Physical restraint use in intensive care units across Europe: The PRICE study

doi:10.1016/j.iccn.2010.08.003

Intensive and Critical Care Nursing

Volume 26, Issue 5, October 2010, Pages 241-245

https://doi.org/10.1016/j.iccn.2010.08.003 Get rights and content

Summary

The use of physical restraint has been linked to delirium in ICU patients and a range of physical and psychological outcomes in non-ICU patients. However, the extent of restraint practice in ICUs is largely unknown. This study was designed to examine physical restraint practices across European ICUs. A prospective point prevalence survey was conducted in adult ICUs across European countries to examine: physical and chemical restraint use during the weekend and weekdays, reasons for physical restraint use, timing of restraint use, type of restraint used and availability of restraint policies. Thirty-four general (adult) ICUs in nine countries participated in the study providing information on 669 patients with details of physical and chemical restraint use in 566 patients. Prevalence of physical restraint use in individual units ranged from 0 to 100% of patients. Thirty-three per cent of patients were physically restrained; those that were restrained were more likely to be ventilated (χ² = 87.56, p < 0.001), sedated (χ² 34.66, p < 0.001), managed in a larger unit (χ² = 10.741, p = .005) and managed in a unit with a lower daytime nurse:patient ratio (χ² = 17.17, p = 0.001). Larger units were more likely to use commercial wrist restraints and smaller units were more likely to have a restraint policy, although these results did not reach significance. As an initial exploration, this study provides evidence of the range of restraint practice across Units in Europe. Variation in the number of units per country limits generalization of findings. However, further examination is needed to determine whether there is a causal element to these relationships. Attention should be paid to developing evidence based guidelines to underpin restraint practices.

Introduction

International studies are undertaken for a number of reasons, including to increase sample size and compare practices or outcomes in different countries (Endacott et al., 2010). They are also, however, fraught with difficulty. This paper has two purposes: firstly, to present findings from a point prevalence survey examining physical restraint practices in intensive care units across Europe and, secondly, to discuss the findings in the context of the methodological limitations.

Section snippets

Background to the study

Restraint is most commonly used in intensive care units (ICUs) to protect the patient from the risks associated with untimely patient-initiated removal of indwelling devices such as endotracheal tubes. Both chemical and physical restraint are used although the prevalence and factors associated with preference and use of each are unknown in Europe. Anecdotally, the practice of using physical restraints in intensive care varies widely, with differing views worldwide about the acceptability of

Study design and methods

A point prevalence survey technique was used in thirty four general ICUs in nine countries. The number of beds in the units ranged from 6 to 24 beds. All patients in the unit on the days of the survey were included. Exclusion criteria were applied at unit, rather than patient, level. Specialist neurosurgery units were excluded from the study, in recognition of the specific challenges to patient management posed by this particular group of patients. Paediatric units were also excluded from the

Results

Thirty-four adult general ICUs in nine countries participated in the study providing data regarding 669 patients with details of physical and chemical restraint in 566 patients. Just over a third (n = 219/566, 39%) were physically restrained; however, the extent of physical restraint varied across units (see Table 1). On the dates of the survey, no patients in the four UK Units or two Portuguese units were restrained and all patients in the single Italian unit were restrained.

Use of physical

Discussion

Previous studies have found similar variation in physical restraint use. In a study of 17 ICUs in the United States (US), Minnick et al. (1998) found that 24% of patients were restrained, although practice did vary across different types of ICU; a study comparing physical restraint practice in 50 patients in one unit in the US with that in 50 patients in one unit in Norway found no physical restraint use in Norway compared to 39% use in the US (Martin and Mathisen, 2005). However, there were

Conclusions

Whilst observational surveys of this nature have their limitations, particularly when undertaken in a number of different countries, they do have some utility in demonstrating variation in practices. This study demonstrated that less than forty per cent of ICU patients were physically restrained on the days of the survey; those that were restrained were more likely to be ventilated, sedated and managed in a unit with a lower daytime nurse:patient ratio. Larger units were more likely to use

Acknowledgements

The research project study was supported by the European Critical Care Research Network of the European Society of Intensive Care Medicine.

References (23)

R. Endacott et al.
Challenges and rewards in multi-national research (guest editorial)
Intensive and Critical Care Nursing
(2010)
K. Bray et al.
British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units
Nurs Crit Care
(2004)
L.-Y. Chang et al.
Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study
Am J Crit Care
(2008)
K. Curry et al.
Characteristics associated with unplanned extubations in a surgical intensive care unit
Am J Crit Care
(2008)
A. Dube et al.
Accidental strangulation from vest restraints
JAMA
(1986)
B.K. Gehlback et al.
Sedation in the intensive care unit
Curr Opin Crit Care
(2002)
C. Hurlock-Chorostecki et al.
Knot-So-Fast: a learning plan to minimize patient restraint in critical care
Dynamics.
(2006)
C. Jones et al.
Memory, delusions and the development of acute posttraumatic stress disorder-related symptoms after intensive care
Crit Care Med
(2001)
C. Jones et al.
Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care
Intensive Care Med
(2007)
C. Kielb et al.
Can minimal patient restraint be safely implemented in the intensive care unit?
Dynamics
(2005)

G.A. Maccioli et al.

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies. American College of Critical Care Medicine Task Force 2001–2002

Crit Care Med

(2003)

Cited by (150)

Non-pharmacological interventions to reduce physical restraints in critical care units
2024, Enfermeria Intensiva
El uso de contenciones mecánicas en las unidades de pacientes críticos es una práctica frecuente, de bajo valor e influida por numerosos factores que configuran una cultura local. La traslación a la práctica clínica de las recomendaciones basadas en la evidencia es escasa por lo que es necesario analizar las intervenciones que pueden ayudar a revertirla. El objetivo de la presente puesta al día es describir e identificar las intervenciones no farmacológicas que contribuyen a la reducción del uso de contenciones mecánicas en pacientes críticos adultos. Las intervenciones se clasifican en 2 grupos: las que incluyen formación aislada y las que combinan la formación con uno o más componentes (intervenciones multicomponente). Estos componentes incluyen: alternativas de contención menos restrictivas, uso de la estimulación física y cognitiva, herramientas de ayuda en la toma de decisiones, comités institucionales multidisciplinares y la implicación del equipo. La heterogeneidad en el diseño de los programas y la baja calidad de la evidencia de las intervenciones no permite establecer recomendaciones en cuanto a su efectividad. Sin embargo, las intervenciones multicomponente basadas en la formación, la estimulación física y cognitiva del paciente, y un cambio de cultura de los profesionales y la organización hacia la visibilización de las contenciones podrían ser las más efectivas. La implementación de estos programas debería fundamentarse en un análisis previo de cada contexto local para diseñar la combinación de intervenciones a medida más efectiva que ayude a reducir o eliminar su aplicación de la práctica clínica.
Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimizing the use of physical restraints in adult critically ill patients. Interventions are classified into 2 groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programs and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organizations towards making restraints visible might be the most effective. The implementation of these programs should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.
The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study
2022, Enfermeria Intensiva
Describir y caracterizar el uso de contenciones mecánicas (CM) en unidades de cuidados críticos (UCC) en términos de frecuencia y calidad de aplicación y analizar su relación con la monitorización del dolor/agitación-sedación/delirio, la ratio enfermera:paciente y la implicación institucional.
Estudio observacional multicéntrico realizado en 17 UCC entre febrero y mayo del año 2016. El tiempo de observación por UCC fue de 96 h. Las principales variables fueron la prevalencia de contenciones, el grado de adherencia a las recomendaciones de uso de CM, la monitorización del dolor/agitación-sedación/delirio y la implicación institucional (protocolos y formación de los profesionales).
Se incluyeron 1.070 pacientes. La prevalencia general de contenciones fue del 19,11%, en pacientes con tubo endotraqueal (TET) del 42,10% y en pacientes sin TET ni vía aérea artificial del 13,92%. Se obtuvieron valores de adherencia entre el 0 y el 40% para las recomendaciones relacionadas con manejo no farmacológico y entre el 0 y el 100% para las relacionadas con la vigilancia de aspectos ético-legales. La menor prevalencia de contenciones se correlacionó con una adecuada monitorización del dolor en pacientes no comunicativos (p < 0,001) y con la impartición de formación a los profesionales (p = 0,020). Se halló correlación inversa entre la calidad de aplicación de CM y su prevalencia, tanto en el grupo general de pacientes ingresados en las UCC (r = −0,431) como en el subgrupo de pacientes con TET (r = −0,521).
Las contenciones son especialmente frecuentes en pacientes con TET/vía aérea artificial, pero también están presentes en otros pacientes que a priori no responden al perfil de uso atribuido. Las alternativas no farmacológicas al uso de CM, la vigilancia de aspectos éticos y legales y la implicación institucional presentan un amplio margen de mejora. La optimización de la interpretación del comportamiento del paciente con herramientas validadas puede constituir un elemento limitador del uso de CM.
To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement.
Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals).
A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = −.431) and in the subgroup of patients with ETT (r = −.521).
Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.
Do we care? Physically restrained patients in the intensive care unit
2022, Intensive and Critical Care Nursing
Quality appraisal of guidelines on physical restraints in intensive care units: A systematic review
2022, Intensive and Critical Care Nursing
Guidelines concerning the use of physical restraints in medical facilities have been published and amended over the years. However, the quality and suitability of these guidelines have not been appraised.
This study aims to assess the suitability and quality of guidelines for the use of physical restraints in intensive care units with the AGREE-REX and AGREE Ⅱ instruments.
A systematic search of electronic databases (e.g., EMBASE), cross-database search platforms (e.g., Clinical Key), guideline web portals (e.g., Guidelines International Network) and society websites (e.g., Society of Critical Care Medicine) was conducted from January 2011 to December 2020. The methodological quality was assessed using AGREE Ⅱ, and the recommendation quality and suitability were assessed using AGREE-REX instruments.
A total of eight guidelines were included. The criteria for overall quality and suitability of guidelines for the use of physical restraints were met by 50–72% and 59–76%, respectively. The “Values and Preferences” domain had the lowest score (38% ± 9%). The criteria for methodological quality of the guidelines were met by 50–83%. Two domains, “Applicability” and “Editorial Independence”, achieved lower scores. There was a strong, positive correlation between the overall methodological quality of guidelines and the overall quality of recommendations (r = 0.968).
There is a potential feasibility of guideline adaptation for the management of physical restraints. In order to implement a physical restraint guideline, the following aspects should be considered: (i) minimize the use of physical restraints, (ii) analyze barriers and facilitators relative to the local context, (iii) consider any specifications, and (iv) modify recommendations to local situation or individual conditions of the patient.
Phase I pilot safety and feasibility of a novel restraint device for critically ill patients requiring mechanical ventilation
2024, Journal of the Intensive Care Society
Restraint in somatic healthcare: how should it be regulated?
2024, Journal of Medical Ethics

View all citing articles on Scopus

¹: Postal address: Faculty of Health, Centre Court, Drake Circus, Plymouth, PL4 8AA.

View full text

International Research SeriesPhysical restraint use in intensive care units across Europe: The PRICE study

Summary

Introduction

Section snippets

Background to the study

Study design and methods

Results

Discussion

Conclusions

Acknowledgements

Intensive and Critical Care Nursing

British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units

Nurs Crit Care

Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study

Am J Crit Care

Characteristics associated with unplanned extubations in a surgical intensive care unit

Am J Crit Care

Accidental strangulation from vest restraints

JAMA

Sedation in the intensive care unit

Curr Opin Crit Care

Knot-So-Fast: a learning plan to minimize patient restraint in critical care

Dynamics.

Memory, delusions and the development of acute posttraumatic stress disorder-related symptoms after intensive care

Crit Care Med

Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care

Intensive Care Med

Can minimal patient restraint be safely implemented in the intensive care unit?

Dynamics

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies. American College of Critical Care Medicine Task Force 2001–2002

Crit Care Med

International Research Series
Physical restraint use in intensive care units across Europe: The PRICE study