A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing

A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing Hongfan Wang, Mei Zhang, Jimin qiao, Yingqian Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6699176/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Agitated patients in emergency settings face challenges during venipuncture due to unpredictable limb movements, leading to procedural failures and injuries. Physical restraint methods are commonly used, but comparative data on their efficacy, time efficiency, and clinical outcomes remain limited. Methods: This retrospective study analyzed data from 387 agitated patients requiring upper limb venipuncture in an emergency department (January 2022–December 2024). Patients were categorized into three restraint groups: elastic band fixation (n=137), splint-band fixation (n=122), and manual hand-holding (n=127). Key outcomes included first-attempt success rate, total procedural time, fixation stability, and complications. Results: Device-based restraints (band and splint groups) showed significantly higher first-attempt success rates compared to manual restraint (P<0.05), with no notable difference between the two device groups. Repeated puncture attempts were more frequent in the hand-holding group (P<0.05). The band group required the shortest total operating time, while the splint group demonstrated superior stability (lowest loosening incidence: 9.8% vs. 29.4% ecchymosis in the manual group). Pain scores were comparable across groups, but splint users reported better comfort. Conclusion: Splint-band fixation offers optimal stability but demands longer setup time and additional personnel, limiting its practicality in urgent scenarios. Elastic band fixation balances efficiency and success, making it preferable for emergency use. Manual restraint suits mildly agitated, cooperative patients but requires backup strategies. A tiered restraint protocol, tailored to agitation severity and clinical urgency, is recommended to improve outcomes and patient safety. emergency restraint venipuncture emergency care agitated patients Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Intravenous access plays a critical role in emergency rescue scenarios, treatment and the prognosis of critically ill patients [ 1 ] . However, for certain patient populations, involuntary limb movements are highly prevalent, including status epilepticus, acute ethanol toxicity, and metabolic encephalopathy delirium [ 2 – 5 ] . Previous studies have shown that the failure rate for first venipuncture is far higher in agitated patients than in their calmer counterparts. This elevated rate of failure rate is associated with a higher risk of complications which can delay treatment and lead to litigation associated with potential iatrogenic injury [ 6 , 7 ] . In the clinical scenarios, managing agitation often requires the application of various restraint methods, including both physical and chemical methods. Physical restraint strategies, which limit a patient’s range-of-motion, are particularly popular [ 8 – 11 ] . In our emergency department, we follow guidelines that utilize three primary types of restraint: (1) elastic restraint proximal fixation (ERPF) which restricts both wrist and elbow flexion with adjustable straps; (2) splint-combined restraint (SCR) which uses prefabricated devices alongside multi-anchor bands for joint immobilization, and (3) Grip-Induced Motion Limitation (GIML); this hand grip method helps patients the use of a grip device to voluntarily maintain functional hand positions. While the efficacy of these methods has been widely discussed, there is a critical shortfall in our current knowledge. Time-sensitive strategies in emergency care have yet to be investigated in detail and there is no unified framework for evaluation. Furthermore, there is a clear need to acquire systematic comparisons of time-critical data to assess clinical accessibility, such as restraint preparation time, total puncture duration, nursing workload and equipment accessibility. This absence of solid evidence often results in a shift of clinical decision-making towards gut feeling risking resource misallocation and potential delays in the critical window available for rescue [ 12 , 13 ] . The use of restraint strategies in the clinic demands a careful balancing act. It is important to balance operational efficiency against patient safety and ethical standards. This challenge becomes even more acute in high-pressure emergency scenarios. The overuse of restraints can aggravate agitation, while underuse may increase operational risks. Therefore, there is a critical need to develop an evidence-based hierarchical restraint scheme to enhance the quality of emergency care [ 14 , 15 ] . Although selection criteria have been developed for different restraint methods, there is a notable lack of research relating to venipuncture for agitated patients in emergency departments. [ 16 , 17 ] Rather, some healthcare professionals may resort to a singular approach and select methods in an empirical manner that could lead to wasted resources or operational delays. In this study, we systematically evaluated the success rate, efficiency, and clinical feasibility of three distinct restraint strategies during venipuncture in agitated patients. Our goal was to provide solid data that will support improved practices in emergency nursing. Methods Data Collection Data for this study were drawn from the hospital's electronic medical record (EMR) system. Patient identities were anonymized and only included disease occurrences and influencing factors. Our investigation recruited 412 patients who exhibited agitation in the emergency department between January 2022 and December 2024. All analyses contain data only, do not involve any patient privacy, and are only analyses in the form of data. These patients exhibited various forms of agitation, including those experiencing seizures, drunkenness, and delirium. Agitation flared up primarily as involuntary or uncontrolled limb movements, thus providing evidence of distress. We collated a range of information for each patient, including: (1) age and gender, (2) basic health conditions such as diabetes, nutritional status, and chronic diseases; (3) Venipuncture metrics, including total success rate, puncture duration, and device fixation time (if restraints were used), and (4) the outcomes of venipuncture, including the occurrence of hematoma, bruising, and pain scores. Data preprocessing In accordance with our hospital's ‘Intravenous Therapy Nursing Technical Operation Specification’, we established clear exclusion criteria. First, patients with absolute contraindications to upper extremity venipuncture were excluded, including those with abnormal coagulation function (INR(international normalized ratio) > 1.5), upper extremity deep vein thrombosis, and severe peripheral vascular lesions. Second, we excluded any cases in which skin integrity was compromised, including local redness, swelling, skin ulcers, or active infections at the puncture site. Next, the head nurse of the emergency department and a specialist nurse meticulously evaluated venipuncture records and eliminated cases involving non-standard restraint positions, those that did not use special equipment or involved unplanned and emergency-only punctures. We only recruited cases that had been completed by a duly competent nurse with appropriate upper limb restraint tools. Data integrity verification was conducted with the hospital EMR system. We focused on core indicators, including constraint duration, the number of punctures, venipuncture complications, and pain assessments using the FLACC scale(a composite of 5 behaviors (“face,” “legs,” “activity,” “cry,” and “consolability”) ). Cases with a missing key data field rate exceeding 15% or those with logical discrepancies were eliminated. Following data cleaning, we included the case data of 386 patients experiencing emergency agitation who met our research criteria. All of this data was anonymized by triple encryption. Analytical methods and factor screening First, case data were meticulously categorized into three distinct groups: a band group, a splint group, and a hand-holding group. We employed the Chi-squared test and ANOVA to compare the foundational circumstances across these groups. This step ensured that we could eliminate potential confounding factors while analyzing the venipuncture process itself. Key metrics included one-try success rates, the total number of punctures, and the cumulative puncture time. Next, we investigated both the duration of immobilization and the frequency of device loosening to confirm the clinical feasibility and adaptability of these three restraint techniques. Post-analysis, we evaluated the efficacy of venipuncture with respect to these methods. We investigated common complications arising from this procedure, including bruising at the puncture site, along with the severity and duration of any bruising. We also evaluated the presence of redness, swelling, pain scores, and discomfort experienced by patients. Our aim was to validate the efficacy of distinct restraint methods in the facilitation of venipuncture for agitated individuals. Finally, we evaluated patient comfort. By comparing comfort levels during the procedure, we aimed to enhance the humanistic aspect of clinical nursing care. Statistical analysis All statistical analyses were performed with SPSS version 25.0 software. Data that were normally distributed are reported as mean ± standard deviation (Mean ± SD) and compared using the independent samples t-test. Non-normally distributed data are reported as median and interquartile ranges (median [IQR]) and compared by the Mann-Whitney U test or the Kruskal-Wallis test. Qualitative data are reported as frequencies and percentages (n [%]) and compared by the Chi-squared test or Fisher's exact test. The significance level was α = 0.05 and p < 0.05 was considered statistically significant. Results General case data First, we compared the patients with respect to age, gender, physical health, and platelet concentration (Table 1); there were no significant differences in these factors when compared between the three patient groups. We also investigated potential confounding variables that could influence the efficacy of venipuncture, including the type of underlying disease, medications, and catheter placement sites. There are no significant differences in the comparison of the basic analysis objects(P > 0.05), indicating that the sample selection has not differentiated the samples.A schematic diagram of the subsequent analysis and constraint methods is shown in Fig. 1 (see Fig. 1 ). Comparative analysis of basic puncture conditions for the three restraint methods Our analysis showed that the rates of venipuncture increased with different restraint methods when compared to traditional hand-holding approach.(P < 0.05) However, the success rates for punctures did not differ significantly when compared between different restraint methods (see Fig. 2 A). In terms of puncture occurrence, the traditional hand grip method exhibited a higher tendency for puncture failures, leading to repeated attempts (see Fig. 2 B). Analysis also suggested suggest that instrument fixation, splinting, and banding could reduce the frequency of unnecessary repeat punctures associated with traditional methods. (P < 0.05) Comparative analysis of puncture time for the three restraint methods and the fixed duration of the two special restraint methods There was a notable difference in puncture times across the three groups(P < 0.05). Only the banding method exhibited a significant reduction in puncture time when compared to the other groups (see Fig. 3 A). (P < 0.05)When we compared fixation times for the banding group and the instrument-fixed splint group, we found that the splint method took notably longer. (see Fig. 3 B)(P < 0.05).Next, we investigated the total puncture duration for successful cases across all three groups, and identified an association between duration and fixation time. There were no significant differences between groups with regard to calculated operation times. Comparative analysis of loosening in the three constraint methods In the band group, loosening occurred following band release, breakage, or via escape of the patient’s upper limb. Patients in the splint group experienced loosening from one or both sides, splint breakage, or escape of the patient’s upper limb. In the hand holding group, there were only instances of the patient breaking away from the control hand. The frequency of loosening showed a downward trajectory across all groups. The splint method was associated with the fewest loosening incidents, surpassing both the band and hand grip groups. Patients in the band group experienced less loosening than those in the hand holding group (see Fig. 4 A)(P < 0.05). Comparison of venipuncture complications and pain comfort scores under the three restraint methods Next, we investigated the frequency and intensity of bruising. Analysis revealed that bruising frequency varied across the groups. While bruising in the hand-held group was notably severe, the overall occurrence remained modest. (see Fig. 4 B) With regard to pain, we only observed minimal variations. Only a handful of cases reported high pain scores, predominantly among those facing repeated punctures. (see Fig. 4 C) Finally, we conducted a survey on the comfort of three different puncture methods, analyzing the details along with the pain scores. (see Table.2) Discussion In this study, we performed retrospective data analysis to investigate the efficacy of three prevalent restraint strategies for agitated emergency patients during venipuncture. Our analysis showed that the splint and banding combined fixation technique (SCR) exhibited a success rate that was far superior to the other groups. This appears to be related to the application of multi-anchor bands and prefabricated splints. Together, these tools effectively tether the patient's joints, minimizing limb movement distractions during puncture. However, while the SCR excelled in terms of stability, this method is associated with a prolonged operating time; the countless fixation steps involved could drain precious time in emergencies. It is important to strike a balance between time and efficiency. Thus, while SCR exhibits good success rates, its time-intensive nature could hinder a rapid response in urgent situations. In contrast, the elastic band proximal fixation method (ERPF) elegantly balances success and speed and was associated with the highest feasibility score from nurses. Clearly, this approach prioritizes convenience and efficacy, thus representing a useful option for the urgent needs of emergency nursing. Conversely, the hand-held method (GIML) offers simplicity but a poor success rate. The higher failure rate of GIML, especially for patients exhibiting moderate to severe agitation, suggests that this method should only be used for patients with mild agitation and a cooperative spirit. This stratified outcome highlights the critical importance of customized restraint strategies that can be tailored to patient agitation levels. For the first time, this study included unified operation time, feasibility, and puncture success rate into a comprehensive analysis framework. This innovative approach bridges the gaps in the existing literature by studies that utilized single indices. For example, existing literature appears to prioritize success rate alone as the endpoint. In the present study, however, we identified a correlation between fixed duration and total operating time. The total duration of the restraint device itself plays a pivotal role in determining overall efficiency, far beyond the mere puncture operation. [ 18 ] Our findings could transform emergency care and suggest that future improvements should streamline installation steps and foster rapid fixation innovations. Furthermore, our findings shed light on how doctors and patients evaluate various restraint methods, specifically with regard to how operational complexity could hinder clinical compliance. The splint method is durable but is associated with poor levels of comfort, despite the team effort required for this technique. This highlights the necessity for clinical decision-making to account for both objective outcomes and the operational experiences of medical staff. Our findings provide the groundwork to develop standardized constraint processes that are both efficient and user-friendly. While this study offers valuable insights, there are limitations to consider. First, retrospective data analysis may have introduced bias. Screening cases based solely on electronic medical records could have omitted important complications or operational nuances. Second, our classification related mostly to nursing notes; however, there is no universal quantitative standard for agitation at present; therefore, the accuracy of our findings may have been affected. In addition, the psychological toll of restraint strategies remains largely unexplored. The possibility of long-term restraint is inevitable, thus enhancing anxiety or inducing post-traumatic stress. This possibility requires further investigation. Future studies should involve prospective designs and objective agitation scoring tools such as the Richmond Agitation-Sedation Scale (RASS) . This could bolster the reliability of results considerably. [ 19 , 20 ] It is also important to incorporate long-term follow-up data relating to patient comfort and psychological impact to enrich the comprehensive evaluation of restraint strategies. Based on our current research results, we should first develop intelligent restraint devices, including adaptive strap or integrated splint systems with adjustable pressure systems, to reduce fixation time and improve stability. Second, we should investigate the combined application of physical restraint and low-dose sedative drugs [ 21 – 23 ] , to balance operational efficiency and patient safety through a "step-by-step" strategy. Third, we should establish a decision-making process for constraint incorporating multidisciplinary collaboration [ 24 ] and develop hierarchical management guidelines based on the input of nurses, physicians, and ethics committees. In addition, cross-center collaboration could be used to expand the sample size and verify the generality of constraint strategies in different healthcare settings [ 25 , 26 ] . For example, the results of this study show that the banding method performs best in terms of overall score; however, its accessibility in low-resource settings needs to be further validated. Finally, the introduction of simulation training and standardized operation training may improve the proficiency of nurses with regard to the operation of complex restraint devices, thereby improving the clinical feasibility score. These investigations will not only help to optimize the practice of emergency nursing, but also provide theoretical support for the construction of a patient-centered safety constraint system. Declarations Ethics Approval and Consent to Participate This retrospective study involving human participants and anonymized medical data was reviewed and approved by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University (Approval No. KY20230829-03; Date of Approval: August 29, 2023). The study strictly adhered to the ethical principles of the Declaration of Helsinki and complied with national/institutional guidelines for retrospective research. Informed Consent Statement Individual informed consent for participation in this study was waived by the Ethics Committee due to the fully anonymized nature of the data and the non-interventional, retrospective design. However, institutional protocols ensured that all patients (or their legal guardians) provided written consent during routine clinical care for their anonymized medical records to be used for research purposes. Data Anonymization and Privacy Protection All patient data were extracted from electronic medical records and anonymized using triple-encryption methods prior to analysis. No personally identifiable information (e.g., names, identification numbers, or contact details) was accessed, stored, or disclosed during the study. Animal Studies This research did not involve animals, client-owned animals, or animal-derived data. Conflict of Interest The authors declare no financial or non-financial conflicts of interest related to this work. Funding statement This study utilized clinical nursing data from the internal records of Nanjing First Hospital. The research received no additional financial support from public, commercial, or not-for-profit funding agencies. All data collection, analysis, and interpretation were conducted using institutional resources without external grants or sponsorships. The authors affirm that no financial or non-financial conflicts of interest influenced the design, execution, or reporting of this work. Consent for Publication We, the undersigned authors of the manuscript titled "A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing", hereby confirm: Consent for Publication: All authors have read and approved the final version of this manuscript. We consent to its publication in its current form and take full responsibility for the content, including the accuracy of the data and the ethical conduct of the research. Ethical Compliance: This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and was approved by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University (Approval No. KY20230829-03; Date of Approval: August 29, 2023). Data Anonymity: All patient data were anonymized using triple-encryption methods prior to analysis. No personally identifiable information was accessed, stored, or disclosed. Conflict of Interest: The authors declare no financial or non-financial conflicts of interest related to this work. Author Signatures: Hongfan Wang, Supervisor Nurse Mei Zhang, Supervisor Nurse Jimin Qiao, Deputy Chief Nursing Yingqian Zhou, Supervisor Nurse References VACHHARAJANI T J, AGARWAL A K, ASIF A. Vascular access of last resort [J]. (1523–755 (Electronic)). WILSON JE, MART M F, CUNNINGHAM C et al. Delirium [J]. (2056-676X (Electronic)). LE, DARé B A-O LAGENTEV. GICQUEL T. Ethanol and its metabolites: update on toxicity, benefits, and focus on immunomodulatory effects [J]. (1097–9883 (Electronic)). SCHAPER A. EBBECKE M. Intox, detox, antidotes - Evidence based diagnosis and treatment of acute intoxications [J]. (1879 – 0828 (Electronic)). THIJS RD, SURGES R, O'BRIEN T J et al. Epilepsy in adults [J]. (1474-547X (Electronic)). IROKU-MALIZE T GRISSOMM. The agitated patient: Steps to take, how to stay safe [J]. (1533–7294 (Electronic)). GOTTLIEB M, LONG B. KOYFMAN A. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6699176","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472032999,"identity":"2a0f1660-c28e-4029-8d68-72bccb505f74","order_by":0,"name":"Hongfan Wang","email":"","orcid":"","institution":"Department of Emergency,Nanjing First Hospital,Nanjing Medical Universuty","correspondingAuthor":false,"prefix":"","firstName":"Hongfan","middleName":"","lastName":"Wang","suffix":""},{"id":472033000,"identity":"91d30992-06c7-4a40-a0ef-8fba00a14649","order_by":1,"name":"Mei Zhang","email":"","orcid":"","institution":"Department of 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21:01:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":914258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6699176/v1/b060c4ec-3238-44a6-89da-3a03679f179f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntravenous access plays a critical role in emergency rescue scenarios, treatment and the prognosis of critically ill patients\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. However, for certain patient populations, involuntary limb movements are highly prevalent, including status epilepticus, acute ethanol toxicity, and metabolic encephalopathy delirium\u003csup\u003e[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Previous studies have shown that the failure rate for first venipuncture is far higher in agitated patients than in their calmer counterparts. This elevated rate of failure rate is associated with a higher risk of complications which can delay treatment and lead to litigation associated with potential iatrogenic injury\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the clinical scenarios, managing agitation often requires the application of various restraint methods, including both physical and chemical methods. Physical restraint strategies, which limit a patient\u0026rsquo;s range-of-motion, are particularly popular\u003csup\u003e[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In our emergency department, we follow guidelines that utilize three primary types of restraint: (1) elastic restraint proximal fixation (ERPF) which restricts both wrist and elbow flexion with adjustable straps; (2) splint-combined restraint (SCR) which uses prefabricated devices alongside multi-anchor bands for joint immobilization, and (3) Grip-Induced Motion Limitation (GIML); this hand grip method helps patients the use of a grip device to voluntarily maintain functional hand positions.\u003c/p\u003e \u003cp\u003eWhile the efficacy of these methods has been widely discussed, there is a critical shortfall in our current knowledge. Time-sensitive strategies in emergency care have yet to be investigated in detail and there is no unified framework for evaluation. Furthermore, there is a clear need to acquire systematic comparisons of time-critical data to assess clinical accessibility, such as restraint preparation time, total puncture duration, nursing workload and equipment accessibility. This absence of solid evidence often results in a shift of clinical decision-making towards gut feeling risking resource misallocation and potential delays in the critical window available for rescue\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe use of restraint strategies in the clinic demands a careful balancing act. It is important to balance operational efficiency against patient safety and ethical standards. This challenge becomes even more acute in high-pressure emergency scenarios. The overuse of restraints can aggravate agitation, while underuse may increase operational risks.\u003c/p\u003e \u003cp\u003eTherefore, there is a critical need to develop an evidence-based hierarchical restraint scheme to enhance the quality of emergency care \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Although selection criteria have been developed for different restraint methods, there is a notable lack of research relating to venipuncture for agitated patients in emergency departments. \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e Rather, some healthcare professionals may resort to a singular approach and select methods in an empirical manner that could lead to wasted resources or operational delays.\u003c/p\u003e \u003cp\u003eIn this study, we systematically evaluated the success rate, efficiency, and clinical feasibility of three distinct restraint strategies during venipuncture in agitated patients. Our goal was to provide solid data that will support improved practices in emergency nursing.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData for this study were drawn from the hospital's electronic medical record (EMR) system. Patient identities were anonymized and only included disease occurrences and influencing factors. Our investigation recruited 412 patients who exhibited agitation in the emergency department between January 2022 and December 2024. All analyses contain data only, do not involve any patient privacy, and are only analyses in the form of data. These patients exhibited various forms of agitation, including those experiencing seizures, drunkenness, and delirium. Agitation flared up primarily as involuntary or uncontrolled limb movements, thus providing evidence of distress. We collated a range of information for each patient, including: (1) age and gender, (2) basic health conditions such as diabetes, nutritional status, and chronic diseases; (3) Venipuncture metrics, including total success rate, puncture duration, and device fixation time (if restraints were used), and (4) the outcomes of venipuncture, including the occurrence of hematoma, bruising, and pain scores.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData preprocessing\u003c/h3\u003e\n\u003cp\u003eIn accordance with our hospital's \u0026lsquo;Intravenous Therapy Nursing Technical Operation Specification\u0026rsquo;, we established clear exclusion criteria. First, patients with absolute contraindications to upper extremity venipuncture were excluded, including those with abnormal coagulation function (INR(international normalized ratio)\u0026thinsp;\u0026gt;\u0026thinsp;1.5), upper extremity deep vein thrombosis, and severe peripheral vascular lesions. Second, we excluded any cases in which skin integrity was compromised, including local redness, swelling, skin ulcers, or active infections at the puncture site. Next, the head nurse of the emergency department and a specialist nurse meticulously evaluated venipuncture records and eliminated cases involving non-standard restraint positions, those that did not use special equipment or involved unplanned and emergency-only punctures.\u003c/p\u003e \u003cp\u003eWe only recruited cases that had been completed by a duly competent nurse with appropriate upper limb restraint tools. Data integrity verification was conducted with the hospital EMR system. We focused on core indicators, including constraint duration, the number of punctures, venipuncture complications, and pain assessments using the FLACC scale(a composite of 5 behaviors (\u0026ldquo;face,\u0026rdquo; \u0026ldquo;legs,\u0026rdquo; \u0026ldquo;activity,\u0026rdquo; \u0026ldquo;cry,\u0026rdquo; and \u0026ldquo;consolability\u0026rdquo;) ). Cases with a missing key data field rate exceeding 15% or those with logical discrepancies were eliminated. Following data cleaning, we included the case data of 386 patients experiencing emergency agitation who met our research criteria. All of this data was anonymized by triple encryption.\u003c/p\u003e\n\u003ch3\u003eAnalytical methods and factor screening\u003c/h3\u003e\n\u003cp\u003eFirst, case data were meticulously categorized into three distinct groups: a band group, a splint group, and a hand-holding group. We employed the Chi-squared test and ANOVA to compare the foundational circumstances across these groups. This step ensured that we could eliminate potential confounding factors while analyzing the venipuncture process itself. Key metrics included one-try success rates, the total number of punctures, and the cumulative puncture time. Next, we investigated both the duration of immobilization and the frequency of device loosening to confirm the clinical feasibility and adaptability of these three restraint techniques. Post-analysis, we evaluated the efficacy of venipuncture with respect to these methods. We investigated common complications arising from this procedure, including bruising at the puncture site, along with the severity and duration of any bruising. We also evaluated the presence of redness, swelling, pain scores, and discomfort experienced by patients. Our aim was to validate the efficacy of distinct restraint methods in the facilitation of venipuncture for agitated individuals.\u003c/p\u003e \u003cp\u003eFinally, we evaluated patient comfort. By comparing comfort levels during the procedure, we aimed to enhance the humanistic aspect of clinical nursing care.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed with SPSS version 25.0 software. Data that were normally distributed are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) and compared using the independent samples t-test. Non-normally distributed data are reported as median and interquartile ranges (median [IQR]) and compared by the Mann-Whitney U test or the Kruskal-Wallis test. Qualitative data are reported as frequencies and percentages (n [%]) and compared by the Chi-squared test or Fisher's exact test. The significance level was α\u0026thinsp;=\u0026thinsp;0.05 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeneral case data\u003c/h2\u003e \u003cp\u003eFirst, we compared the patients with respect to age, gender, physical health, and platelet concentration (Table\u0026nbsp;1); there were no significant differences in these factors when compared between the three patient groups. We also investigated potential confounding variables that could influence the efficacy of venipuncture, including the type of underlying disease, medications, and catheter placement sites. There are no significant differences in the comparison of the basic analysis objects(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating that the sample selection has not differentiated the samples.A schematic diagram of the subsequent analysis and constraint methods is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparative analysis of basic puncture conditions for the three restraint methods\u003c/h3\u003e\n\u003cp\u003eOur analysis showed that the rates of venipuncture increased with different restraint methods when compared to traditional hand-holding approach.(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) However, the success rates for punctures did not differ significantly when compared between different restraint methods (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). In terms of puncture occurrence, the traditional hand grip method exhibited a higher tendency for puncture failures, leading to repeated attempts (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Analysis also suggested suggest that instrument fixation, splinting, and banding could reduce the frequency of unnecessary repeat punctures associated with traditional methods. (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eComparative analysis of puncture time for the three restraint methods and the fixed duration of the two special restraint methods\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere was a notable difference in puncture times across the three groups(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Only the banding method exhibited a significant reduction in puncture time when compared to the other groups (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)When we compared fixation times for the banding group and the instrument-fixed splint group, we found that the splint method took notably longer. (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB)(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).Next, we investigated the total puncture duration for successful cases across all three groups, and identified an association between duration and fixation time. There were no significant differences between groups with regard to calculated operation times.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eComparative analysis of loosening in the three constraint methods\u003c/h3\u003e\n\u003cp\u003eIn the band group, loosening occurred following band release, breakage, or via escape of the patient\u0026rsquo;s upper limb. Patients in the splint group experienced loosening from one or both sides, splint breakage, or escape of the patient\u0026rsquo;s upper limb. In the hand holding group, there were only instances of the patient breaking away from the control hand. The frequency of loosening showed a downward trajectory across all groups. The splint method was associated with the fewest loosening incidents, surpassing both the band and hand grip groups. Patients in the band group experienced less loosening than those in the hand holding group (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA)(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison of venipuncture complications and pain comfort scores under the three restraint methods\u003c/h2\u003e \u003cp\u003eNext, we investigated the frequency and intensity of bruising. Analysis revealed that bruising frequency varied across the groups. While bruising in the hand-held group was notably severe, the overall occurrence remained modest. (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) With regard to pain, we only observed minimal variations. Only a handful of cases reported high pain scores, predominantly among those facing repeated punctures. (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC)\u003c/p\u003e \u003cp\u003eFinally, we conducted a survey on the comfort of three different puncture methods, analyzing the details along with the pain scores. (see Table.2)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we performed retrospective data analysis to investigate the efficacy of three prevalent restraint strategies for agitated emergency patients during venipuncture.\u003c/p\u003e \u003cp\u003eOur analysis showed that the splint and banding combined fixation technique (SCR) exhibited a success rate that was far superior to the other groups. This appears to be related to the application of multi-anchor bands and prefabricated splints. Together, these tools effectively tether the patient's joints, minimizing limb movement distractions during puncture. However, while the SCR excelled in terms of stability, this method is associated with a prolonged operating time; the countless fixation steps involved could drain precious time in emergencies.\u003c/p\u003e \u003cp\u003eIt is important to strike a balance between time and efficiency. Thus, while SCR exhibits good success rates, its time-intensive nature could hinder a rapid response in urgent situations. In contrast, the elastic band proximal fixation method (ERPF) elegantly balances success and speed and was associated with the highest feasibility score from nurses. Clearly, this approach prioritizes convenience and efficacy, thus representing a useful option for the urgent needs of emergency nursing.\u003c/p\u003e \u003cp\u003eConversely, the hand-held method (GIML) offers simplicity but a poor success rate. The higher failure rate of GIML, especially for patients exhibiting moderate to severe agitation, suggests that this method should only be used for patients with mild agitation and a cooperative spirit. This stratified outcome highlights the critical importance of customized restraint strategies that can be tailored to patient agitation levels.\u003c/p\u003e \u003cp\u003eFor the first time, this study included unified operation time, feasibility, and puncture success rate into a comprehensive analysis framework. This innovative approach bridges the gaps in the existing literature by studies that utilized single indices. For example, existing literature appears to prioritize success rate alone as the endpoint. In the present study, however, we identified a correlation between fixed duration and total operating time. The total duration of the restraint device itself plays a pivotal role in determining overall efficiency, far beyond the mere puncture operation.\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur findings could transform emergency care and suggest that future improvements should streamline installation steps and foster rapid fixation innovations. Furthermore, our findings shed light on how doctors and patients evaluate various restraint methods, specifically with regard to how operational complexity could hinder clinical compliance.\u003c/p\u003e \u003cp\u003eThe splint method is durable but is associated with poor levels of comfort, despite the team effort required for this technique. This highlights the necessity for clinical decision-making to account for both objective outcomes and the operational experiences of medical staff. Our findings provide the groundwork to develop standardized constraint processes that are both efficient and user-friendly.\u003c/p\u003e \u003cp\u003eWhile this study offers valuable insights, there are limitations to consider. First, retrospective data analysis may have introduced bias. Screening cases based solely on electronic medical records could have omitted important complications or operational nuances. Second, our classification related mostly to nursing notes; however, there is no universal quantitative standard for agitation at present; therefore, the accuracy of our findings may have been affected. In addition, the psychological toll of restraint strategies remains largely unexplored. The possibility of long-term restraint is inevitable, thus enhancing anxiety or inducing post-traumatic stress. This possibility requires further investigation.\u003c/p\u003e \u003cp\u003eFuture studies should involve prospective designs and objective agitation scoring tools such as the Richmond Agitation-Sedation Scale (RASS)\u003c/p\u003e \u003cp\u003e. This could bolster the reliability of results considerably. \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e It is also important to incorporate long-term follow-up data relating to patient comfort and psychological impact to enrich the comprehensive evaluation of restraint strategies.\u003c/p\u003e \u003cp\u003eBased on our current research results, we should first develop intelligent restraint devices, including adaptive strap or integrated splint systems with adjustable pressure systems, to reduce fixation time and improve stability. Second, we should investigate the combined application of physical restraint and low-dose sedative drugs\u003csup\u003e[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, to balance operational efficiency and patient safety through a \"step-by-step\" strategy. Third, we should establish a decision-making process for constraint incorporating multidisciplinary collaboration \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e and develop hierarchical management guidelines based on the input of nurses, physicians, and ethics committees. In addition, cross-center collaboration could be used to expand the sample size and verify the generality of constraint strategies in different healthcare settings\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. For example, the results of this study show that the banding method performs best in terms of overall score; however, its accessibility in low-resource settings needs to be further validated. Finally, the introduction of simulation training and standardized operation training may improve the proficiency of nurses with regard to the operation of complex restraint devices, thereby improving the clinical feasibility score. These investigations will not only help to optimize the practice of emergency nursing, but also provide theoretical support for the construction of a patient-centered safety constraint system.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003cbr\u003e\u003c/strong\u003eThis retrospective study involving human participants and anonymized medical data was reviewed and approved by the\u0026nbsp;Ethics Committee of Nanjing First Hospital, Nanjing Medical University\u0026nbsp;(Approval No. KY20230829-03; Date of Approval: August 29, 2023). The study strictly adhered to the ethical principles of the Declaration of Helsinki and complied with national/institutional guidelines for retrospective research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e\u003cbr\u003eIndividual informed consent for participation in this study was waived by the Ethics Committee due to the fully anonymized nature of the data and the non-interventional, retrospective design. However, institutional protocols ensured that all patients (or their legal guardians) provided written consent during routine clinical care for their anonymized medical records to be used for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Anonymization and Privacy Protection\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All patient data were extracted from electronic medical records and anonymized using triple-encryption methods prior to analysis. No personally identifiable information (e.g., names, identification numbers, or contact details) was accessed, stored, or disclosed during the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnimal Studies\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research did not involve animals, client-owned animals, or animal-derived data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no financial or non-financial conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study utilized clinical nursing data from the internal records of Nanjing First Hospital. The research received no additional financial support from public, commercial, or not-for-profit funding agencies. All data collection, analysis, and interpretation were conducted using institutional resources without external grants or sponsorships. The authors affirm that no financial or non-financial conflicts of interest influenced the design, execution, or reporting of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe, the undersigned authors of the manuscript titled\u0026nbsp;\"A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing\", hereby confirm:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eConsent for Publication: All authors have read and approved the final version of this manuscript. We consent to its publication in its current form and take full responsibility for the content, including the accuracy of the data and the ethical conduct of the research.\u003c/li\u003e\n \u003cli\u003eEthical Compliance: This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and was approved by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University (Approval No. KY20230829-03; Date of Approval: August 29, 2023).\u003c/li\u003e\n \u003cli\u003eData Anonymity: All patient data were anonymized using triple-encryption methods prior to analysis. No personally identifiable information was accessed, stored, or disclosed.\u003c/li\u003e\n \u003cli\u003eConflict of Interest: The authors declare no financial or non-financial conflicts of interest related to this work.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Signatures:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHongfan Wang, Supervisor Nurse\u003c/li\u003e\n \u003cli\u003eMei Zhang, Supervisor Nurse\u003c/li\u003e\n \u003cli\u003eJimin Qiao, Deputy Chief Nursing\u003c/li\u003e\n \u003cli\u003eYingqian Zhou, Supervisor Nurse\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVACHHARAJANI T J, AGARWAL A K, ASIF A. Vascular access of last resort [J]. (1523\u0026ndash;755 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWILSON JE, MART M F, CUNNINGHAM C et al. Delirium [J]. 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(2397\u0026ndash;3374 (Electronic)).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cimg src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img175017401536.png\" alt=\"image\"\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img1750174015.png\" alt=\"image\"\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"emergency, restraint, venipuncture, emergency care, agitated patients","lastPublishedDoi":"10.21203/rs.3.rs-6699176/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6699176/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAgitated patients in emergency settings face challenges during venipuncture due to unpredictable limb movements, leading to procedural failures and injuries. Physical restraint methods are commonly used, but comparative data on their efficacy, time efficiency, and clinical outcomes remain limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis retrospective study analyzed data from 387 agitated patients requiring upper limb venipuncture in an emergency department (January 2022–December 2024). Patients were categorized into three restraint groups: elastic band fixation (n=137), splint-band fixation (n=122), and manual hand-holding (n=127). Key outcomes included first-attempt success rate, total procedural time, fixation stability, and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Device-based restraints (band and splint groups) showed significantly higher first-attempt success rates compared to manual restraint (P\u0026lt;0.05), with no notable difference between the two device groups. Repeated puncture attempts were more frequent in the hand-holding group (P\u0026lt;0.05). The band group required the shortest total operating time, while the splint group demonstrated superior stability (lowest loosening incidence: 9.8% vs. 29.4% ecchymosis in the manual group). Pain scores were comparable across groups, but splint users reported better comfort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSplint-band fixation offers optimal stability but demands longer setup time and additional personnel, limiting its practicality in urgent scenarios. Elastic band fixation balances efficiency and success, making it preferable for emergency use. Manual restraint suits mildly agitated, cooperative patients but requires backup strategies. A tiered restraint protocol, tailored to agitation severity and clinical urgency, is recommended to improve outcomes and patient safety.\u003c/p\u003e","manuscriptTitle":"A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 09:21:48","doi":"10.21203/rs.3.rs-6699176/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5be06a16-b9cf-4e19-b31c-3fd50fe2cb75","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-13T20:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 09:21:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6699176","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6699176","identity":"rs-6699176","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}