(682) Clinical Factors Associated With Physical Restraint Use in Critically Ill Children

Introduction: Physical restraints are used in critically ill children due to a perceived increase in patient safety. However, restraint use in the pediatric intensive care unit (PICU) may increase the risk of agitation, delirium, physical harm, and even death. Current literature focuses on provider perspective, and comprehensive data on the patient-level factors that influence restraint use in the PICU is lacking. Thus, we aimed to investigate the patient-related factors associated with physical restraint use in critically ill children.

Methods: We present a secondary analysis of prospectively collected data from the baseline phase of the PICU Up! multicenter pilot trial. All patients under the age of 18 with a length of stay ≥3 days were included. A generalized estimating equation logistic regression analysis was performed to identify factors associated with restraint usage.

Results: Our analysis encompassed 1,157 patients, of whom 19% (n=218) were physically restrained during their ICU stay. Out of 11,522 patient days included in the analysis, restraints were used in 9.11% (n=1,050) of days. Episodes of restraint had a median duration of 3 days (IQR 2-5). The odds of receiving physical restraints increased if a patient was restrained on the previous day (aOR 22.80, 95% CI 16.72-31.07). When compared to an SBS of 0, children with SBS score of -1 had increased odds of being restrained (aOR 1.72, 95% CI 1.24-2.36) and SBS score of –3 was associated with decreased restraint use (aOR 0.37, 95% CI 0.17-0.79). No other SBS scores were associated with restraint usage. Mechanical ventilation (aOR 2.98 vs room air, 95% CI 1.39-6.38), use of benzodiazepines (aOR 1.49, 95% CI 1.05-2.11), and use of opioids (aOR 1.99, 95% CI 1.42-2.78) showed increased odds of receiving restraints.

Conclusions: Independent of clinical status, a history of restraints is the strongest predictor for being restrained. Despite studies indicating patient agitation as a leading cause of restraint use, only light sedation (SBS= -1) was shown to increase the odds of being restrained, not higher SBS scores. Our study underscores the role of clinical inertia in restraint use. It also highlights the importance of de-escalation of restraints, and education regarding appropriate usage only for patients who require restraints due to unsafe behavior.