Background: Physical and chemical restraints are used in Emergency Departments (EDs) to manage agitation in older people; however their prevalence and impact on clinical outcomes in this specific setting remain under-researched. Therefore, the aim of this study was analyze the prevalence, identify independent predictors, and evaluate the impact on clinical prognosis (mortality, admission, and length of stay) of physical and chemical restraint use in a large cohort of older patients.
Methods: An observational, analytical, retrospective, multicenter study (EDEN-50 Study) was conducted across 52 Spanish EDs between 1 and 7 April 2019. We consecutively included 25,321 consecutive patients aged 65 years or older. The primary outcome was the need for restraint, subdivided into chemical and physical modalities. Multivariate logistic regression analysis was performed to determine independent predictors, and models were adjusted to quantify the association with adverse outcomes (all-cause mortality, ED and hospital length of stay).
Results: Restraint use was recorded in 109 patients (0.43%), with a predominance of chemical (0.35%; n = 89) over physical restraint (0.14%; n = 36), including 16 patients who received both. Restrained patients exhibited a more vulnerable profile: higher median age (86 vs. 78 years; p < 0.001), previous cognitive impairment (54.1% vs. 13.2%; p < 0.001), and nursing home residence (28.4% vs. 6.0%; p < 0.001). Patients presenting with acute confusion or disorientation had the highest risk of restraint (aOR 6.80; 95% CI 4.30-10.76), followed by arrival by ambulance (aOR 3.43; 95% CI 2.08-5.67) and a history of delirium (aOR 3.25; 95% CI 1.96-5.38)). Institutionalization and high comorbidity were associated with physical rather than chemical restraint. Restraint use was independently associated with higher all-cause mortality (aOR 2.14; 95% CI 1.19-3.85) and prolonged ED and hospital length of stay (aOR 2.52; 95% CI 1.61-3.95 and aOR 2.34; 95% CI 1.41-3.88, respectively).
Conclusions: The use of restraint in the ED identifies a specific patient phenotype-advanced age, with cognitive impairment and altered mental status upon arrival-and serves as a sentinel marker for imminent mortality and prolonged ED and hospital length of stay.
Keywords: Chemical restraint; Delirium; Emergency departments; Length of stay; Mortality; Older people; Physical restraint.
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