Prevalence, risk factors, and outcomes associated with physical restraint use in mechanically ventilated adults

Louise Rose; Lisa Burry; Ranjeeta Mallick; Elena Luk; Deborah Cook; Dean Fergusson; Peter Dodek; Karen Burns; John Granton; Niall Ferguson; John W Devlin; Marilyn Steinberg; Sean Keenan; Stephen Reynolds; Maged Tanios; Robert A Fowler; Michael Jacka; Kendiss Olafson; Yoanna Skrobik; Sangeeta Mehta

doi:10.1016/j.jcrc.2015.09.011

Prevalence, risk factors, and outcomes associated with physical restraint use in mechanically ventilated adults

J Crit Care. 2016 Feb;31(1):31-5. doi: 10.1016/j.jcrc.2015.09.011. Epub 2015 Sep 25.

Authors

Louise Rose¹, Lisa Burry², Ranjeeta Mallick³, Elena Luk⁴, Deborah Cook⁵, Dean Fergusson³, Peter Dodek⁶, Karen Burns⁷, John Granton⁸, Niall Ferguson⁹, John W Devlin¹⁰, Marilyn Steinberg¹¹, Sean Keenan¹², Stephen Reynolds¹², Maged Tanios¹³, Robert A Fowler¹⁴, Michael Jacka¹⁵, Kendiss Olafson¹⁶, Yoanna Skrobik¹⁷, Sangeeta Mehta¹⁸

Affiliations

¹ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada, M4N 3M5; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON, Canada, M5T 1P8.
² Department of Pharmacy and Medicine, Mount Sinai Hospital, 600 University Ave, Toronto, ON, Canada, M5G 1X5; University of Toronto, Toronto, ON, Canada.
³ Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, Canada, K1Y 4E9; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON, Canada, M5T 1P8.
⁵ St Joseph's Healthcare, 50 Charlton Ave E, Hamilton, ON, Canada, L8N 4A6; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
⁶ Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, BC, Canada, V6Z 1Y6; University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada, V6Z 1Y6.
⁷ Department of Critical Care, St Michael's Hospital, 30 Bond St, Toronto, ON, Canada, M5B 1W8; Interdepartmental Division of Critical Care Medicine and the Li Ka Shing Institute, Toronto, ON, Canada.
⁸ Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada, M5G 2C4; General Research Institute, 200 Elizabeth St, Toronto, ON, Canada, M5G 2C4; Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
⁹ Critical Care and Pulmonary Medicine, University Health Network, 200 Elizabeth St, Toronto, ON, Canada, M5G 2C4; Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada.
¹⁰ School of Pharmacy, Northeastern University, 360 Huntington Ave, Boston, MA, United States, 02115.
¹¹ Mount Sinai Hospital, 600 University Ave, Toronto, ON, Canada, M5G 1X5.
¹² Department of Critical Care, Royal Columbia Hospital, Division of Critical Care, 330 E Columbia St, New Westminster, BC, Canada, V3L 3W7; University of British Columbia, Vancouver, BC, Canada.
¹³ Department of Medicine, Long Beach Memorial Medical Center, 2801 Atlantic Ave, Long Beach, CA, 90806.
¹⁴ Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada, M4N 3M5; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada, M4N 3M5.
¹⁵ Department of Anesthesiology, University of Alberta Hospitals, 8440 112 St NW, Edmonton, AB, Canada, T6G 2B7.
¹⁶ Section of Critical Care, Department of Medicine, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, Canada, R3T 2N2.
¹⁷ Department of Medicine, McGill University, 3605 Rue de la Montagne, Montréal, QC H3G 2M1.
¹⁸ University of Toronto, Toronto, ON, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, 600 University Ave, Toronto, ON, Canada, M5G 1X5. Electronic address: Geeta.mehta@utoronto.ca.

PMID: 26489482
DOI: 10.1016/j.jcrc.2015.09.011

Abstract

Purpose: The purpose was to describe characteristics and outcomes of restrained and nonrestrained patients enrolled in a randomized trial of protocolized sedation compared with protocolized sedation plus daily sedation interruption and to identify patient and treatment factors associated with physical restraint.

Methods: This was a post hoc secondary analysis using Cox proportional hazards modeling adjusted for center- and time-varying covariates to evaluate predictors of restraint use.

Results: A total of 328 (76%) of 430 patients were restrained for a median of 4 days. Restrained patients received higher daily doses of benzodiazepines (105 vs 41 mg midazolam equivalent, P < .0001) and opioids (1524 vs 919 μg fentanyl equivalents, P < .0001), more days of infusions (benzodiazepines 6 vs 4, P < .0001; opioids 7 vs 5, P = .02), and more daily benzodiazepine boluses (0.2 vs 0.1, P < .0001). More restrained patients received haloperidol (23% vs 12%, P = .02) and atypical antipsychotics (17% vs 4%, P = .003). More restrained patients experienced unintentional device removal (26% vs 3%, P < .001) and required reintubation (8% vs 1%, P = .01). In the multivariable analysis, alcohol use was associated with decreased risk of restraint (hazard ratio, 0.22; 95% confidence interval, 0.08-0.58).

Conclusions: Physical restraint was common in mechanically ventilated adults managed with a sedation protocol. Restrained patients received more opioids and benzodiazepines. Except for alcohol use, patient characteristics and treatment factors did not predict restraint use.

Trial registration: ClinicalTrials.gov NCT00675363.

Keywords: Chemical restraint; Daily sedation interruption; Intensive care; Physical restraint; Sedation protocol.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Alcohol Drinking / epidemiology
Analgesics, Opioid / therapeutic use*
Antipsychotic Agents / therapeutic use*
Benzodiazepines / therapeutic use*
Clinical Protocols
Device Removal
Female
Fentanyl / therapeutic use
Haloperidol / therapeutic use
Humans
Hydromorphone / therapeutic use
Intensive Care Units*
Lorazepam / therapeutic use
Male
Midazolam / therapeutic use
Middle Aged
Morphine / therapeutic use
Multivariate Analysis
Prevalence
Proportional Hazards Models
Respiration, Artificial / methods*
Restraint, Physical / statistics & numerical data*
Risk Factors
Ventilators, Mechanical

Substances

Analgesics, Opioid
Antipsychotic Agents
Benzodiazepines
Morphine
Haloperidol
Lorazepam
Hydromorphone
Midazolam
Fentanyl

Associated data

ClinicalTrials.gov/NCT00675363

Grants and funding

Canadian Institutes of Health Research/Canada