More than Words: Race, Language Preference, and Restraint Use in the Intensive Care Unit

Nurses’ Attitudes, Clinical Experience, and Practice Issues With Use of Physical Restraints in Critical Care Units

Rationale: Physical limb restraints are commonly used in intensive care units (ICUs) to protect patients and staff but are associated with increased morbidity and disparities in care, particularly in intubated patients. Whether disparities in restraint use persist for nonintubated patients remains less clear. Objectives: We sought to identify whether patient race, ethnicity, and preferred language are associated with restraint use in nonintubated patients across multiple ICUs in a large U.S. hospital system. Methods: We performed a retrospective cohort study using electronic health record data across five ICUs within the University of California, San Francisco, from 2013 to 2022. We included adults who were 18 years of age and older. We excluded patients who received mechanical ventilation during their ICU stay. Our primary independent variables were primary language, race, and ethnicity. The outcome of interest was restraint use, defined as at least one restraint order placed during the patient's ICU stay. We modeled any restraint use using a multivariable logistic regression adjusted for sociodemographic and clinical covariates and explored interactions of our primary exposures using sensitivity analyses and Wald testing. Results: Across 22,259 unique ICU admissions, we identified 11,676 nonintubated patients. Of these, 2,411 (20%) received an order for physical restraints. In a multivariable regression model, compared with English, Chinese (all dialects) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.31-1.87) and a language other than Chinese, English, or Spanish (OR, 1.60; 95% CI, 1.36-1.89) were associated with increased use of restraints. Patients identifying as Black or African American were also more likely to be restrained at least once during the encounter (OR, 1.51; 95% CI, 1.27-1.79) compared with non-Hispanic White patients. Conclusions: Patients preferring Chinese or any language other than English or Spanish and those who identify as Black are more likely to be restrained in the ICU when not intubated. Interventions to minimize the use of unnecessary physical restraints could improve an inequity known to be associated with downstream harms.

Elderly patients' reports of physical restraint experiences in intensive care units

The use of restraints in hospitalized patients is associated with physical and psychological adversity for patients and staff. The minimization of restraint use is a key goal in the hospital setting. Reaching this goal requires an accurate assessment of existing patterns of use across clinical settings. This study reports the rate of physical restraints among patients hospitalized within a multi-entity healthcare network along with stratification by care context, diagnostic, and demographic factors, and examines the sensitivity and specificity of ICD-10 code Z78.1 "physical restraint status" for defining physical restraints relative to electronic health record (EHR) documentation. The EHR was used for a retrospective analysis of all adults hospitalized between 2017 and 2022. Hospitalized adults. Patient demographics, structured diagnostic information, care area, length of stay, and in-hospital mortality, Z78.1 coding for physical restraints, restraint documentation in orders and flowsheets. Among 742,607 hospitalizations, 6.3% (n=47,041) involved the use of physical restraint based on coding or EHR documentation. Treatment in the intensive care unit (ICU) included restraint in 39% of encounters whereas treatment outside the ICU included restraint use in 1.3% of encounters. Besides critical illness, demographic factors including increasing age (adjusted odds ratio (aOR)=1.21 [1.19-1.23]), male gender (aOR=1.56, [1.52-1.60]), unknown race (aOR=1.27 [1.19-1.35]), and preferred language other than English (aOR=1.24, [1.18-1.29]) were associated with higher odds of restraint utilization. As compared to EHR orders or documentation of restraint, the ICD-10 code for physical restraint had a sensitivity of 1.5% and a specificity of 99.99%. Among adults admitted to acute care hospitals, clinical, demographic, and operational factors were associated with increased odds of restraint, with care in the ICU associated with greatly increased odds of restraint. Research into restraint utilization using coded administrative claims data is likely limited by the sensitivity of physical restraint coding.

Restricciones físicas en UCI: su utilización y percepción de pacientes y familiares

Determinants of Nurses' Use of Physical Restraints in Surgical Intensive Care Unit Patients.

The use of physical restraints on patients in intensive care units (ICUs) is a common intervention aimed at ensuring patient safety, particularly in preventing the dislodgement of vital invasive devices. However, this practice raises ethical and clinical dilemmas due to the complex considerations involved. The aim of this study was to explore the ethical and clinical considerations in the use of restraints for patient safety in the intensive care setting. This research employed a qualitative phenomenological design, with data collected through in-depth interviews involving eight participants in the intensive care unit. Data were analyzed using the Colaizzi method. The study identified three major themes: considering the patient's needs, preventing the dislodgement of invasive devices, and experiencing contradictory feelings. The findings highlight the need for clearer, standardized policies on the use of restraints in intensive care units that incorporate both ethical and clinical perspectives.

Investigating influencing factors of physical restraint use in China intensive care units: A prospective, cross-sectional, observational study

Nurses’ knowledge, attitude, and practice regarding the use of physical restraints in children in the intensive care setting in China: A cross-sectional multicentre study

Changing perceptions of physical restraint use in the ICU

Use of Physical Restraints in Adult Critical Care: A Bicultural Study

Predictors of physical restraint use on critical care units: An observational structural equation modeling approach

The use of physical restraint has been a common phenomenon in clinical practice. However, the current status of physical restraints in intensive care unit (ICU) patients and related potential factors in China remains unclear. We aimed to evaluate the status of physical restraint use of patients in ICU, and to identify the potential factors affecting the physical restraint use. Patients in 16 ICUs of five hospitals from September 15 to October 15, 2019 were included. The ICU Patients' Physical Restraint Evaluation Scale was used for survey investigation. The basic information, the behavioral, treatment and muscle strength level with 35 detailed items were collected and evaluated. Multivariate logistic regression analyses were performed to identify the potential risks of physical restraint use. A total of 386 ICU patients were included, the incidence of physical restraint use was 59.07%. The incidence of physical restraint uses in patients with irritability, unconsciousness and disorientation, Richmond agitation-sedation scale (RASS) ≥2 or -3< RASS <2 were significantly higher that other conditions (all P<0.05); the incidence of physical restraint uses in patients with continuous renal replacement therapy (CRRT), temporary pacemaker, intracranial pressure (ICP) monitor, invasive blood pressure monitoring, tracheotomy, central venous catheter (CVC), extracorporeal membrane oxygenation (ECMO), peripheral intravenous infusion were significantly higher that other conditions (all P<0.05); the male gender, mechanical ventilation, retained catheters or tubes with level II or irritability were the independently influencing factors for the physical restraint use (all P<0.05). The incidence of physical restraint use is rather high in ICU, clinical attentions are needed especially for those patients with male gender, mechanical ventilation, retained catheters or tubes with level II or irritability.

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.

Clinical decision making on the use of physical restraint in intensive care units