Acute Care of the Elderly ColumnPhysical Restraint in Critical Care Settings: Will They Go Away?
Section snippets
How Common Is Physical Restraint in Critical Care?
In a recent observational study in 40 acute care hospitals in 6 cities, we conducted rounds on every nonpsychiatric unit (n = 434 units) between the hours of 5 and 7 a.m.1 We used the definition of physical restraint from the Centers for Medicare and Medicaid: “any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that the person could not remove easily and that restricted freedom of movement or access to the body.”2 Types of
What Influences ICU Clinicians’ Use of Physical Restraint?
Whereas ICUs overall accounted for less than one fifth of the hospital beds, they accounted for more than half of all restraint use; however, considerable variation exists in the use, even within similar types of ICUs. What could account for this variation within and between ICUs?
Patient Population
The characteristics of the patient appear to influence the decision to use physical restraint given that the type of unit (e.g., adult medical vs. coronary care) had differences in overall rates of use. For this large population-based study, we were able to collect data on the patient's age, sex, and whether he or she was mechanically ventilated. Men were more likely to be restrained than women, but no differences were noted by age. Ventilation days were modestly correlated with restraint days,
ICU Resources and Processes of Care
Perhaps the variation in practice can be explained by variation in the number and kind of health care personnel who staff the ICUs. We examined more than 100 administrative and environmental variables among 55 of the ICUs at 39 of the hospitals.3 The ICUs did not differ in nurse-to-patient ratios. However, other resources did vary, and the ICUs could be grouped or clustered into 1 of 2 groups: those with more resources beyond that of nurse labor versus those with less. When put into a
Nurse-Specific Factors
Some have suggested that nurse-specific factors, such as age, years of experience, and education, influence the nurse's decision to use physical restraint. To date, there have been no conclusive findings on these factors.
The Intertwining of Physical Restraint and Patient-Initiated Device Disruption (PDD)
No discussion regarding physical restraint use in critical care can be complete without acknowledging the major concern of critical care personnel: that the absence of physical restraint will result in patients’ premature disruption or termination of life-sustaining therapies or such disruption could cause significant damage to the patient. Thus, ICU nurses primarily use physical restraints to maintain the patients’ devices and therapy, such as endotracheal tubes, central lines, and arterial
Recommendations
Our challenge is to identify preventive interventions that also minimize reliance on restraint in critical care settings. Although results are still inconclusive, a growing body of knowledge is available to help us bundle activities that would reduce PDD and physical restraints. Any decision a nurse makes, whether to use restraint or nonrestraint strategies, will result in an outcome: patient condition worsens, patient condition improves, or no change in condition. We know from numerous case
Lorraine C. Mion, PhD, RN, FAAN, is an Independence Foundation Professor of Nursing, Vanderbilt University School of Nursing, Nashville, TN, and a senior nurse researcher, MetroHealth Medical Center, Cleveland OH.
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Cited by (36)
Intention to use physical restraint in paediatric intensive care units and correlated variables: A multicentre and cross-sectional study
2024, Intensive and Critical Care NursingPredictors of physical restraint use on critical care units: An observational structural equation modeling approach
2021, International Journal of Nursing StudiesCitation Excerpt :Clinicians must balance the safety of the patient, other patients, and staff with the patient's right to freedom and autonomy (Goethals et al., 2012). Restraint use can have a variety of adverse effects, including psychological trauma, physical injuries, and death (Evans et al., 2003; Mion, 2008). Despite this guidance, restraints continue to be used at a high rate in critical care units across many countries.
The Conditions for Ethical Application of Restraints
2019, ChestCitation Excerpt :In the Netherlands, 23% of all ICU patients are restrained,5 and in South Africa, nearly one-half (48%) of all ICU patients are restrained.6 In the United States, 50 of every 1,000 patient-days are spent physically restrained.7 This scenario amounts to approximately 27,000 patients restrained daily.
Therapeutic restraint management in Intensive Care Units: Phenomenological approach to nursing reality
2016, Enfermeria IntensivaPrevalence, risk factors, and outcomes associated with physical restraint use in mechanically ventilated adults
2016, Journal of Critical CareCitation Excerpt :Given the recognized adverse physical and psychological patient consequences of physical restraints and their lack of efficacy in preventing device removal, professional society guidelines, government legislation, and hospital accreditation standards advocate that physical restraint use be minimized across all health care settings [11–13]. Physical restraint use varies substantially across countries from 0% to 100% [14] and even among hospitals in the same country [15]. In a 2013 survey of 121 French ICUs, restraints were used at least once during mechanical ventilation in more than 50% of patients; and in 65% of these ICUs, restraints were applied for more than 50% of mechanical ventilation days [16].
Adaptation and validation of the Physical Restraint-Theory of Planned Behaviour Questionnaire to the paediatric context
2024, Nursing in Critical Care
Lorraine C. Mion, PhD, RN, FAAN, is an Independence Foundation Professor of Nursing, Vanderbilt University School of Nursing, Nashville, TN, and a senior nurse researcher, MetroHealth Medical Center, Cleveland OH.