Factors influencing the use of physical restraints in Canadian ICUs

Introduction

Physical restraint (PR) use in critically ill patients has been associated with delirium, unplanned extubation, prolonged ICU length of stay, and post-traumatic stress disorder. Our objectives were to define prevalence of PR use, and to examine patient, treatment, or institutional factors associated with their use in Canadian ICUs.

Methods

We conducted an analysis of a database of sedative, analgesic, antipsychotic and neuromuscular blocker prescribing practices and PR use in 711 mechanically ventilated (MV) adults in 51 Canadian ICUs (3,619 patient-days). Data were collected during a 2-week period (2008 to 2009). Logistic and Poisson regression analysis were used to identify factors associated with PR use and number of days of use respectively.

Results

PR was used on 1 or more days in 52.6% (374/711) of patients. For patients restrained, the mean number of days restrained was 4.1 ± 4.0 and the mean number of restraint applications per patient was 1.2 ± 0.5. Treatment characteristics associated with PR use were: daily benzodiazepine dose (OR = 1.01, 95% CI: 1.00 to 1.01), daily opiate dose (OR = 1.00, 95% CI: 1.00 to 1.01), daily sedation interruption (OR = 1.84, 95% CI: 1.24 to 2.72), use of antipsychotics (OR = 3.42, 95% CI: 1.98 to 5.91) and agitation (Sedation-Agitation Scale (SAS) >4, OR = 2.55, 95% CI: 1.20 to 5.44). Additionally, number of days of PR use was increased according to the following: daily sedation interruption (IRR = 4.52, 95% CI: 2.09 to 9.75), use of antipsychotics (IRR = 18.65, 95% CI: 7.95 to 43.77), the presence of a heavily sedated score (SAS <3, IRR = 2.57, 95% CI: 1.06 to 6.24) or the presence of an adverse event, such as selfextubation (IRR = 10.46, 95% CI: 2.55 to 42.92). Hospital characteristics associated with PR use included the proportion of MV patients in the ICU. University hospitals were associated with reduced PR use, compared with community hospitals (OR = 0.272, 95% CI: 0.15 to 0.50). Nonmodifiable patient characteristics (age, sex, APACHE score, patient category, prior substance abuse, prior psychotropic medication, preexisting psychiatric condition or dementia) were not associated with PR use.

Conclusion

We identified multiple factors associated with PR use and number of days of PR use. Particularly among those related to treatment, strategies such as daily sedation interruption or use of antipsychotics are associated with PR use and increasing the number of days of use.