Recent trends and risk factors for chemical and physical restraint use in the emergency department evaluation and treatment of trauma patients

Background: Despite research linking chemical and physical restraints to negative outcomes including unplanned intubations and psychological distress, there is little guidance for their use in the care of trauma patients. We used institutional data to describe recent trends in chemical and physical restraint in the emergency department evaluation and treatment of trauma patients and to identify characteristics associated with their use.

Methods: This study includes adult trauma activations at a United States urban level I trauma center from January 2016 to July 2022. Data were collected from the trauma registry and medical record. We assessed the use of chemical restraints and physical restraints during care provided in the trauma resuscitation bay and emergency department. We assessed trends over time graphically and with logistic regression. We used multivariable regression models to evaluate associations between restraint use and patient and clinical characteristics and the outcomes of ICU admission, hospitalization duration, and mortality.

Results: Of the 8,112 patients, most were male (74.8 %), White (55.8 %), and privately insured (35.2 %). Overall, 8.1 % were restrained with 7.1 % chemically restrained and 2.7 % physically restrained. Overall restraint use increased 254 % (p < 0.001) from 2016 to 2022 driven primarily by a 460 % (p < 0.001) increase in chemical restraint use including a 630 % increase in ketamine administrations (p < 0.001). Use of restraints was associated with pre-existing psychotic disorders, intoxication, altered mental status, increasing injury severity, and Medicaid insurance (p < 0.001). Chemical restraint administration was associated with a 3.5 percentage point (95 %CI 1.1-5.9; p = 0.004) increase in the probability of ICU admission and a 1.0 day (95 %CI 0.6-1.4; p < 0.001) increase in hospitalization duration.

Conclusions: In this institutional study, nearly one-in-twelve trauma patients were restrained during emergency department evaluation and treatment. Restraint utilization increased during the study driven primarily by increases in ketamine and restraints utilized during trauma bay evaluation and resuscitation. Future research should assess the generalizability of these findings. It is important that rigorous guidelines are established to ensure the safe and effective use of restraints in trauma.