Physical restraint and associated agitation
Authors: Cohen Shimon , Meyer Avraham , Ifrach Nisim , Dichtwald Sara 
Published: July 2024

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.