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.

[Efficacy of hydrotherapy versus gym treatment in primary total knee prosthesis due to osteoarthritis: a randomized controlled trial]

BACKGROUND

Physiotherapy is postulated as an effective treatment after total knee arthroplasty (TKA). The objective of the study was to assess the efficacy of hydrotherapy versus gym kinesitherapy during the second phase of treatment in TKA patients, with regard to the improved gait test, pain, stiffness, joint balance, muscle strength and inflammation.

METHODS

A controlled and randomized trial was carried out. TKA patients received a first rehabilitative phase (15 60-minutes sessions) at the gym. In the second phase (15 40-minute sessions), one group performed physiotherapy in a gym and another in a swimming pool. Different variables were assessed (basal, after 15 and after 30 ses-sions): functional capacity, pain and stiffness with WOMAC index, joint balance with goniometer; muscle strength with Lovett scale, and result of 6-minute gait test.

RESULTS

A total of 115 patients participated, 59 (51.3%) in the gym group and 56 (48.7?%) in the pool group. After the second phase of re-habilitation, higher clinical improvements were observed in the pool group, with statistically significant differences in pain (p?=?0.005), stiffness (p?=?0.010), joint balance (p?=?0.027) and muscle strength (p?=?0.049) in the operated knee, and in the result of the 6-minute gait test (p?=?0.002).

CONCLUSIONS

In TKA patients, hydrotherapy during the second phase of rehabilitative treatment was more effective than gym physiother-apy in terms of improved pain, stiffness, joint balance, muscle strength and gait testing.

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients

OBJECTIVE

To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients.

DESIGN

A multicentre, prospective observational study was designed to validate a scale measuring instrument.

SETTING

Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System.

PARTICIPANTS

A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients.

PROCEDURE

Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure.

MAIN VARIABLES

ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS.

RESULTS

A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88).

CONCLUSION

ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

[Therapeutic restraint management in Intensive Care Units: Phenomenological approach to nursing reality]

AIMS

To identify nursing experience on physical restraint management in Critical Care Units. To analyse similarities and differences in nursing experience on physical restraint management according to the clinical context that they are involved in.

METHOD

A multicentre phenomenological study was carried out including 14 Critical Care Units in Madrid, classified according to physical restraint use: Common/systematic use, lacking/personalised use, and mixed use. Five focus groups (23 participants were selected following purposeful sampling) were convened, concluding in data saturation. Data analysis was focused on thematic content analysis following Colaizzi's method.

FINDINGS

Six main themes: Physical restraint meaning in Critical Care Units, safety (self-retreat vital devices), contribution factors, feelings, alternatives, and pending issues. Although some themes are common to the 3 Critical Care Unit types, discourse differences are found as regards to indication, feelings, systematic use of pain and sedation measurement tools.

CONCLUSIONS

In order to achieve real physical restraint reduction in Critical Care Units, it is necessary to have a deep understanding of restraints use in the specific clinical context. As self-retreat vital devices emerge as central concept, some interventions proposed in other settings could not be effective, requiring alternatives for critical care patients. Discourse variations laid out in the different Critical Care Unit types could highlight key items that determine the use and different attitudes towards physical restraint.