Avoiding Excessive Physical Restraints to Reduce ICU Pseudo Delirium

Due to the prevalence of risk factors such as mechanical ventilation, emergency surgery, advanced age, and sepsis, the incidence of ICU delirium ranges from 11% to 80% [1]. However, it is important to note that a small subset of patients may experience agitation as a result of excessive use of physical restraints, which can be misinterpreted as hyperactive delirium and demands careful consideration.

Due to the widespread shortage of medical, nursing, and rehabilitation personnel in China, the implementation of delirium prevention and control strategies often faces challenges due to practical constraints [2]. Despite the introduction of nonpunitive reporting of adverse events, nurses frequently resort to using physical restraints to avoid incidents such as falls from the bed or unplanned tube extubation, driven by work pressure and strained interpersonal relationships. As a result, even conscious patients who have been successfully weaned off mechanical ventilation may still be subjected to physical restraints.

Furthermore, influenced by considerations such as diagnosis-related group (DRG) assessments and average length of stay [3], many general wards are hesitant to accept patients transferred from the ICU. Before transferring to the general wards, the patients may not only require routine medical and nursing care but also need to undergo rehabilitation therapy from rehabilitation therapists to further restore their physical functions. This additional recovery process causes further delays in transfers. During this waiting period, patients may be subjected to excessive physical restraint measures.

The aforementioned reasons can result in the following clinical scenarios: awake patients who have successfully been weaned off mechanical ventilation may still be subjected to ongoing physical restraints, which restrict their autonomy and create difficulties in coughing. This, in turn, hampers early rehabilitation activities and contributes to emotional agitation. Additionally, noncompliant patients may be mistakenly diagnosed with hyperactive delirium, leading to an increase in the use of restraints. This cycle continues until nurses resort to requesting the attending physician to excessively administer sedative medications to patients. In severe cases, tracheal reintubation may become necessary. This entire process can sometimes create a hostile atmosphere between the healthcare team, including doctors, nurses, and rehabilitation therapists, and patients.

The observations mentioned above occurred incidentally within the ICU, but their incidence in China lacks sufficient research. Considering the current realities in the Chinese medical market, the following suggestions can be discussed: (1) Establishing transitional care units post-ICU discharge: The creation of transitional care units that provide a lower level of monitoring and allow for the presence of family members can facilitate a smoother transition for patients. These units can focus on early rehabilitation training and provide a supportive environment for recovery. (2) Comprehensive interdisciplinary education: It is crucial to provide patient-centered interdisciplinary education to healthcare professionals. The education should include, but not be limited to, ethics education, education on the harms of delirium, and training on the identification and assessment of delirium, etc. These programs should aim to prevent healthcare professionals, including doctors, nurses, and rehabilitation therapists, from becoming excessively focused on institutional routines. Instead, they should emphasize the importance of maintaining judgment capabilities and considering individual patient needs. This shift may helps healthcare professionals avoid becoming mere tools within the healthcare system.

Disclosure statement

The author declares that he has no competing interests.