Physical restraint and associated agitation.

Background: Physical restraint of patients in intensive care units (ICUs) has an estimated prevalence of 50%. Many medical centres do not have specific protocols for physical restraint, and the decision of whether to physically restrain a patient is up to the nursing staff. Disadvantages of physical restraint include injuries, exacerbation of agitation and an increased risk of developing post-traumatic stress disorder (PTSD).

Aim: To report prevalence and outcomes in terms of morbidity and mortality of physical restraint in general ICU patients in an 800-bed secondary medical centre.

Study Design: This retrospective study included 647 patients admitted to a general ICU in an 800-bed secondary medical centre in Kfar Saba, Israel, between January and December 2020. Data included demographics, medical history, length of stay, need for mechanical ventilation, number of ventilation days, 28-day mortality, reason for admission, agitation rate assessed by Richmond Agitation and Sedation Scale (RASS) score, need for physical restraint and need for anti-psychotics.

Results: Among the patients, 40% (256 of 647) required physical restraint. Older adult patients had a greater likelihood of being physically restrained along with those admitted because of sepsis or acute respiratory failure. Among the study sample, 11% (71 of 647) required anti-psychotics. Patients who were restrained had longer duration of ventilation (5.9 ± 8.2 vs. 0.36 ± 1.4 days; p < .001) and higher 28-day mortality (0.26 ± 0.45 vs. 0.07 ± 0.25, Z = 6.86, p < .001). There was no difference in medical history, except for chronic drug abuse, which was more frequent in the restraint group (18 [6.9%] vs. 11 [2.8%], respectively; p = .019), as well as the use of anti-psychotic medications (24 [9.3%] vs. 19 [4.8%], respectively; p = .034) and anti-depressants (55 [21.2%] vs. 59 [14.8%], respectively; p = .042). The restraint group had higher disease severity scores, as reflected in requirements for vasopressor support (174 [67.2%] vs. 69 [17.3%], respectively; p < .001) and need for dialysis (39 [15.1%] vs. 19 [4.8%], respectively; p < .001); higher frequency of in-hospital anti-psychotic treatment (60 [23.2%] vs. 11 [2.8%], respectively; p < .001); a greater tendency for agitation events and more severe agitation scores (episodes of RASS above zero [1.7 ± 4.0 vs. 0.04 ± 0.27, respectively; p < .001] and maximum RASS score [0.19 ± 1.6 vs. 0.01 ± 0.54, respectively; p < .001]). Overall, advanced age, number of ventilation days and need for dialysis were associated with increased 28-day mortality. In the restraint group, advanced age, chronic use of diuretics and the use of dialysis during ICU admission were associated with increased mortality risk.

Conclusions: Restrained patients tended to have higher morbidity and mortality during ICU and hospital stays, as well as a greater tendency for agitation events and more severe agitation scores, with an increased need for in-hospital anti-psychotic treatment. These findings regarding patient characteristics might be used to formulate treatment plans to reduce the rate of physical restraint in the ICU.

Relevance To Clinical Practice: Because restrained ICU patients tend to have higher morbidity and mortality, treatment plans should be formulated to reduce the rate of physical restraint in the ICU.

Clinical Trial Registration: NCT04771793.