investigate rates of PR use, in-hospital mortality, length of stay, and total hospital charges.

Results

There were 242,994,110 hospitalizations during the study period. 1,538,791 (0.63%) had coding to signify PRs, compared with 241,455,319 (99.3%), which did not. From 2011 to 2014, there was a significant increase in PR use (p-trend<.01) and a nonsignificant increase in PR rates from 2016-2019 (p-trend=.07). Over time, PR use increased (2011-2012: 0.52% vs 2018-2019: 0.73%; p<.01). Patients with PRs reported a higher adjusted odds for in-hospital mortality in 2011-2012 (adjusted odds ratio [aOR], 3.9; 95% CI, 3.7-4.2; p<.01) and 2018-2019 (aOR, 3.5; 95% CI, 3.4-3.7; p<.01). Length of stay was prolonged for patients with PRs in 2011-2012 (adjusted mean difference [aMD], 4.3 days; 95% CI, 4.1-4.5; p<.01) and even longer in 2018-2019 (aMD, 5.8 days; 95% CI, 5.6-6.0; p<.01). Total hospital charges were higher for patients with PRs in 2011-2012 (aMD, +$55,003; 95% CI, $49,309-$60,679; p<.01). Following adjustment for inflation, total charges remained higher for patients with PRs compared with those without PRs in 2018-2019 (aMD, +$70,018; 95% CI, $65,355-$74,680; p<.01).

Conclusion

Overall, PR rates did not decrease across the study period, suggesting that messaging and promulgating best practice guidelines have yet to translate into a substantive change in practice patterns.

Factors affecting nursing practice of patient physical restraint among nurses

BACKGROUND

This study was aimed to identify perception, knowledge, attitude and nursing practice toward use of physical restraints among clinical nurses.

METHODS

The research participants were 180 nurses from general hospitals located in Korea. Data were collected using self-report questionnaires regarding perception, attitude, knowledge, and nursing practice on application of physical restraints and analyzed using t-test, ANOVA, Pearson correlation coefficients, and multiple regression.

RESULTS

There were significant negative relationships attitudes towards the use of physical restraints with knowledge (r = -.32, p < .001). Knowledge showed a positive correlation with nursing practice (r = .28, p < .001). Factors affecting nursing practice of clinical nurses were identified as knowledge (β = .23), education experiences on physical restraints (Yes) (β = .18), and work unit (ICU) (β = .43). The explanation power of this regression model was 22% and it was statistically significant (F = 7.45, p < .001).

CONCLUSION

This study suggests that knowledge, education experiences on physical restraints, and work unit were the strongest predictor on nursing practice toward use of patient physical restraints. Therefore, developing and applying evidence-based educational intervention programs by work unit to reduce the inappropriate use of physical restraints in hospitals are required.

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.

Association of language concordance and restraint use in adults receiving mechanical ventilation

PURPOSE

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes.

METHODS

We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect).

RESULTS

Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common.

CONCLUSIONS

We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Understanding nurses' justification of restraint in a neurosurgical setting: A qualitative interview study

BACKGROUND

Despite its negative impact on patients and nurses, the use of restraint in somatic health care continues in many settings. Understanding the reasons and justifications for the use of restraint among nurses is crucial in order to manage this challenge.

AIM

To understand nurses' justifications for restraint use in neurosurgical care.

RESEARCH DESIGN

A qualitative, descriptive design was used. Data were analysed with inductive qualitative content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden.

ETHICAL CONSIDERATIONS

Approved by The Regional Ethics Committee, Stockholm, Sweden.

FINDINGS

The analysis resulted in three categories. The category Patient factors influencing restraint use describes patient factors that trigger restraint, such as a diminished decision-making competence, restlessness, and need for invasive devices. The category Specific reasons for justifying restraint describes reasons for restraining patients, such as restraint being used for the sake of the patient or for the sake of others. The category General reasoning in justifying restraint describes how nurses reason when using restraint, and the decision to use restraint was often based on a consequentialist approach where the nurses' weighed the pros and cons of different alternatives.

DISCUSSION

Nurses with experience of restraint use were engaged in a constant process of justifying and balancing different options and actions. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse.

CONCLUSION

How nurses reason when justifying restraint, why they use restraint, and who they use restraint on must be considered when creating programs and guidelines to reduce the use of restraint and to ensure that when it is used it is used carefully, appropriately, and with respect.

Prevalence, Risk Factors and Outcomes Associated with Physical Restraint in Acute Medical Inpatients over 4 Years-A Retrospective Cohort Study

BACKGROUND

Physical restraints are frequently used in acute care hospitals. Their application is associated with negative outcomes, while their intended preventive effect is debated.

OBJECTIVES

To determine the prevalence of physical restraints and associated outcomes on medical wards in a tertiary care hospital.

METHODS

Retrospective cohort study (January 2018 to December 2021). We included all adult medical in-patients and excluded patients with admission to the intensive care unit, short stays (length of stay (LOS) < 48 h), and patients declining informed consent.

RESULTS

Of 11,979 admissions, the prevalence of patients with at least one restraint was 6.4% (n = 772). Sensor mats were used most frequently (73.0%, n = 666), followed by blanket restrictions (14.5%, n = 132), bedrails (8.8%, n = 80) and belts (3.7%, n = 34). On average, restraints were applied 19 h (standard deviation (SD) ± 161) before a fall. Average restraint duration was 42 h (SD ± 57). Patients with a restraint had longer LOS 8 days (IQR 5-14) vs. 5 days (IQR 3-9). Median nurses' time expenditure was 309 h (IQR 242-402) vs. 182 h (IQR 136-243) for non-restrained patients. Patients with restraints fell more often (22.5% vs. 2.7%) and were more likely to die (13.3% vs. 5.1%). These differences persisted after adjusting a regression model for important clinical confounders. We saw a decline in the duration of restraints over the years, but no variation between wards.

CONCLUSION

Approximately 6% of medical patients, mostly older and severely ill, were affected by restraint use. For the first time, we report data over 4 years up to ward-level granularity.

Prevention of physical restraints in the acute care setting (PROTECT): study protocol for a cluster-randomised controlled pilot study

INTRODUCTION

Physical restraints (PR) are regularly used in acute care settings, although evidence for their effectiveness and safety (eg, for prevention of falls) is lacking. Their use is associated with adverse events, such as decreased mobility and injuries for patients. We developed a complex intervention to prevent PR in acute care settings according to the UK Medical Research Council Framework, and investigated the feasibility. The intervention comprised the qualification of key nurses as multipliers and a short interprofessional information session. The intervention has proven to be feasible. It also became apparent that further development of the intervention and the study procedures is necessary. Therefore, this study aims to refine and pilot the complex intervention. Furthermore, the objective of this pilot study is to improve study procedures.

METHODS AND ANALYSIS

In a preparatory phase, we will conduct focus groups and individual interviews with the target groups to explore the possibilities for adaption of the intervention and implementation strategies. Subsequently, a cluster-randomised controlled trial with a 6-month follow-up period will be conducted. It is planned to recruit eight general hospitals in Germany (area of Halle (Saale) and Leipzig) with 28 wards and 924 patients per observation period (2772 overall). Primary outcome is the proportion of patients with at least one PR after 6 months. Data will be collected by direct observation over a period of seven consecutive days and three times a day. Secondary outcomes are falls, interruptions in therapy and prescription of psychotropic medication. A comprehensive process evaluation will accompany the study.

ETHICS AND DISSEMINATION

The Ethics committee of the Medical Faculty of the University of Halle (Saale) approved the study protocol. Results will be published in a peer-reviewed journal and presented at conferences. Study information and additional material will be freely available on an already existing website.

TRIAL REGISTRATION NUMBER

DRKS00027989.

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.

Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings

BACKGROUND

Physical restraints, such as bedrails, belts in chairs or beds, and fixed tables, are commonly used for older people in general hospital settings. Reasons given for using physical restraints are to prevent falls and fall-related injuries, to control challenging behavior (such as agitation or wandering), and to ensure the delivery of medical treatments. Clear evidence of their effectiveness is lacking, and potential harms are recognised, including injuries associated with the use of physical restraints and a negative impact on people's well-being. There are widespread recommendations that their use should be reduced or eliminated.

OBJECTIVES

To assess the best evidence for the effects and safety of interventions aimed at preventing and reducing the use of physical restraint of older people in general hospital settings. To describe the content, components and processes of these interventions.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 20 April 2022.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials that investigated the effects of interventions that aimed to prevent or reduce the use of physical restraints in general hospital settings. Eligible settings were acute care and rehabilitation wards. We excluded emergency departments, intensive care and psychiatric units, as well as the use of restrictive measures for penal reasons (e.g. prisoners in general medical wards). We included studies with a mean age of study participants of at least 65 years. Control groups received usual care or active control interventions that were ineligible for inclusion as experimental interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles for inclusion, extracted data, and assessed the risk of bias of all included studies. Data were unsuitable for meta-analysis, and we reported results narratively. We used GRADE methods to describe our certainty in the results.

MAIN RESULTS

We included four studies: two randomised controlled trials (one individually-randomised, parallel-group trial and one clustered, stepped-wedge trial) and two controlled clinical trials (both with a clustered design). One study was conducted in general medical wards in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. A total of 1709 participants were included in three studies; in the fourth study the number of participants was not reported. The mean age ranged from 67 years to 84 years. The duration of follow-up covered the period of patients' hospitalisation in one study (21 days average length of stay) and ranged from 4 to 11 months in the other studies. The definition of physical restraints differed slightly, and one study did not include bedrails. Three studies investigated organisational interventions aimed at implementing a least-restraint policy to reduce physical restraints. The theoretical approach of the interventions and the content of the educational components was comparable across studies. The fourth study investigated the use of pressure sensors for participants with an increased falls risk, which gave an alarm if the participant left the bed or chair. Control groups in all studies received usual care. Three studies were at high risk of selection bias and risk of detection bias was unclear in all studies. Because of very low-certainty evidence, we are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on our primary efficacy outcome: the use of physical restraints in general hospital settings. One study found an increase in the number of participants with at least one physical restraint in the intervention and control groups, one study found a small reduction in both groups, and in the third study (the stepped-wedge study), the number of participants with at least one physical restraint decreased in all clusters after implementation of the intervention but no detailed information was reported. For the use of bed or chair pressure sensor alarms for people with an increased fall risk, we found moderate-certainty evidence of little to no effect of the intervention on the number of participants with at least one physical restraint compared with usual care. None of the studies systematically assessed adverse events related to use of physical restraint use, e.g. direct injuries, or reported such events. We are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on the number of participants with at least one fall (very low-certainty evidence), and there was no evidence that organisational interventions or the use of bed or chair pressure sensor alarms for people with an increased fall risk reduce the number of falls (low-certainty evidence from one study each). None of the studies reported fall-related injuries. We found low-certainty evidence that organisational interventions may result in little to no difference in functioning (including mobility), and moderate-certainty evidence that the use of bed or chair pressure sensor alarms has little to no effect on mobility. We are uncertain about the effect of organisational interventions on the use of psychotropic medication; one study found no difference in the prescription of psychotropic medication. We are uncertain about the effect of organisational interventions on nurses' attitudes and knowledge about the use of physical restraints (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India

Background

There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients.

Methods

We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study.

Results

The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers.

Conclusion

The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

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.

[Development and feasibility of an intervention to reduce physical restraints in hospitals: A mixed methods study]

Development and feasibility of an intervention to reduce physical restraints in hospitals: A mixed methods study Abstract. Background: Physical restraints (PR) are regularly used in people with dementia or delirium in general hospital settings. There is no clear evidence for the effectiveness of PR, but their use is associated with an increased risk for harm. Therefore, a restraint-free care is recommended. Aim: Development and feasibility test of an intervention to reduce PR in general hospital settings. Methods: Systematic literature reviews and theory-guided modelling of an intervention involving relevant clinical stakeholders and mixed methods study in two wards of a university hospital (geriatric traumatology and neurology). Results: The complex intervention comprises the following components: qualification of multipliers, interprofessional education about PR reduction, regular audit and feedback meetings, and the support regarding the aim of the intervention from nursing and medical leaders. The results of the feasibility test indicate that the intervention is feasible and helpful, but the interprofessional approach was not implemented as planned. An important barrier hampering PR reduction was the high workload. The results on the prevalence of PR could not be interpreted due to a very low number of measures applied. Conclusion: The complex intervention with a multiplier approach for preventing PR use was judged as feasible, but there is a need for further development to strengthen interprofessional cooperation. The feasibility of the intervention should also be tested in other departments.

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives'/patients' requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories 'Restrictive' and 'Supportive' devices aimed at 'Preventing risks' and at 'Promoting support', respectively, have emerged. Reasons triggering 'restrictive devices' involved patients' risks, the health professionals' and/or the relatives' concerns. In contrast, the 'supportive' ones were triggered by patients' problems/needs. 'Restrictive' and 'Supportive' devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with 'restrictive devices' (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.

Nurses' Views on the Use of Physical Restraints in Intensive Care: A Qualitative Study

Despite the worldwide promotion of a “restraint-free” model of care due to the questionable ethical and legal issues and the many adverse physical and psychosocial effects of physical restraints, their use remains relatively high, especially in the intensive care setting. Therefore, the aim of the present study was to explore the experiences of nurses using physical restraints in the intensive care setting. Semi-structured interviews with 20 nurses working in intensive care units for at least three years, were conducted, recorded, and transcribed verbatim. Then, the transcripts were analyzed according to the qualitative descriptive approach by Sandelowsky and Barroso (2002). Six main themes emerged: (1) definition of restraint, (2) who decides to restrain? (3) reasons behind the restraint use, (4) physical restraint used as the last option (5) family involvement, (6) nurses’ feelings about restraint. Physical restraint evokes different thoughts and feelings. Nurses, which are the professionals most present at the patient’s bedside, have been shown to be the main decision-makers regarding the application of physical restraints. Nurses need to balance the ethical principle of beneficence through this practice, ensuring the safety of the patient, and the principle of autonomy of the person.

Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study

AIM AND OBJECTIVES

To describe nurses' experiences of using restraint in neurosurgical care.

BACKGROUND

Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce.

DESIGN

A qualitative, descriptive design guided by a naturalistic inquiry was used.

METHODS

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist.

RESULTS

The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines.

CONCLUSION

Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.

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.

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.

Nurses' knowledge and practices of physical restraints in intensive care units: An observational study

Aim

To investigate the knowledge and practice of physical restraints (PR) among Jordanian intensive care unit (ICU) nurses.

Design

A descriptive, observational design was used.

Methods

A convenience sampling was used to recruit participants. We examined the knowledge of PR in 301 nurses (knowledge check) and the real-time practice of PR in 81 nurses (direct observation) in ICU. A knowledge questionnaire was used to collect data on knowledge about PR use, and data on their practice of PR were observed and documented using an observation checklist.

Results

The mean scores of nurses' knowledge and practices were 61.5 (SD = 12.1) and 57.4 (SD = 9.7), respectively. More than half of nurses had poor knowledge of PR use and incorrect practice of implementing PR (51.5% and 60.5%, respectively). Results indicated a positive correlation between nurses' knowledge and their use of PR.

Overcoming the Use of Mechanical Restraints in Psychiatry: A New Challenge in the Everyday Clinical Practice at the Time of COVID-19

Restraining interventions, which comprise physical (PR) and mechanical restraint (MR), have a long history in mental health services [...].

The Effectiveness of Educational Training or Multicomponent Programs to Prevent the Use of Physical Restraints in Nursing Home Settings: A Systematic Review and Meta-Analysis of Experimental Studies

This review assesses the effectiveness of interventions to reduce physical restraint (PR) use in older people living in nursing homes or residential care facilities. A systematic search of studies published in four electronic databases (MEDLINE, CINHAL, PsycINFO, Cochrane Central Register of Controlled Trials). The review included individual and cluster randomized controlled trials that compared educational training and multicomponent programs to avoid PR use. Risk bias of randomized controlled trials (RCTs) was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. This review includes 16 studies in a qualitative synthesis that met the inclusion criteria, nine of them offered a multicomponent program and seven offered only educational training. The results of the 12 studies included in the meta-analysis showed a significant trend in favor of intervention over time and intensity of PR use tends to decrease. The review indicates that educational programs and other supplementary interventions should be effective, but the heterogeneous operative definition of physical restraints can make difficult data generalization.

Factors associated with the use of physical restraint in intensive care patients

OBJECTIVE

To verify the frequency of physical restraint in patients and the factors associated with its use in the intensive care unit.

METHOD

An observational and prospective study on the use of restraint in patients observed over two days, considering the variables: age and gender, personal and clinical characteristics, devices, adverse event and restraint use. The frequency was verified in three groups of patients with different conditions by applying the Chi-Squared, Likelihood Ratio or Kruskal-Wallis tests. The association of the variables was verified with the Multinomial Logistic Regression.

RESULTS

Eighty-four (84) patients participated. Restraint was observed in 77.4% of the 84 analyzed patients, and was more frequent in the presence of sedation, agitation and invasive devices. The chance of being restrained was at least five times higher in sedation conditions, whether in weaning or daily awakening, mechanical ventilation weaning, agitation or the presence of invasive devices.

CONCLUSION

Restraint use was high and was associated with female gender, sedation, agitation and invasive airway. It is emphasized and important to apply policies to reduce restraint use in intensive care.

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.

Nurses' Knowledge, Attitude, and Influencing Factors regarding Physical Restraint Use in the Intensive Care Unit: A Multicenter Cross-Sectional Study

Background

Physical restraint is a common practice in the intensive care units which often result in frequent skin laceration at restraint site, limb edema, restricted circulation, and worsening of agitation that may even end in death. Despite the sensitivity of the problem, however, it is felt that there are nurses' evidence-based practice gaps in Ethiopia. To emphasize the importance of this subject, relevant evidence is required to develop protocols and to raise evidence-based practices of health professionals. So, this study aimed to assess the knowledge, attitude, and influencing factors of nurses regarding physical restraint use in the intensive care units in northwest Ethiopia.

Methods

An institution-based cross-sectional study was maintained from March to September 2019 at Amhara regional state referral hospitals, northwest Ethiopia. A total of 260 nurses in the intensive care units were invited to take part in the study by a convenience sampling technique. The Level of Knowledge, Attitudes, and Practices of Staff regarding Physical Restraints Questionnaire was used to assess the nurses' knowledge and attitude. Linear regression analysis was employed to examine the influencing factors of knowledge and attitude. Adjusted unstandardized beta (β) coefficient with a 95% confidence interval was used to report the result of association with a p value < 0.05 statistical significance level.

Result

The mean scores of nurses' knowledge and attitude regarding physical restraint use among critically ill patients were 7.81 ± 1.89 and 33.75 ± 6.50, respectively. These mean scores are above the scale midpoint nearer to the higher ranges which imply a moderate level of knowledge and a good attitude regarding physical restraint. Lower academic qualification and short (<2 years) work experience were associated with lower-level of knowledge, and reading about restraint from any source and taken training regarding restraints were factors associated with a higher knowledge. Diploma and bachelor's in academic qualification were significantly associated with a negative attitude regarding restraint. Besides, there was a more positive attitude among nurses with a higher level of knowledge and who received training regarding physical restraint use.

Conclusion

The nurses working in the intensive care unit had a moderate level of knowledge and a good attitude regarding physical restraint use. So, developing and providing educational and in-service training to the nurses regarding physical restraint are necessary to strengthen the quality of care for critically ill patients.

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.

Improving practice and informing policy development: The impact of gerontological nursing research

Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.

The Adverse Effects of Physical Restraint Use among Older Adult Patients Admitted to the Internal Medicine Wards: A Hospital-Based Retrospective Cohort Study

OBJECTIVES

To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients.

DESIGN

A retrospective cohort study.

SETTING

Internal medicine wards of a tertiary medical center in Taiwan.

PARTICIPANTS

Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study.

MEASUREMENTS

Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis.

RESULTS

Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322-3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627-7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794-7.160, p<0.001) after adjustment for covariates.

CONCLUSION

The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality.

Restraint in a Neurosurgical Setting: A Mixed-Methods Study

OBJECTIVE

To investigate the extent to which restraint is used in neurosurgical care, under what circumstances, and how it is documented.

METHODS

A cross-sectional study with a mixed-methods approach was used to identify neurosurgical inpatients subjected to restraint. The data were collected in 2 phases: (1) a study-specific questionnaire was distributed to nurses in which they identified if restraints had occurred during their shifts, and if so, which restraint and to which patient; and (2) scrutinizing of electronic medical records of patients identified by the questionnaires. Numeric data were analyzed using descriptive and analytic statistical methods, and textual data were analyzed using qualitative content analysis. The findings from the different data sources were compared and merged.

RESULTS

Of the 517 patients admitted to the studied department during the study period, 58 (11%) were reported to have been subjected to restraint and most of the restraining events occurred in the neurointensive care unit. Most restraint measures were not documented in the electronic medical records. The identified patients were predominantly diagnosed with traumatic brain injury or subarachnoid hemorrhage. The qualitative content analysis showed the circumstances when restraints were used: when patients were considered a danger to self or others (theme) and which symptoms and behaviors (categories) were observed in relation to the use of restraint.

CONCLUSIONS

Restraint in neurosurgical care is mostly used to prevent patients from harming themselves or others. Because of the lack of documentation, restraint measures cannot be openly assessed, thus putting patients' safety at risk.

The Attitudes Towards the Use of Restraint and Restrictive Intervention Amongst Healthcare Staff on Acute Medical and Frailty Wards-A Brief Literature Review

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but they are often not classified as “restraints”. Examples of these include the use of bed rails or tables to prevent patients from “wandering” and to reduce the risk of falls and injuries. More indirect techniques would involve passive interactions with patients or leaving mobility aids out of reach. Staff subconsciously restrain patients and reduce their liberties despite agreeing that patient autonomy should be upheld—a necessary evil to maintain a duty of care. Whilst the use of restraints is often justified to ensure patient care and prevent injury, it is not without consequence. There are physical and psychological health risks such as pressure sores from the inability to mobilise, or the brewing of anger and frustration when denied access to everyday actions. The reasons why restraints are used, whilst stemming from maintaining patient safety, are often due to low staffing levels and the inability to constantly watch at-risk patients due to a large workload. Inadequate training is another factor; by improving education in direct and indirect restraint and providing alternative methods, more ethical decisions and positive outcomes can be implemented. Healthcare professionals are reluctant to use restraint but often conduct it without realising it; assessing their understanding of restraint and providing education to raise awareness of the consequences of direct and indirect methods would result in positive steps toward reducing their use at the same time as looking to provide alternatives to uphold patient care whilst maintaining their dignity and liberty.

Knowledge, Attitudes, and Practices of Chinese Critical Care Nurses Regarding Physical Restraint

BACKGROUND

This multicenter cross-sectional study sought to determine the knowledge, attitudes, and practices regarding the use of physical restraints by Chinese nurses in intensive care units (ICUs) of tertiary hospitals.

METHOD

A scale technique was used to measure the knowledge, attitudes, and practices of 383 RNs from eight tertiary hospitals in Chongqing, China.

RESULTS

A total of 383 valid questionnaires were returned, for a response rate of 89.49%. Approximately 8.1% of the nurses were male, 67.1% had a bachelor's degree or above, and 55.09% were ICU specialists. The average age was 28.62 years (SD = 4.56). The mean scores were 74.33 of 111 (SD = 9.552), 24.41 of 40 (SD = 4.872), and 65.66 of 130 (SD = 20.880) regarding knowledge, attitudes, and nursing practices, respectively. For the attitude scale, the scores of nurses who were certified ICU specialists and had extensive working experience were higher than those with less experience; the difference was statistically significant (p < .05).

CONCLUSION

Results indicated that nurses employed in the ICUs of tertiary hospitals in Chongqing, China, have relatively insufficient knowledge, comparatively incorrect attitudes, and unreasonable means of practicing physical restraint. Continuing education should focus strongly on the relationship between physical restraint and unplanned extubation, and guidelines on physical restraint urgently need to be developed. [J Contin Educ Nurs. 2019;50(3):121-126.].

Accidental removal of devices in intensive care unit: An eight-year observational study

BACKGROUND

In the intensive care unit, invasive devices can be accidentally removed by the patient or by the operators, increasing workload, staff stress level and hospitalisation costs.

OBJECTIVE

to know the incidence of accidental removal of devices in critical patients, to identify their cause, when they occur and if they are repositioned.

METHODS

Retrospective observational study carried out in an academic, tertiary-level critical care department composed of three intensive care units. All adult patients recovered between 2011 and 2018 were enrolled. We calculated rates per 1000 device-years.

RESULTS

In the study period 10514 patients (194372 device-days) were admitted to the intensive care units and the number of reported accidental removal of devices was 451, corresponding to a rate of 2.3 episodes per 1000 device-days (95% confidence interval: 2.1-2-5). The overall rates of accidental removals were as follows: gastric tubes 10.2 (n = 270), intracranial devices 3.9 (n = 9), endotracheal tubes 2.4 (n = 27), central venous catheters and arterial catheters 1.5 (n = 92), peripheral intravenous catheters 1.2 (n = 25), surgical drains 0.5 (n = 15), urinary catheters 0.4 (n = 11), Extra Corporeal Membrane Oxygenation cannulas 0.4 (n = 1), tracheostomy cannulas 0.1 (n = 1).

CONCLUSION

Compared to the literature, this study shows fewer incidents of accidental removal of devices. The number of accidental removals could be an indicator of the quality and safety of the care.

Factors associated with mechanical restraint in the hospital environment: a cross-sectional study

OBJECTIVE

To estimate the prevalence of mechanical restraint in the hospital environment and the factors associated with its performance.

METHOD

A cross-sectional, observational study with patients from a public hospital from the medical clinic, surgical clinic and intensive care unit evaluated by descriptive, univariate and multivariate analyses.

RESULTS

One hundred eleven (111) patients participated in the study. The prevalence of mechanical restraint was 51.4%; bilateral rails on the bed were used in 100% of the restraints, and bilateral wrist restraints were also observed in 29.8%. The most common justifications were the risk of falls (100.0%) and the risk of non-scheduled removal of invasive devices (57.9%). The restrained patients differ significantly from those not restrained by the following associated factors: male gender; age; stroke diagnosis; the hospitalization unit; ambulation capacity; the use of sedative medication; and the use of invasive devices.

CONCLUSION

This study estimated a high mechanical restraint prevalence in the hospital environment and determined factors associated with the risk of a patient being restrained. A medical restraint evaluation team is recommended for an in-depth analysis of indication and therapy.

The effect of physical restraint on neurovascular complications in intensive care units

BACKGROUND

To reduce the neurovascular complications caused by physical restraint in intensive care patients, there is a need to examine the occurrence of neurovascular complications and their rate.

OBJECTIVES

The objective of this research was to investigate the effect of physical restraint on the occurrence of neurovascular complications and their rate.

METHODS

A prospective observational cohort study was carried out. A total of 90 patients from anaesthesia and internal intensive care units participated in this study. Patients were assessed at intervals of 24 h for 4 days using the following instruments: Individual Characteristics Form, Richmond Agitation-Sedation Scale (RASS), Behavioral Pain Scale, and Complication Diagnostic Diary.

RESULTS

Redness (p < 0.001), limb movement (p < 0.001), oedema (p < 0.001), and colour complication (p < 0.001) increased, whereas pulse strength (p < 0.001) decreased in physically restrained sites on the arm from day 1 to day 4. Redness was increased in patients physically restrained with all types of materials (p < 0.001; p < 0.001; p = 0.020). Although there was a statistically significant difference in terms of movement (p = 0.006; p = 0.003) and oedema (p < 0.001; p < 0.001), both with a roll of gauze and tough cuff, these complications were not significantly different in patients restrained with green foam tie (p > 0.05). According to logistic regression analysis, material type, position of the limb, space between the physical restraint and limb, age, RASS, and pain were independent risk factors for neurovascular complications. RASS and pain were independent protective factors against movement complications.

CONCLUSIONS

The duration of physical restraint increases neurovascular complications. This study revealed that nurses did not regularly check the restrained wrist and did not focus on the peripheral circulation. It is necessary to develop training programs, standards, and appropriate follow-up strategies in intensive care units in Turkey.

Reducing Use of Restraints in Intensive Care Units: A Quality Improvement Project

BACKGROUND

Use of physical restrainst is scrutinized in intensive care units today. Usage rates for the 5 intensive care units in the Christiana Care Health Services, Newark, Delaware, were higher than the National Database of Nursing Quality Indicators mean rate of 9.61% to 15.43% for many months during fiscal years 2013 and 2014.

OBJECTIVE

To reduce and sustain the restraint rates to less than the national database mean rates for all 5 intensive care units.

METHODS

A quality improvement process was used that included forming a multiunit restraint collaborative; reviewing restraint data, including self-extubation rates; surveying staff nurses to examine alignment with evidence-based practice; and selecting a new restraint-alternative product.

RESULTS

All 5 intensive care units were able to successfully decrease restraint rates to less than the national database mean for the majority of the months since the start of the restraint collaborative in September 2012.

CONCLUSION

Use of a restraint collaborative with subsequent adoption of restraint alternatives led to a decrease in restraint rates for the 5 intensive care units to less than the national database mean, enabled sustained success, and helped align nurses' beliefs with evidence-based practice.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective:

To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient’s appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.

Conclusion:

The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.

Systematic review registry number:

CRD42017054440.

Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study)

Background

Hospitalized older persons with Alzheimer’s disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer’s disease and related dementias (ADRD) and improving FCG preparedness and experiences.

Method

We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds.

Discussion

Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD.

Trial registration

ClinicalTrials.gov, ID: NCT03046121. Registered on 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2875-1) contains supplementary material, which is available to authorized users.

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.

Validity and measurement invariance of the Physical Restraint Use Questionnaire (PRUQ) in nursing staff

AIMS AND OBJECTIVES

To study the internal structure and measurement invariance of the Physical Restraint Use Questionnaire and to compare perceptions, experience and training, regarding use of physical restraint on the older people between nursing staff working in hospitals and nursing homes.

BACKGROUND

Physical restraint of patients is still common in many countries, and thus, it is important to study the attitudes of nursing staff. One of the most common tools used to assess perceptions regarding its use is the Physical Restraint Use Questionnaire. However, gaps exist in its internal structure and measurement invariance across different groups of respondents.

DESIGN

Cross-sectional multicentre survey.

METHODS

Data were collected from nurses working in eight Spanish hospitals and 19 nursing homes. All registered nurses and nurse assistants (N = 3,838) were contacted, of whom 1,635 agreed to participate. Confirmatory factor analysis was performed to determine internal structure and measurement invariance of Physical Restraint Use Questionnaire, after which scale scores and other measures of experience and training were compared between hospital-based (n = 855) and nursing homes-based (n = 780) nurses.

RESULTS

The Physical Restraint Use Questionnaire showed three invariant factors across type of facility, and also professional category and sex. Nursing staff working in both types of facility scored similarly; prevention of therapy disruption and prevention of falls were rated more important. Nurses working in nursing homes reported using restraint "many times" more frequently (52.9% vs. 38.6%), less severe lack of training (18.2% vs. 58.7%) being perceived as more adequate (33.4% vs. 17.7%), than hospital-based nurses.

CONCLUSIONS

These findings support Physical Restraint Use Questionnaire as a valid and reliable tool for assessing the importance given to the use of physical restraint in the older people by nursing professionals, regardless of the setting being studied.

RELEVANCE TO CLINICAL PRACTICE

The information would help design more specifically the physical restraint training of nursing staff and to plan institutional interventions aimed at reducing its use.

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.

Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study

BACKGROUND

Although it is plausible that nurse staffing is associated with use of physical restraints in hospitals, this has not been well established. This may be due to limitations in previous cross-sectional analyses lacking adequate control for unmeasured differences in patient-level variables among nursing units.

OBJECTIVE

To conduct a longitudinal study, with units serving as their own control, examining whether nurse staffing relative to a unit's long-term average is associated with restraint use.

DESIGN

We analyzed 17 quarters of longitudinal data using mixed logistic regression, modeling quarterly odds of unit restraint use as a function of quarterly staffing relative to the unit's average staffing across study quarters.

SUBJECTS

3101 medical, surgical, and medical-surgical units in US hospitals participating in the National Database of Nursing Quality Indicators during 2006-2010. Units had to report at least one quarter with restraint use and one quarter without.

MAIN MEASURES

We studied two nurse staffing variables: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention.

KEY RESULTS

Nursing skill mix was inversely correlated with restraint use for fall prevention and for any reason. Compared to average quarters, odds of fall prevention restraint and of any restraint were respectively 16 % (95 % CI: 3-29 %) and 18 % (95 % CI: 8-29 %) higher for quarters with very low skill mix.

CONCLUSIONS

In this longitudinal study there was a strong negative correlation between nursing skill mix and physical restraint use. Ensuring that skill mix is consistently adequate should reduce use of restraint.