Predictors of physical restraint use in Canadian intensive care units

Abstract

IntroductionPhysical restraint (PR) use in the intensive care unit (ICU) has been associated with higher rates of self-extubation and prolonged ICU length of stay. Our objectives were to describe patterns and predictors of PR use.MethodsWe conducted a secondary analysis of a prospective observational study of analgosedation, antipsychotic, neuromuscular blocker, and PR practices in 51 Canadian ICUs. Data were collected prospectively for all mechanically ventilated adults admitted during a two-week period. We tested for patient, treatment, and hospital characteristics that were associated with PR use and number of days of use, using logistic and Poisson regression respectively.ResultsPR was used on 374 out of 711 (53%) patients, for a mean number of 4.1 (standard deviation (SD) 4.0) days. Treatment characteristics associated with PR were higher daily benzodiazepine dose (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00 to 1.11), higher daily opioid dose (OR 1.04, 95% CI 1.01 to 1.06), antipsychotic drugs (OR 3.09, 95% CI 1.74 to 5.48), agitation (Sedation-Agitation Scale (SAS) >4) (OR 3.73, 95% CI 1.50 to 9.29), and sedation administration method (continuous and bolus versus bolus only) (OR 3.09, 95% CI 1.74 to 5.48). Hospital characteristics associated with PR indicated patients were less likely to be restrained in ICUs from university-affiliated hospitals (OR 0.32, 95% CI 0.17 to 0.61). Mainly treatment characteristics were associated with more days of PR, including: higher daily benzodiazepine dose (incidence rate ratio (IRR) 1.07, 95% CI 1.01 to 1.13), daily sedation interruption (IRR 3.44, 95% CI 1.48 to 8.10), antipsychotic drugs (IRR 15.67, 95% CI 6.62 to 37.12), SAS <3 (IRR 2.62, 95% CI 1.08 to 6.35), and any adverse event including accidental device removal (IRR 8.27, 95% CI 2.07 to 33.08). Patient characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, admission category, prior substance abuse, prior psychotropic medication, pre-existing psychiatric condition or dementia) were not associated with PR use or number of days used.ConclusionsPR was used in half of the patients in these 51 ICUs. Treatment characteristics predominantly predicted PR use, as opposed to patient or hospital/ICU characteristics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and occurrence of an adverse event predicted PR use or number of days used.

Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study

“…This hypothesis is supported by the finding that antipsychotic drug use was also associated with the use of physical restraints, which should, in theory, not be required for sedated or nonagitated patients. 18 Low adoption of delirium assessment tools has been reported in several other studies in various countries. The results reported here are similar to those obtained in a retrospective cohort study conducted at 71 US academic hospitals in 2010.…”

“…17 Details of the study methods have been previously published in full. 17,18 Data were prospectively collected by pharmacists practising in 51 ICUs in both university-affiliated and community hospitals across all 10 Canadian provinces. Study approval was obtained from each local institutional review board, and the need for informed consent was waived at each site.…”

“…Further details on hospital and baseline patient characteristics have been previously reported. 17,18 A delirium assessment tool was implemented as part of routine ICU practice at 7 (13.7%) of the 51 sites: 4 sites used the CAM-ICU, 9 2 sites used the ICDSC, 10 and 1 site used the NEECHAM confusion scale.…”

Ocorrência de eventos adversos como indicadores de qualidade assistencial em unidade de terapia intensiva

“…Profissionais inexperientes e fixação inadequada do tubo também podem ser importantes, enquanto o uso de contenção física permanece controverso 32,33 . As contenções físicas são comumente utilizadas pelos profissionais de saúde para facilitar a tolerância de dispositivos de assistência que causam desconforto e prevenir prematura ou inadvertida remoção de tais dispositivos 31,34 . Nos últimos anos, os debates éticos têm criticado o uso de contenções físicas sem consentimento dos paciente 31 .…”

“…É importante limitar o uso desses dispositivos para situações clinicamente apropriadas, e somente quando medidas alternativas para reduzir a ansiedade ou a agitação do paciente tenham falhado 31 . Ainda são restritas as recomendações baseadas em evidências científicas sobre métodos para minimizar o uso de contenção em pacientes 34 . Quanto à fixação inadequada do tubo orotraqueal, ela aumenta o risco para uma extubação acidental.…”