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.

Interprofessional intensive care unit (ICU) team perspectives on physical restraint practices and minimization strategies in an adult ICU: A qualitative study of contextual influences.

BACKGROUND: Guidelines advocate for minimization of physical restraint (PR) use in intensive care units (ICU). Interprofessional team perspectives on PR practices can inform the design and implementation of successful PR minimization interventions. AIM: To identify ICU staff perspectives of contextual influences on PR practices and minimization strategies. STUDY DESIGN: A qualitative descriptive study in a single ICU in Toronto, Canada. METHODS: One-on-one semi-structured interviews were conducted with 14 ICU staff. A deductive content analysis of interviews was undertaken using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. RESULTS: Five themes were developed: risk-averse culture, leadership, practice monitoring and feedback processes, environmental factors, and facilitation. Participants described a risk-averse culture where prophylactic application of PR for intubated patients was used to prevent unplanned extubation thereby avoiding blame from colleagues. Perceived absence of leadership and interprofessional team involvement situated nurses as the primary decision-maker for restraint application and removal. Insufficient monitoring of restraint practices, lack of access to restraint alternatives, and inability to control environmental contributors to delirium and agitation further increased PR use. Recommendations as to how to minimize restraint use included a nurse facilitator to advance leadership-team collaboration, availability of restraints alternatives, and guidance on situations for applying and removing restraints. CONCLUSIONS: This analysis of contextual influences on PR practices and minimization using the i-PARIHS framework revealed potentially modifiable barriers to successful PR minimization, including a lack of leadership involvement, gaps in practice monitoring, and collaborative decision-making processes. A team approach to changing behaviour and culture should be considered for successful implementation and sustainability of PR minimization. RELEVANCE TO PRACTICE: The establishment of an interprofessional facilitation team that addresses risk-averse culture and promotes collaboration among ICU stakeholders will be crucial to the success of any approach to restraint minimization.

Implementation of nonpharmacologic physical restraint minimization interventions in the adult intensive care unit: A scoping review.

OBJECTIVE: To identify the elements informing the successful implementation of nonpharmacologic physical restraint minimization interventions in adult intensive care unit patients. To map those elements to innovation, context, recipients and facilitation domains of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and to describe the outcomes of those interventions. METHODOLOGY: A scoping review of studies published in English reporting on restraint minimization interventions in adult intensive care units. We searched seven databases (MEDLINE, CIHAHL, Embase, Web of Science, Cochrane Library, PROSPERO and Joanna Briggs) from inception to 2021. Two authors independently screened articles for inclusion, extracted study characteristics and mapped intervention data to the i-PARIHS domains. RESULTS: Seven studies met inclusion criteria. Innovations comprised multicomponent interventions including education, decision aids/protocols and restraint alternatives. No studies utilised an implementation science framework to diagnose the baseline practice context. A commonly reported barrier to restraint minimization was a risk averse culture. Change was mostly driven by the external context (i.e. national regulations). Overall, nurses were the primary facilitators and recipients of practice change. Outcomes were changes in restraint incidence and prevalence abstracted from the medical record. However, no study validated the accuracy of restraint documentation. All studies documented an initial decrease in physical restraint use, but no long-term results were reported. CONCLUSION: Restraint minimization intervention studies report nurse-facilitated multicomponent interventions and short-term practice change. Future restraint minimization research incorporating implementation science frameworks, interprofessional teams and patient/family perspectives is warranted.