Background: Delirium is a common clinical syndrome, particularly among elderly patients in the inpatient hospital setting, and carries considerable associated morbidity. These patients can display symptoms of inattention, agitation, and restlessness, often necessitating the use of chemical or physical restraints to ensure the safety of the patient and staff. Unfortunately, these interventions are not without the risk of harm. Adverse effects from physical restraints have been shown to increase the incidence of falls, physical injuries, thrombotic events, even rhabdomyolysis and death. Often, chemical restraints in the form of antipsychotics are used to minimize the use of physical restraints. Little research has been done into the frequency of these interventions, and what factors influence their implementation.
Methods: A cross-sectional analysis was previously performed of all adult hospital admissions to a large, tertiary care, academic hospital looking at the outcome of receipt of mechanical restraints from August 1, 2018 to February 1, 2020. This study is an in-depth analysis of each case where a patient was mechanically restrained but did not receive antipsychotics. Admissions were then analyzed by demographic and clinical factors such as length of stay, receipt of antipsychotic medication and result of delirium screening. With mechanical restraints being the primary outcome, patients who were ever in the ICU were excluded, to avoid the confounding use of restraints during mechanical ventilation.
Results: 23,366 non-ICU admissions were originally included in this study. Of these, 55 met the criteria of having a positive delirium screening, mechanical restraints ordered, and not receiving an antipsychotic, over the course of their admission. Of these patients, 67% identified as White and 61% identified as Male. These patients had an average length of stay of 9.33 days, and restraints were ordered for an average of 2.27 days. A substantial portion of these cases were admitted to a medicine teaching service at 35%. Surprisingly, only 13% of patients studied had documented prior adverse effects from antipsychotics or concerns for QT prolongation. 22% of these patients were subsequently discharged to a hospice facility or home with hospice services.
Conclusions: Only a small number of cases met inclusion criteria to be included in this analysis. Patients receiving mechanical restraints without antipsychotics had worse outcomes. Interestingly, the majority of patients in this data set did not have a medical contraindication to receiving an antipsychotic. This data demonstrates an opportunity to better understand which delirious patients are not receiving antipsychotics prior to mechanical intervention, and lead to future interventions to improve the quality of care delivered to each of our patients.