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The purpose was to describe characteristics and outcomes of restrained and nonrestrained patients enrolled in a randomized trial of protocolized sedation compared with protocolized sedation plus daily sedation interruption and to identify patient and treatment factors associated with physical restraint. This was a post hoc secondary analysis using Cox proportional hazards modeling adjusted for center- and time-varying covariates to evaluate predictors of restraint use. A total of 328 (76%) of 430 patients were restrained for a median of 4 days. Restrained patients received higher daily doses of benzodiazepines (105 vs 41 mg midazolam equivalent, P < .0001) and opioids (1524 vs 919 μg fentanyl equivalents, P < .0001), more days of infusions (benzodiazepines 6 vs 4, P < .0001; opioids 7 vs 5, P = .02), and more daily benzodiazepine boluses (0.2 vs 0.1, P < .0001). More restrained patients received haloperidol (23% vs 12%, P = .02) and atypical antipsychotics (17% vs 4%, P = .003). More restrained patients experienced unintentional device removal (26% vs 3%, P < .001) and required reintubation (8% vs 1%, P = .01). In the multivariable analysis, alcohol use was associated with decreased risk of restraint (hazard ratio, 0.22; 95% confidence interval, 0.08-0.58). Physical restraint was common in mechanically ventilated adults managed with a sedation protocol. Restrained patients received more opioids and benzodiazepines. Except for alcohol use, patient characteristics and treatment factors did not predict restraint use.

To explore family perspectives on physical restraint practices and their minimization in an adult intensive care unit. A qualitative descriptive study with one-on-one semi-structured interviews. A deductive content analysis approach was undertaken using the Theoretical Domains Framework. A 20-bed medical, surgical, trauma ICU in Toronto, Canada. Fifteen family members were interviewed. Three themes emerged: (i) barriers and facilitators to restraint minimization. Barriers noted by families included patient agitation posing risks of losing endotracheal tubes, nurse reluctance to remove restraints, lack of family involvement, limited knowledge of alternatives, and a noisy environment. Facilitators included family involvement in decision-making, timely extubation, use of less restrictive alternatives such as mittens, mandating shorter periods of restraints application, and environmental modifications; (ii) unilateral decision-making regarding physical restraint use, where clinicians made decisions with inadequate communication with families nor obtaining consent; and (iii) the emotional impact of physical restraint use, with families experiencing sadness and shock and believing the patient would feel similarly. This qualitative study highlights significant issues surrounding the use of physical restraints, particularly the lack of family involvement in decision-making, the emotional toll on families, and various barriers and facilitators to minimizing restraint use. Effective communication and collaboration between clinicians and families are crucial to addressing these issues. Our findings underscore the critical need to enhance communication between clinicians and families, alongside consent processes. Identifying barriers and facilitators at various levels can inform individualized strategies to reduce restraint use, including integrating alternatives like mittens and involving families in care. Timely introduction of alternatives and family involvement are vital to prevent further emotional distress for families. Prioritizing the reduction of restraint duration is crucial, particularly in settings emphasizing harm minimization.

Physical restraints are frequently used in ICU patients, while their effects are unclear. To explore differences in patient reported mental health outcomes and quality of life between physical restrained and non-physical restrained ICU patients at 3- and 12-months post ICU admission, compared to pre-ICU health status. Prospective cohort study. Patients were included when 16 years or older, admitted for at least 12 h and provided informed consent. Differences between groups were analysed using linear mixed model analyses. Two ICUs, a 35 bed academic ICU and a 12 bed ICU in a teaching hospital in the Netherlands. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale, post-traumatic stress disorder using the Impact of Event Scale-Revised, and Quality of life using the Short Form-36 scores. 2,764 patients were included, of which 486 (17.6 %) were physically restrained for median 2 [IQR 1–6] days. Significantly worse outcomes were reported at 3-months by physically restrained patients (symptoms of depression 0.89, 95 %CI 0.37 to 1.41, p < 0.001; PCS −2.82, 95 %CI −4.47 to −1,17p < 0.001; MCS −2.67, 95 %CI −4.39 to −0.96, p < 0.01). At 12-months, only the PCS scores remained significantly lower (−1.71, 95 %CI −3.42 to −0.004, p < 0.05). Use of physical restraints is associated with worse self-reported symptoms of depression and decreased quality of life 3-months post ICU, and lower physical quality of life after 12-months. Use of physical restraints is associated with statistical significant worse mental and physical outcomes.

To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients. A retrospective cohort study. Internal medicine wards of a tertiary medical center in Taiwan. Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study. Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis. Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322–3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627–7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794–7.160, p<0.001) after adjustment for covariates. The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality.

Objective To explore the impact of physical restraint (PR) on the occurrence of venous thromboembolism (VTE) in stroke patients. Methods Totally 321 stroke patients were randomly enrolled and categorized into 2 groups according to whether PR was used or not. Moreover, the effect of PR on VTE in stroke patients was explored, and the independent influencing factors for the occurrence of VTE in stroke patients were also identified. Results Among the enrolled patients, 68 cases (21.18%) developed VTE, including 60 with muscular calf vein thrombosis, 6 with great saphenous vein thrombosis, and 2 with deep vein thrombosis (DVT). Of these 68 patients, 49 had cerebral infarction and 19 had intracerebral hemorrhage (ICH). Also, there were 39 patients (39/96) developing VTE with PR, and 29 (29/225) developing VTE without PR. Through analyzing the relationship between the incidence of VTE in stroke patients and clinicopathological parameters, it was discovered that diagnose (χ2 = 33.058 P = 0.000), history of diabetes (χ2 = 12.80 P = 0.000), muscle strength (χ2 = 21.608 P = 0.000), activity of daily living (ADL) (χ2 = 41.952 P = 0.000), and PR (χ2 = 31.004 P = 0.000) were significantly correlated with the occurrence of VTE. Moreover, as revealed by multivariate analysis of variance ICH (OR 4.485 (1.653–12.169), P = 0.003), previous history of diabetes (OR 2.511 (1.257–5.018), P = 0.009), low ADL (OR 0.208 (0.109–0.397), P = 0.000), and PR (OR 5.048 (2.520–10.113), P = 0.000) were the independent risk factors for VTE in stroke patients, while muscle strength (OR 0.679 (0.366–1.259), P = 0.219) had an impact on the occurrence of VTE, but was not an independent risk factor. Conclusion This treatment center can lower the occurrence of VTE by standardizing the use of PR. Meanwhile, for the patients with ICH who have a history of diabetes and poor ADL, more education and care should be provided to minimize the occurrence of VTE.

Healthcare staff use coercive measures to manage patients at acute risk of harm to self or others, but their effect on patients' mental health is underexplored. This nationwide Swiss study emulated a trial to investigate the effects of coercive measures on the mental health of psychiatric inpatients at discharge. We analysed retrospective longitudinal data from all Swiss adult psychiatric hospitals that provided acute care (2019-2021). The primary exposure was any coercive measure during hospitalization; secondary exposures were seclusion, restraint and forced medication. Our primary outcome was Health of the Nations Outcome Scale (HoNOS) score at discharge. We used inverse probability of treatment weighting to emulate random assignment to the exposure. Of 178,369 hospitalizations, 9.2% (  = 18,800) included at least one coercive measure. In patients exposed to coercive measures, mental health worsened a small but statistically significant amount more than in non-exposed patients. Those who experienced at least one coercive measure during hospitalization had a significantly higher HoNOS score (1.91-point,  < .001, 95% confidence interval [CI]: 1.73; 2.09) than those who did not experience any coercive measure. Results were similar for seclusion (1.60-point higher score,  < .001, 95% CI: 1.40; 1.79) and forced medication (1.97-point higher score,  < .001, 95% CI: 1.65; 2.30). Restraint had the strongest effect (2.83-point higher score,  < .001, 95% CI: 2.38; 3.28). Our study presents robust empirical evidence highlighting the detrimental impact of coercive measures on the mental health of psychiatric inpatients. It underscores the importance of avoiding these measures in psychiatric hospitals and emphasized the urgent need for implementing alternatives in clinical practice.

ABSTRACTBackgroundIn April 2016, the Japanese government introduced an additional benefit for dementia care in acute care hospitals (dementia care benefit) into the universal benefit schedule of public healthcare insurance program. The benefit includes a financial disincentive to use physical restraint. The present study investigated the association between the dementia care benefit and the use of physical restraint among inpatients with dementia in general acute care settings. MethodsA national cross-sectional study design was used. Eight types of care units from acute care hospitals under the public healthcare insurance program were invited to participate in this study. A total of 23,539 inpatients with dementia from 2,355 care units in 937 hospitals were included for the analysis. Dementia diagnosis or symptoms included any signs of cognitive impairment. The primary outcome measure was “use of physical restraint.” ResultsAmong patients, the point prevalence of physical restraint was 44.5% ( n = 10,480). Controlling for patient, unit, and hospital characteristics, patients in units with dementia care benefit had significantly lower percentage of physical restraint than those in any other units (42.0% vs. 47.1%; adjusted odds ratio, 0.76; 95% confident interval [0.63, 0.92]). ConclusionsThe financial incentive may have reduced the risk of physical restraint among patients with dementia in acute care hospitals. However, use of physical restraint was still common among patients with dementia in units with the dementia care benefit. An educational package to guide dementia care approach including the avoidance of physical restraint by healthcare professionals in acute care hospitals is recommended.

To determine the intention to use physical restraint (PR) and the relationship with sociodemographic and professional variables of the Paediatric Intensive Care Unit (PICU) nurses. A multicentre and correlational study was carried out from October 2021 to December 2023 in five paediatric intensive care units from five maternal and child hospitals in Spain. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire was provided. Moreover, sociodemographic and employment variables were registered. A total of 230 paediatric nurses participated in the study. A total of 87.7 % were females with an average age of 35.5 ± 9.7 years and working experience of 10.5 ± 8.4 years. The mean scores obtained were 21.1 ± 3.8 for attitude, 13.1 ± 5.0 for subjective norms, 14.4 ± 4.3 for perceived behavioural control and 28.0 ± 6.0 for intention. The nurses apply more physical restraint to anxious patients, with scarce analgesics and sedation, those affected with pharmacological withdrawal symptoms and those with a high risk of accidental removal of vital support devices or fall from bed. The sex (p = 0.007) and type of employment contract (p = 0.01) are the variables that are significantly correlated with the intention to use of PR. The paediatric nurses analysed had a moderate attitude, social pressure and perceived behavioural control towards the use of PR. It is important to know the factors that influence the intention to use physical restraint in order to standardise safe practice for critically ill paediatric and to ensure that patients' rights are respected by obtaining informed consent and assessing the prescription, continuation and removal of physical restraint.

IntroductionIntensive care units (ICUs) manage patients with or likely to have one or more life-threatening acute organ failures that might require the use of invasive supportive therapies. The use of physical restraint is frequent, with rates up to 50%, and usually initiated to maintain patient safety especially if the patient is agitated. Physical restraints have been associated with delirium, post-traumatic stress disorder and physical injuries while restricting patients’ individual freedom. Moreover, the incidence of invasive therapeutic devices’ self-removal by patients might not be decreased by physical restraint use. No recommendation is available concerning ICU patients and physical restraint management, despite being a daily practice. The main objective is to evaluate whether a strategy aimed at decreasing physical restraint use in ICU patients with that of a strategy based on routine and subjective caregivers’ decision is safe and efficient.Methods and analysisARBORea is a multicentre randomised, stepped-wedge trial testing an innovative, dedicated web-based, multiprofessionally developed, experts validated, nursing management strategy in comparison with standard care. The primary outcome is physical restraint use rate (effectiveness) measured at least every 8 hours and incidents’ rate (tolerance) defined as the rate of incidents attributable to non-compliance, corresponding to the deterioration or self-removal of critical devices, a fall or self-aggressive or heteroaggressive behaviours. Planned enrolment is 4000 ICU adult participants at 20 French academic and non-academic centres. Safety and long-term outcomes will be evaluated.Ethics and disseminationTrial results will be reported according to the Consolidated Standards of Reporting Trials 2010 guidelines. Findings will be published in peer-reviewed journals and presented at local, national and international meetings and conferences to publicise and explain the research to clinicians, commissioners and service users. The trial is funded by the French Ministry of Health and has been approved by the French local ethics committee (Comité de Protection des Personnes Sud-Ouest et Outre-Mer 2, Toulouse, France with registration number: 2020-A02904-35).Trial registration number(ClinicalTrials.gov) NCT04957238 on 12 July 2021 before first inclusion in study.

Background Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints. Methods We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation. Results The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8–33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5–27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated. Conclusion Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.