Influence of physical restraint on delirium of adult patients in ICU: A nested case-control study

Disparities in Delirium across the Continuum of Care and Associations with Social Determinants of Health

Disparities exist in the identification, treatment, and management of delirium. These disparities can be most holistically and comprehensively understood by using a social-ecological model-which acknowledges multilevel impacts including individual, interpersonal, organizational, community, and policy-level factors-as well as a social determinant of health framework, that considers nonmedical factors that influence health outcomes. This narrative review leverages both frameworks to identify and discuss existing literature pertaining to the intersection of these social risk factors and delirium, focusing specifically on disparities due to racial and/or ethnic identity, language ability, and socioeconomic differences. We also look at disparities and the potential role of these social risk factors throughout the continuum of care, including prehospitalization, hospitalization, and posthospitalization factors. Understanding and analyzing the role of these inequities is critical to ensuring better health outcomes for patients at risk of and/or with delirium.

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

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

BACKGROUND

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

AIMS

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator

Background and purpose

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

Methods

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

Result

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

Conclusion

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

How to cite this article

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Adverse events related to physical restraint use in intensive care units: A review of the literature

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.

A qualitative study of geriatric specialist nurses' experiences to navigate delirium in the elderly

BACKGROUND

The experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing interventions. This qualitative study aims to explore these experiences and perceptions to inform the enhancement of clinical geriatric nursing and care practices.

METHODS

Utilizing a qualitative exploratory design, this research engaged a convenience sample of geriatric specialist nurses at a tertiary hospital in Shanghai, China through focus groups and semi-structured interviews. Data were rigorously analyzed using Colaizzi's phenomenological method, which facilitated the identification of themes that emerged from the narratives of the geriatric specialist nurses.

RESULTS

The thematic analysis yielded three major themes that encapsulate the nurses' experiences and perceptions. Theme 1: Understanding of Delirium, highlighted the nurses' awareness of the condition's significance, yet it was often deprioritized due to the pressing demands of managing more acute and immediately life-threatening conditions. Theme 2: Barriers in Application, brought to light the multifaceted challenges faced by nurses, including language barriers, the frequency and consistency of delirium assessments, the social determinants of health, and the nurses' own competencies in assessment. Theme 3: Evolution of Nursing Approaches, detailed the adaptive strategies employed by nurses, such as managing nursing adverse events, improving communication with patients' families, and adopting a proactive stance towards long-term patient outcomes.

CONCLUSIONS

The findings suggest that while geriatric specialist nurses recognize the importance of delirium assessment, there are several barriers to effective application. The study underscores the imperative for the advancement of more refined delirium assessment and care protocols, tailored to address the unique requirements of geriatric nursing care.

Delirium During Critical Illness and Subsequent Change of Treatment in Patients With Cancer: A Mediation Analysis

OBJECTIVES

To assess whether delirium during ICU stay is associated with subsequent change in treatment of cancer after discharge.

DESIGN

Retrospective cohort study.

SETTING

A 50-bed ICU in a dedicated cancer center.

PATIENTS

Patients greater than or equal to 18 years old with a previous proposal of cancer treatment (chemotherapy, target therapy, hormone therapy, immunotherapy, radiotherapy, oncologic surgery, and bone marrow transplantation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We considered delirium present if Confusion Assessment Method for the ICU was positive. We assessed the association between delirium and modification of the treatment after discharge. We also performed a mediation analysis to assess both the direct and indirect (i.e., mediated by the development of functional dependence after discharge) of delirium on modification of cancer treatment and whether the modification of cancer treatment was associated with mortality at 1 year. We included 1,134 patients, of whom, 189 (16.7%) had delirium. Delirium was associated with the change in cancer treatment (adjusted odds ratio [OR], 3.80; 95% CI, 2.72-5.35). The association between delirium in ICU and change of treatment was both direct and mediated by the development of functional dependence after discharge. The proportion of the total effect of delirium on change of treatment mediated by the development of functional dependence after discharge was 33.0% (95% CI, 21.7-46.0%). Change in treatment was associated with increased mortality at 1 year (adjusted OR, 2.68; 95% CI, 2.01-3.60).

CONCLUSIONS

Patients who had delirium during ICU stay had a higher rate of modification of cancer treatment after discharge. The effect of delirium on change in cancer treatment was only partially mediated by the development of functional dependence after discharge. Change in cancer treatment was associated with increased 1-year mortality.

Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study

PURPOSE

Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention.

MATERIALS AND METHODS

Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted.

RESULTS

The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification.

CONCLUSION

Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.

Dynamic Nomogram for Subsyndromal Delirium in Adult Intensive Care Unit: A Prospective Cohort Study

Purpose

To develop a dynamic nomogram of subsyndromal delirium (SSD) in intensive care unit (ICU) patients and internally validate its efficacy in predicting SSD.

Patients and Methods

Patients who met the inclusion and exclusion criteria in the ICU of a tertiary hospital in Zhejiang from September 2021 to June 2022 were selected as the research objects. The patient data were randomly divided into the training set and validation set according to the ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to screen the predictors of SSD, and R software was used to construct a dynamic nomogram. Receiver operating characteristic (ROC) curve, calibration band and decision curve were used to evaluate the discrimination, calibration and clinical effectiveness of the model.

Results

A total of 1000 eligible patients were included, including 700 in the training set and 300 in the validation set. Age, drinking history, C reactive protein level, APACHE II, indwelling urinary catheter, mechanical ventilation, cerebrovascular disease, respiratory failure, constraint, dexmedetomidine, and propofol were predictors of SSD in ICU patients. The ROC curve values of the training set was 0.902 (95% confidence interval: 0.879-0.925), the best cutoff value was 0.264, the specificity was 78.4%, and the sensitivity was 88.0%. The ROC curve values of the validation set was 0.888 (95% confidence interval: 0.850-0.930), the best cutoff value was 0.543, the specificity was 94.9%, and the sensitivity was 70.9%. The calibration band showed good calibration in the training and validation set. Decision curve analysis showed that the net benefit in the model was significantly high.

Conclusion

The dynamic nomogram has good predictive performance, so it is a precise and effective tool for medical staff to predict and manage SSD in the early stage.

Machine learning for prediction of delirium in patients with extensive burns after surgery

AIMS

Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns.

METHODS

Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital.

RESULTS

Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%).

CONCLUSION

The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.

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.

A Review of Biomarkers in Delirium Superimposed on Dementia (DSD) and Their Clinical Application to Personalized Treatment and Management

Delirium superimposed on dementia (DSD) occurs when patients with pre-existing dementia develop delirium. This complication causes patients to become impaired, posing safety concerns for both hospital staff and patients. Furthermore, there is an increased risk of worsening functional disability and death. Despite medical advances, DSD provides both diagnostic and therapeutic challenges to providers. Identifying at-risk patients and providing personalized medicine and patient care can decrease disease burden in a time-efficient manner. This review delves into bioinformatics-based studies of DSD in order to design and implement a personalized medicine-based approach. Our findings suggest alternative medical treatment methods based on gene-gene interactions, gene-microRNA (miRNA) interactions, gene-drug interactions, and pharmacogenetic variants involved in dementia and psychiatric disorders. We identify 17 genes commonly associated with both dementia and delirium including apolipoprotein E (ApoE), brain-derived neurotrophic factor (BDNF), catechol-O-methyltransferase (COMT), butyrylcholinesterase (BChE), acetylcholinesterase (AChE), DNA methyltransferase 1 (DNMT1), prion protein (PrP), tumor necrosis factor (TNF), serine palmitoyltransferase long chain base subunit 1 (SPTLC1), microtubule-associated protein tau (MAPT), alpha-synuclein (αS), superoxide dismutase 1 (SOD1), amyloid beta precursor protein (APP), neurofilament light (NFL), neurofilament heavy, 5-hydroxytryptamine receptor 2A (HTR2A), and serpin family A member 3 (ERAP3). In addition, we identify six main genes that form an inner concentric model, as well as their associated miRNA. The FDA-approved medications that were found to be effective against the six main genes were identified. Furthermore, the PharmGKB database was used to identify variants of these six genes in order to suggest future treatment options. We also looked at previous research and evidence on biomarkers that could be used to detect DSD. According to research, there are three types of biomarkers that can be used depending on the stage of delirium. The pathological mechanisms underlying delirium are also discussed. This review will identify treatment and diagnostic options for personalized DSD management.

Incidence, characteristics and risk factors of delirium in the intensive care unit: An observational study

AIMS AND OBJECTIVE

To investigate the incidence, characteristics and risk factors of delirium in the ICU.

BACKGROUND

Identifying the risk factors of delirium is important for early detection and to prevent adverse consequences.

DESIGN

An observational cohort study conducted according to STROBE Guidelines.

METHOD

The study was conducted with patients who stayed in ICU ≥24 h and were older than 18 years. Patients were assessed twice daily using the RASS and CAM-ICU until either discharge or death. Cumulative incidence was calculated. Demographic/clinical characteristics, length of stay and mortality were compared between patients with and without delirium. A logistic regression model was used to investigate risk factors.

RESULTS

The incidence of delirium was 31.8% and hypoactive type was the most frequent (41.5%). The median onset of delirium was 3 days (IQR = 2) with a mean duration of 5.27 ± 2.32 days. Patients with delirium were significantly older, had higher APACHE-II, SOFA and CPOT scores, higher blood urea levels, higher requirements for mechanical ventilation, sedation and physical restraints, longer stays in the ICU and higher mortality than those without delirium. The logistic regression analysis results revealed that a CPOT score ≥3 points (OR = 4.70, 95% CI: 1.05-20.93; p = .042), physical restraint (OR = 10.40, 95% CI: 2.75-39.27; p = .001) and ICU stay ≥7 days (OR = 7.26, 95% CI: 1.60-32.84; p = .010) were independent risk factors of delirium.

CONCLUSIONS

In this study, the incidence of delirium was high and associated with several factors. It is critical that delirium is considered by all members of the healthcare team, especially nurses, and that protocols are established for improvements.

RELEVANCE TO THE CLINICAL PRACTICE

Based on the results of this study, delirium could be decreased by preventing the presence of pain, prudent use of physical restraints and shortening the ICU stay.

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.

Effects of a financial incentive scheme for dementia care on medical and long-term care expenditures: A propensity score-matched analysis using LIFE study data

OBJECTIVE

Japan introduced a financial incentive scheme in April 2016 to improve hospital-based dementia care, but its effectiveness remains unclear. This study aimed to investigate the scheme's impact on medical and long-term care (LTC) expenditures, as well as on changes in care needs levels and daily living independence levels among older persons one year after hospital discharge.

METHODS

We linked medical and LTC claims databases, and retrospectively identified patients who received LTC needs certification and daily living independence assessments in Fukuoka, Japan. Case patients (received care under the new scheme) were those admitted from April 2016 to March 2018, and control patients were those admitted from April 2014 to March 2016 (before the scheme was implemented). Through propensity score matching, we identified 260 case patients and 260 control patients, and compared using t-tests, and chi-square tests.

RESULTS

The analyses found no significant differences between the case and control groups in medical expenditure (US$26,685 vs US$24,823, P = 0.37), LTC expenditure (US$16,870 vs US$14,374, P = 0.08), daily living independence level changes (26.5% vs 20.4%, P = 0.12), or care needs level changes (36.9% vs 30%, P = 0.11).

CONCLUSIONS

The financial incentive scheme for dementia care did not demonstrate any beneficial effects on patients' healthcare expenditures or health conditions. Further studies are needed to examine the scheme's long-term effects.

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

Pad cultures: An ethnography of continence care and its consequences for people living with dementia during a hospital admission

BACKGROUND

There is little research examining how continence care is organised and delivered to people living with dementia across an acute hospital admission, despite the prevalence of this patient population and their vulnerability within these settings.

OBJECTIVE

To explore how continence care is delivered to people living with dementia during an acute hospital admission.

DESIGN

Ethnographic.

SETTING(S)

Acute medical units and wards within three hospitals across England and Wales.

PARTICIPANTS

People living with dementia and ward staff (registered nurses and care assistants) on participating wards.

METHODS

Ethnographic fieldwork collected over a period of 12 months (180 days of non-participant observation) focussing on the organisation and delivery of continence care to people living with dementia. Observations were supported with in situ ethnographic interviews (n = 562) with patients, visitors and staff within the six observed wards. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.

RESULTS

The findings comprised of five overall themes: (1) visibility of continence; (2) rationales of continence care; (3) containment and contagion; (4) consequences of continence care and (5) supporting continence.

CONCLUSIONS

We introduce the term 'pad cultures' to refer to the established routine use of continence pads in the care of a wider group of people living with dementia (regardless of continence status and independence), with the rationale to provide safeguards, ensure containment and prevent 'accidents' or incontinent episodes. There was an expectation within acute wards that people living with dementia not only wear continence pads but that they also use them.

Critical care nurses' experiences of physical restraint in intensive care units: A qualitative systematic review and meta-synthesis

INTRODUCTION

Physical restraint is widely used in intensive care units. Critical care nurses are the primary decision makers and practitioners of physical restraint. However, little is known about the qualitative evidence of their experience of physical restraint.

AIMS

To aggregate, synthesise and interpret the qualitative evidence of studies that explored critical care nurses' experiences of physical restraint in intensive care units.

METHODS

A qualitative systematic review and meta-synthesis was conducted following Joanna Briggs Institute methodology and reported following the ENTREQ statement. Qualitative studies published in the English and Chinese were systematically searched in eight databases. PubMed, Web of Science, CINAHL, EMBASE, PsycINFO, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature Database from inception to November 2021. Two reviewers independently assessed the study eligibility and performed the data extraction and the quality appraisal. A meta-aggregative approach was used to synthesise findings. The review protocol was registered prospectively with PROSPERO (CRD42021278671).

RESULTS

Thirteen studies were included. A total of 48 intact and definite codes were extracted and classified into ten sub-categories. Four themes were finally identified: intention, alternatives, determinants, and reflection.

CONCLUSION

The intention of critical care nurses to use physical restraint is primarily driven by patient safety. Nurses will consider alternatives; however, many determinants urge nurses to implement physical restraint. Nurses prefer to sacrifice patients' comfort to ensure their safety. When nurses reflect on what they have done, some experience moral distress, but most rationalise their decision making. Further studies should explore the safety of alternatives, reduce the use of physical restraint, and pay more attention to nurses' moral distress through these insights.

RELEVANCE TO CLINICAL PRACTICE

Developing alternatives, providing relevant training for nurses, physicians, patients, and families to facilitate a restraint-free culture, and developing high-quality guidelines and regulations are essential strategies to reduce the use of physical restraint in ICUs.

Study of Alarm Threshold for Assumed Nasogastric Tube Self-removal Action Using a Contact Sensor System

Physical restraints negatively impact the physical, mental, and social well-being of patients. However, elderly people with dementia are often physically restrained by preventing nasogastric tube (NG tube) self-removal. This study aimed to examine alarm threshold settings limited to the actions that the subject makes contact with the NG tube out of feeling uneasy for the NG tube (assumed self-removal actions) using a contact sensor system in order to achieve non-physical restraint. In this study, subjects with experience in caring for older people with dementia were required to perform an assumed self-removal action along with 15 kinds of non-self-removal actions, while we observed the contact detection and measured the voltage. The alarm thresholds for the assumed self-removal action were examined from the ROC curve using the voltage zero time and the number of times the voltage was up and down during each action as a variable. The system presented in this study allowed us to reduce the false alarm rate from 23.3% to 8.5%. Furthermore, we used this alarm threshold to verify the data of three new subjects, observing a false alarm rate of 0.0%. Our future research would focus on investigating and evaluating elderly with dementia using the alarm threshold of the assumed self-removal action that we examined. In addition, we would use ICT to link contact detection with the nurse call system. Clinical Relevance- In this study, we examined the alarm threshold limited to the expected self-removal action using a contact sensor system. We showed that it is possible to detect the NG tube self-removal with few false alarms.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: (1) delirium prevention, (2) pharmacological treatment, (3) non-pharmacological treatment, and (4) barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

O papel do enfermeiro na prevenção do delirium no paciente adulto/idoso crítico

Introdução: Delirium é uma disfunção cerebral aguda, associado ao aumento da mortalidade e morbilidade, que atinge frequentemente o paciente adulto/idoso crítico. O enfermeiro tem um papel determinante na prevenção/controlo do delirium, através da implementação de intervenções não farmacológicas. Objetivo: Conhecer as intervenções de enfermagem na identificação, prevenção e controlo do delirium no paciente adulto/idoso crítico. Materiais e métodos: Realizada uma Revisão Integrativa da Literatura de artigos publicados entre 2014 e 2018, que identificaram intervenções de enfermagem dirigidas à prevenção e controlo do delirium no paciente adulto/idoso crítico. Foram realizadas quatro pesquisas, nas bases de dados electrónicas da EBSCOhost e na B-on. Resultados: Identificaram-se 13 estudos, que apresentam intervenções de enfermagem, maioritariamente não farmacológicas, para prevenção e controlo do delirium no paciente adulto/idoso crítico. Destas, evidenciam-se intervenções relacionadas com o ambiente, promoção do sono, intervenção terapêutica precoce, avaliação cognitiva e orientação dos pacientes, intervenções sistematizadas em protocolos, bem como intervenções direcionadas à participação dos familiares, à formação dos enfermeiros e ao ensino dos pacientes. Foram também identificados fatores de risco para o desenvolvimento do delirium e instrumentos de avaliação. Discussão: A prevenção do delirium é importante e imperativa, já que nos pacientes críticos a sua ocorrência está associada ao aumento da mortalidade, morbilidade, do tempo de internamento e a um elevado custo hospitalar. A identificação dos fatores de risco para a ocorrência do delirium devem estar incluídos nos protocolos de abordagem do delirium. Conclusão: As evidências demonstraram que o enfermeiro é fundamental na identificação precoce, prevenção e controlo do delirium, evitando a progressão da doença, contribuindo para a diminuição da morbilidade e mortalidade. A intervenção de enfermagem deve incluir a identificação de fatores predisponentes e/ou precipitantes de modo a contribuir para a diminuição da ocorrência e/ou resolução do quadro de delirium.

[Colorectal cancer and preoperative geriatric assessment]

With the ageing of the population and the increase in the incidence of cancer in the population over 75 years of age, a partnership between geriatricians and oncologists is becoming necessary to optimise the management of these patients. There is great variability in the profiles of elderly patients and age cannot be the only criterion of the decision making. Thus, it is necessary to identify patients who will benefit from an in-depth geriatric assessment (IGA) and the G8 screening tool used in oncology consultations allows to do so. The EGA offers a multidisciplinary approach to functional, psychological, nutritional, cognitive and social status of the person, and has been shown to have prognostic value for survival and relevance in guiding treatment choices.

Restraining patients in acute care hospitals-A qualitative study on the experiences of healthcare staff

AIM

The focus was to explore the perceptions and experiences of healthcare workers with respect to the use of restraints in acute care hospitals.

DESIGN

The study followed a qualitative design.

METHODS

Three topic-based focus group interviews were conducted, involving 19 participants from the fields of nursing, physical therapy and medicine. For data collection and analysis, the method of mapping techniques for rapid qualitative data analysis was used. After discussing and validating the individual mind maps, all data were condensed to identify the key findings.

RESULTS

Participants described restraints as safety measures for the patients. The implementation of most restraints was led by nurses. The use of restraints differed significantly, even in the interprofessional team. Attitudes and experiences were the main determinants for restraint use. Nurses asked for more discussion about restraints in the team, for more support at an interprofessional level and for better guidelines to help with the decision-making process.

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

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

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: 1) Delirium prevention, 2) Pharmacological treatment, 3) Non-pharmacological treatment, and 4) Barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding nurses' perspectives of physical restraints during mechanical ventilation in intensive care: A qualitative study

AIMS AND OBJECTIVES

This study explored the experiences of nurses using physical restraints on mechanically ventilated patients in intensive care.

BACKGROUND

Physical restraints are frequently used to prevent treatment interference and maintain patient safety in intensive care units worldwide. However, physical restraints are found to be ineffective in preventing treatment interference and cause negative outcomes for patients. The practices surrounding physical restraints are inconsistent due to a lack of education, training and protocols.

DESIGN

This research was conducted as a qualitative study with a naturalistic inquiry framework adhering to the Consolidated Criteria for Reporting Qualitative Research guidelines.

METHODS

Twelve in-depth, semi-structured conversations were conducted with registered nurses who have experience working in intensive care and have cared for patients who were physically restrained and mechanically ventilated. These conversations were audio-recorded and transcribed. Thematic analysis was used to analyse the data.

RESULTS

Three major themes emerged from the data. The themes were as follows: the ICU culture and its impacts on physical restraint practices; the consequences of physical restraints through a nursing lens; and understanding the ways of learning.

CONCLUSION

The insights into the ICU culture, the nurses' understanding of the consequences of physical restraints and the ways in which nurses learn physical restraint practices have provided a greater depth of knowledge and understanding of the realities of current practice in ICU. This new information demonstrates nurses' understanding of the potential harm caused by physical restraints and the way in which current practices are guided more-so by workplace norms and expectations rather than on critical thinking and decision-making.

RELEVANCE TO CLINICAL PRACTICE

These insights provide valuable information to intensive care clinicians, educators and policymakers to guide future practice and improve patient outcomes by highlighting the importance of education on physical restraint practices and informing the development of policies and guidelines.

Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study

BACKGROUND

Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population.

OBJECTIVES

Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients.

METHODS

We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality.

RESULTS

The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship.

CONCLUSIONS

ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.

Analysis of Delirium From the Dynamic Symptoms Model: A Literature Review

Delirium is a manifestation of brain injury or acute and generalized dysfunction of the upper cerebral cortical processes. In this way, it is important to analyze delirium more broadly as a symptom to understand and intervene taking into account that it is manifesting the presence of brain lesions whose consequences are deleterious to the neurological performance of patients. This article is intended to present a comprehensive approach of delirium analyzed from a symptom perspective and from theoretical and conceptual structure, such as the Dynamic Symptoms Model, specific to the nursing practice. A literature review related to delirium and components of Dynamic Symptoms Model was carried out. We searched the MEDLINE, ScienceDirect, SciELO, and Scopus databases using the terms Delirium, Intensive Care Units, Nursing, and Risk Factor. The existing literature provides evidence of the antecedents, experience, interventions, interactions, and consequences of delirium, which are components of the Model. Thus, the analysis from the Dynamic Symptoms Model perspective bears relevance and contributes to the understanding and approach of delirium.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Application of Joanna Briggs Institute physical restraint standards to critical emergency department patients following CONSORT guidelines

To explore the effect of Joanna Briggs Institute (JBI) physical restraint standards in improving physical restraint in critical and emergency department patients.Enrolled 300 critical patients admitted in our hospital's emergency department from January to December 2019: 150 patients admitted January to June 2019 as control group and 150 patients admitted July to December 2019 as observation group. Routine restraints were applied in control group. Emergency department nurses in the observation group received thematic and practical JBI standardized training. This included pre-restraint assessment, principles of physical restraint, informed consent, using a restraint decision-making wheel, and alternatives to physical restraint. The incidence of restraint-associated adverse events (e.g., skin bruising, swelling) and restraint utilization rate were examined between 2 groups.The incidence of adverse events and the restraint utilization rate were significantly lower in the observation group (P < .05).The application of JBI physical restraint standards for emergency department patients can effectively reduce the incidence of adverse events and the restraint utilization rate.

Nurses' knowledge and attitudes regarding physical restraint in Turkish intensive care units

BACKGROUND

Physical restraint is still widely used despite studies supporting a reduction in its use. The development of guidelines to reduce the use of PR first requires the identification of factors related to the use of alternative methods.

AIM

This study aimed to determine factors associated with the use of alternatives to physical restraint (PR) in intensive care units.

DESIGN

This was a cross-sectional descriptive study.

METHODS

Data were collected from adult intensive care units of three hospitals in Turkey using the Physical Restraint Knowledge, Attitude and Practice Scale and a questionnaire including open-ended questions.

RESULTS

Overall, 202 nurses (80% response rate) completed the questionnaire. Nurses' knowledge, attitude, and practice scores regarding PR were 6.89 ± 1.79, 29.85 ± 4.93, and 36.76 ± 3.36, respectively. PR was reported to be necessary for patients at risk of self-harm, with dangerous behaviours, and who were trying to remove their catheters. Most nurses (64.9%) stated that they needed a written doctor's order. Analysis of free-text responses showed that patient disorientation (because of delirium, sedation, or agitation), nurses' workload, and lack of training regarding restraint were the primary reasons why nurses could not use alternatives. The main alternatives suggested by nurses were categorized as sedation, communication, and environmental regulation. Logistic regression analysis identified training (P = .009), working unit (P = .001), and nurses' practice score to use PR (P = .004) as independent risk factors for not using alternative methods of PR.

CONCLUSIONS

The results of this study revealed a moderate level of knowledge, attitude, and practice among nurses regarding the use of PR. Thus, education of nurses about the prevention of delirium and alternatives to PR according to the characteristics of their units is required.

RELEVANCE TO CLINICAL PRACTICE

Clinical guidelines and in-service training need to be developed to increase the use of alternatives to PR and delirium management.

Therapeutic options for agitation in the intensive care unit

Agitation is common in the intensive care unit (ICU). There are numerous contributing factors, including pain, underlying disease, withdrawal syndrome, delirium and some medication. Agitation can compromise patient safety through accidental removal of tubes and catheters, prolong the duration of stay in the ICU, and may be related to various complications. This review aims to analyse evidence-based medical literature to improve management of agitation and to consider pharmacological strategies. The non-pharmacological approach is considered to reduce the risk of agitation. Pharmacological treatment of agitated patients is detailed and is based on a judicious choice of neuroleptics, benzodiazepines and α2 agonists, and on whether a withdrawal syndrome is identified. Specific management of agitation in elderly patients, brain-injured patients and patients with sleep deprivation are also discussed. This review proposes a practical approach for managing agitation in the ICU.

Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study

BACKGROUND

Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting.

OBJECTIVE

To evaluate the impact of early reinitiation of NPMs.

METHODS

This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group).

RESULTS

The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038).

CONCLUSIONS

After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.

Does missed nursing care influence the use of physical restraint and its duration in acute medical patients? Secondary analysis of a longitudinal study

Missed nursing care and physical restraint have been identified as indicators of patient safety, but no studies to date have explored their relation. To explore the relation between these two phenomena, a secondary analysis of a longitudinal study on 1464 in-hospital patients and 314 registered nurses was performed. The use of physical restraint was assessed at the bedside on a daily basis; missed care was assessed with the MISSCARE survey. Individual, nursing care, and hospital-level variables were measured. A total of 184 (12.6%) patients were restrained for 20.33% of their in-hospital stay. No significant differences emerged in the occurrence of missed care between restrained and unrestrained patients. However, some common antecedents of these two phenomena emerged: in units where there is a lack of personnel, both an increase in missed care and physical restraint duration should be expected. As a consequence, patients are threatened in their right to receive the required care and they are at risk of being restrained. Moreover, a higher skill mix is a preventive factor, which suggests that the increased numbers of registered nurses on the team, may prevent routine forms of physical restraint use by analyzing the physical restraint in place critically and removing them as soon as possible, thus reducing the duration of the restraints.

Perception of a multidisciplinary team on physical restraint use on older adults: care paradoxes

OBJECTIVE: To describe the perception of a multidisciplinary team on the use of physical restraint in older adults. METHODS: Qualitative research conducted with 58 health professionals in two long term care facilities for older adults located in the state of Rio de Janeiro, Brazil. Semi-structured interviews were further analyzed using thematic content analysis. The data was collected from November 2017 to June 2018. RESULTS: Twenty-one initial codes were identified and organized in three categories: team perception of the consequences and risks of a physical restraint (the patient’s safety paradox); implications of the decision of physical restraint of the older adults; and strategies to restrain and not restrain. CONCLUSIONS: The results reinforce the need for training of professionals on restraint-free alternatives of care, as part promoting a culture of care that respects the right to freedom and the dignity of people — especially the most vulnerable ones.

Role of Wearable Accelerometer Devices in Delirium Studies: A Systematic Review

We sought to determine the feasibility of using wearable accelerometer devices for determining delirium effects on patients' physical activity patterns and detecting delirium and delirium subtype.

DATA SOURCES

PubMed, Embase, and Web of Science.

STUDY SELECTION

Screening was performed using predefined search terms to identify original research studies using accelerometer devices for studying physical activity in relation to delirium.

DATA EXTRACTION

Key data were extracted from the selected articles.

DATA SYNTHESIS

Among the 14 studies identified, there were a total of 315 patients who wore accelerometer devices to record movements related to delirium. Eight studies (57.1%) used accelerometer devices to compare the activity of delirious and nondelirious patients. Delirious patients had lower activity levels, lower restlessness index, higher number of daytime immobility minutes, lower mean activity levels during the day, and higher mean activity levels at night. Delirious patients also had lower actual sleep time, lower sleep efficiency, fewer nighttime minutes resting, fewer minutes resting over 24 hours, and smaller change in activity from day to night. Six studies (42.9%) evaluated the feasibility of using accelerometer devices for detection of delirium and its subtype. Variables including number of postural changes during daytime, frequency of ultrashort, short, and continuous movements were significantly different among the nondelirium and the three delirium subtypes.

CONCLUSIONS

The results from the studies using accelerometer devices in studying delirium demonstrate that accelerometer devices can potentially detect the differences between delirious and nondelirious patients, detect delirium, and determine delirium subtype. We suggest the following directions as the next steps for future studies using accelerometer devices for predicting delirium: benchmark studies with longer data collection, larger and more diverse population size, incorporating related factors (e.g., medications), and evaluating delirium subtype and severity.

Physical restraint in critical care units from the experience of doctors and nursing assistants: In search of an interdisciplinary interpretation

OBJECTIVES

The study aim was to explore the experience of doctors and nursing assistants in the management of physical restraint (PR) in critical care units.

METHOD

A multicentre phenomenological study that included 14 critical care units (CCU) in Madrid (Spain). The CCU were stratified according to their use of physical restraint: "frequently used" versus "seldom used". Three focus groups were formed: the first comprised nursing assistants from CCUs that frequently used physical restraint, the second comprised nursing assistants from CCUs that seldom used physical constraint, and the final group comprised doctors from both CCU subtypes. Sampling method: purposive.

DATA ANALYSIS

thematic content analysis. Data saturation was achieved.

RESULTS

Four principle themes emerged: 1) concept of safety and risk (patient safety versus the safety of the professional), 2) types of restraint, 3) professional responsibilities (prescription, recording, and professional roles) and 4) "zero restraint" paradigm. The conceptualisation regarding the use of physical contentions shows differences in some of the principal themes, depending on the type of CCU, in terms of policies, use and management of physical constraint (frequently used versus seldom used).

CONCLUSIONS

The real reduction in the use of physical restraint in CCU must be based on one crucial point: acceptance of the complexity of the phenomenon. The use of physical restraint observed in the different CCU is influenced by individual, group and organisational factors. These factors will determine how doctors and nursing assistants interpret safety and risk, the centre of care (patient or professional-centred care), the concept of restraint, professional responsibilities and interventions, interactions of the team and the leadership.

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.