Patient Race and Preferred Language Influence the Use of Physical Restraints in Non-intubated ICU Patients.

Rationale: Physical limb restraints are commonly used in intensive care units (ICUs) to protect patients and staff but are associated with increased morbidity. While many intubated patients in the US are physically restrained, predictors for restraints in non-intubated patients remain less clear.

Objective: To identify whether patient race, ethnicity, and preferred language are associated with restraint use in non-intubated patients across multiple ICUs in a large US hospital system.

Methods: We performed a retrospective cohort study using electronic health record (EHR) data across five ICUs within the University of California, San Francisco from 2013-2022. We included adults ≥18 years of age. We excluded patients who received mechanical ventilation during their ICU stay. Our primary independent variables were primary language and race. The outcome of interest was restraint use, defined as at least one restraint order placed during the patient's ICU stay. We modeled any restraint use using a multivariable logistic regression adjusted for sociodemographic and clinical covariates and explored interactions of our two primary exposures using sensitivity analyses and Wald testing.

Results: Across 22,259 unique ICU admissions, we identified 11,676 non-ventilated patients. Of these, 2,411 (20%) received an order for physical restraints. In a multivariable regression model, compared to English language, Chinese language (All Dialects) (OR 1.57 [95% CI 1.31, 1.87]) and a language other than Chinese, English or Spanish (OR 1.60 [95% CI 1.36, 1.89]) were associated with increased use of restraints. Patients identifying as Black or African American were also more likely to be restrained at least once during the encounter (OR 1.51 [95% CI 1.27 - 1.79]) compared to Non-Hispanic White patients. Dialysis (OR 9.15 [95% CI 7.74, 10.83]), tube feeds (OR 4.65 [95% CI 3.44, 6.29]), and SOFA score (OR 1.17 [95% CI 1.15, 1.19] per 1 point increase) also independently increased odds of restraint use.

Conclusions: Patients preferring a language other than English or Spanish and those identifying as Black are more likely to be restrained in the ICU when not intubated. Interventions to minimize the use of unnecessary physical restraints could improve an inequity known to be associated with downstream harms.