Restraint use as a quality indicator for the hospital setting: a secondary data analysis

INTRODUCTION:
A reduction in restraint use is recommended for all health care settings. For this purpose, local
or national quality measurement and improvement initiatives have been implemented in various countries, primarily in the mental health and long-term care settings. However, restraints are also frequently used in the somatic acute care hospital setting, and strong variations in their
prevalence rates have been reported. Therefore, the aim of this study was to reanalyse existing data on restraint use in Swiss hospitals in order to assess the potential of restraint use as a national quality indicator for the hospital setting.

METHODS:
Using a cross-sectional, multicentre design, data were collected between 2016 and 2018 as part of the ANQ"s (Swiss National Association for Quality Development in Hospitals and Clinics) "falls and pressure ulcers" national prevalence measurement in acute care hospitals in Switzerland. The hospitals measured restraint use on a voluntary basis in addition to falls and pressure ulcers. All
medical specialities and patients aged 18 and over who gave their informed consent were included in the measurement. Descriptive and multilevel regression analyses were performed using institutional, ward and patient-level data relating to restraint use.

RESULTS:
The sample consisted of 18,938 inpatients from 55 hospitals. The 30-day prevalence rate of patients with at least one restraint was 10.2% (n = 1933). The riskadjusted hospital comparison revealed that hospitals in Switzerland differ significantly in their restraint use, even
after adjusting for patient characteristics. In total, 10 hospitals used restraints significantly less and 12 used them significantly more than the national average.

CONCLUSION:
Restraint use varies significantly between Swiss hospitals: 40% of all hospitals used restraints either significantly more or significantly less often than the average. In comparison to the other quality indicators, this is a very high value, indicating potential for improvements in the quality of care. Since restraint use is associated not only with quality of care, but also with human rights, these large differences seem questionable from a professional, ethical and legal point of view. Clearer and binding regulations in combination with monitoring and benchmarking of restraint use in hospitals, such as with a national quality indicator, seem necessary. These would help to ensure
that restraint use is in alignment with professional values, as well as ethical and legal requirements