Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

Silvia Thomann,Dirk Richter,Sabine Hahn,Silvia Bauer,Sandra Zwakhalen

doi:10.1186/s12913-021-06362-y

Abstract

BackgroundIn restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects).MethodsA secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016–2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed.ResultsThe study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%.ConclusionsThe use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible.

Highlights

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role
Response rate of all patients hospitalized (N = 39,106) on the measurement days in the 140 hospitals was 75.4% (95% confidence interval [95% confidence intervals (CI)] 74.9–75.8%; Switzerland: 76.3% [95% CI = 75.8–76.8%] N = 26,934; Austria 73.3% [95% CI = 72.5– 74.0%] N = 12,172)
We found that the availability of guidelines regarding restraint use on the institutional level and refresher courses for at least 80% of ward nursing staff in the last 2 years are associated with less restraint use

Summary

Introduction

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects). Large differences in restraint prevalence rates can be detected depending on the ward type studied (intensive care units often have a much higher prevalence rate) and by the definition of restraints used (e.g. only restraint belts; alternatively, bed rails and electronic monitoring can be considered as restraints)

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