Discussion Guide for the Bardia Article

Use of physical restraints remains common in the intensive care unit (ICU). However, use of restraints is associated with adverse patient outcomes, such as delirium, agitation, lengthier mechanical ventilation, and functional decline. When health care systems experience strain from extraordinary patient volume, acuity, or staffing limitations, ICU clinicians may increase reliance on patient restraints as perceived safety measures. Emerging evidence also indicates that restraints may be disproportionately implemented among racial and ethnic minorities. Therefore, this study examined the impact of the COVID-19 pandemic on use of physical restraints within the ICU and how patterns of use varied across different racial and ethnic groups.This retrospective cohort study included adult patients admitted to any ICU at an academic medical center in Boston, Massachusetts, between January 1, 2018, and December 31, 2022, grouping patients into a pre-COVID-19 phase and a COVID-19 phase. Patient characteristics, including COVID-19 infection status, race, ethnicity, and primary language, were obtained at ICU admission, and daily ICU data were collected on use of physical restraints, antipsychotic medication, mechanical ventilation, hemodialysis, and extracorporeal membrane oxygenation. Generalized additive models were used to examine differences in physical restraint use between study phases and to assess associations with patient characteristics and daily ICU data, and segmented time-series regression was used to assess trends in restraint use over time.The analysis included 17 285 admissions during the pre–COVID-19 period and 20 421 admissions during the COVID-19 phase (N = 37 706). There were no meaningful differences in restraint use between the 2 study phases. However, patients with COVID-19 who received mechanical ventilation had 20% greater odds of restraints being used than did uninfected patients who received mechanical ventilation. Regardless of COVID-19 status, each additional day of mechanical ventilation was associated with a 10-fold increase in the odds of restraint exposure. Moreover, the odds of restraint use were 29% higher for non–English-speaking patients, 15% higher for male patients, and 11% higher for patients of Hispanic ethnicity. After adjustment for patient characteristics and clinical data, restraint rates increased sharply in COVID-positive patients at the start of the pandemic and declined over time, whereas restraint use remained stable throughout both study phases for COVID-negative patients.During the COVID-19 pandemic, restraint use increased among patients with COVID-19 who received mechanical ventilation and declined over time, paralleling the stabilization of health care system conditions following the initial surge. Differences in restraint use by ethnicity and language status persisted, with higher restraint exposure observed among Hispanic and non–English-speaking patients. Together, these findings illustrate how periods of strain in health care systems may be associated with increased restraint use among high-acuity ICU patients and minority populations. Future research should examine system- and practice-level factors that contribute to disparities in restraint use within ICUs and inform strategies to support equitable, evidence-based critical care.Dr Amit Bardia’s interest in the use of physical restraints during critical illness emerged during the COVID-19 pandemic. He recalls noticing concerning practice patterns “during the early phases of the pandemic, when ICUs were operating under extraordinary pressure,” in which restraints were repeatedly used due to “system strain, staffing shortages, and communication barriers, rather than clinical necessity”—especially among patients who were experiencing delirium, non–English speaking, or socially isolated. Knowing restraint use was linked to “delirium, psychological trauma, and longer ICU stays,” Dr Bardia recognized its critical value as a quality-of-care metric for health care systems. From these organic experiences, he became interested in exploring the use of restraints “as a marker of health care system strain and equity,” rather than a sole consequence of individual decisions made by clinicians. The pandemic provided Dr Bardia with a natural opportunity to examine through this lens how system-level health care crises shape ICU practices.Dr Bardia shares, “by demonstrating that restraint use increased during periods of system stress—and that non–English-speaking and minority patients were disproportionately affected—our study highlights restraint use as both a safety and equity issue.” For ICU clinicians, these findings encourage closer attention to the contextual factors that influence restraint decisions, including workload, communication barriers, and delirium risk, especially among high-acuity patients. Although the study was observational, it has already prompted reflection on local practice at Dr Bardia’s institution. “This work has already sparked discussions within our institution about the need for better communication resources, delirium prevention strategies, and staff support during crisis conditions,” he notes. Stemming from his view of restraints as “not only a safety measure, but also an indicator for quality of care,” Dr Bardia believes that more attention should be given to the factors that drive restraint use in ICU settings, particularly those factors aimed at supporting equitable and evidence-based care when health care systems are under undue strain.This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Amit Bardia, MBBS, MPH, completed his medical training at the All India Institute of Medical Sciences in New Delhi and at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Early in his training, he came to view the ICU as a “space where physiology, systems, and human factors intersect in a very tangible way,” which led him to become “deeply interested in how clinical decisions, communication, and workflow pressures influence patient outcomes.” Over time, these interests evolved into a broader focus on perioperative and ICU quality. This systems-oriented perspective also shapes how Dr Bardia approaches research and mentorship. Across projects, he has found that progress depends not only on technical rigor but also on shared purpose: “One key lesson I learned was the importance of establishing shared goals early.” Dr Bardia views research as central to his professional identity, and he sees research as a tool for strengthening everyday clinical decision-making and the systems that support it. As he puts it, “Research is most impactful when it remains grounded in patient care and addresses problems clinicians recognize at the bedside.”