Physical restraint practices in an adult intensive care unit: A prospective observational study

Aim and objectives To conduct a diagnostic evaluation of physical restraint practice using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Background Evidence indicates that physical restraints are associated with adverse physical, emotional and psychological sequelae and do not consistently prevent intensive care unit (ICU) patient-initiated device removal. Nevertheless, physical restraints continue to be used extensively in ICUs both in Canada and internationally. Implementation science frameworks have not been previously used to diagnose, develop and guide the implementation of restraint minimisation interventions. Design A prospective observational study of restrained patients in a 20-bed, academic ICU in Toronto, Canada. Methods Data collection methods included patient observation, electronic medical record review, and verbal check with the point-of-care nurses. Data were collected pertaining to framework domains of unit culture (restraint application/removal), evaluation capacity (documentation) and leadership (rounds discussion). The reporting of this study followed the STROBE guidelines. Results A total of 102 restrained patients, 67 (66%) male and mean age 58 years (SD 1.92), were observed. All observed devices were wrist restraints. Restraint application and removal time was verified in 83 and 57 of 102 patients respectively. At application, 96.4% were mechanically ventilated and 71% sedated/unarousable. Nurses confirmed 71% were prophylactically restrained; 7.2% received restraint alternatives. Restraint removal occurred after interprofessional team rounds (87%), during daytime (79%) and following extubation (52.6%). Of the 923 discrete patient observation of physical restraint use, 691 (75%) were not documented. Of the 30 daytime interprofessional team rounds reviewed, physical restraint was discussed at 3 (10%). Conclusion In this single-centre study, a culture of prophylactic physical restraint was observed. Future facilitation of restraint minimisation warrants theoretically informed implementation strategies including leadership involvement to advance interprofessional collaboration. Relevance to clinical practice The findings draw attention to the importance of a preliminary diagnostic study of the context prior to designing, and implementing, a physical restraint minimisation intervention.