Patient Restraint and Seclusion

Function

The impetus to administer restraint and seclusion protocol is to obviate potential violence and potentiate harm reduction. Hazards to be avoided include both harm to the patient and the caretaker. This danger encompasses both nonviolent and violent risks. Healthcare providers are always encouraged to remain vigilant. However, data suggest that incidents involving the following risk factors may be associated with increased patient agitation diathesis: 

• Interpersonal communication
• Environment
• Waiting time
• Drug and alcohol intoxication or withdrawal
• Metabolic conditions (eg, hypoglycemia, hypoxia)
• Neurologic conditions (eg, infection, dementia, stroke)
• Psychiatric disorders (eg, schizophrenia, psychosis, personality disorder)[1][2]

Issues of Concern

Healthcare Safety

As many as 50% of providers report being the victim of violence at 1 point in their careers.[3] In a survey specifically for Emergency Medicine residents and attendings, 78% reported being involved in a violent workplace act within the past year.[4] Furthermore, 4-8% of patients presenting to a psychiatric emergency department are armed.[5]

General Prevention Measures 

General prophylactic safety measures to best obviate workplace violence include and prevent the use of seclusion and restraint: 

• Security — A survey of 250 emergency departments in the United States showed that nearly 77% of hospitals did not have 24-hour security, and only 1.6% used metal detectors.[6] Although healthcare workers are among the highest risk groups of workplace violence, this survey suggests that they remain vulnerable to agitated patients and visitors partly due to limited or absent security. A 2008 study of 3518 surveys from 65 emergency department locations noted that guns or knives were consistently brought into the emergency department daily or weekly.[7] Security personnel with sufficient training and experience are a principal aspect of violence prevention. 
• The efficiency of operation — Long waiting times have been associated with a predisposition to violence in emergency departments. A census of approximately 50,000 patients showed that a waiting time of 2 hours is significantly associated with an increased incidence of violence.[8]
• Warning sign recognition — Training personnel to recognize disruptive patients at the onset of a visit can help raise staff awareness and increase set precautions. A 1997 survey of 517 psychiatric residents indicated that 36% were physically assaulted, and nearly 66% described themselves as undertrained or without training in managing violent patients.[9]
• Access control — A study of emergency department security in 250 hospitals concluded that only 21% of hospitals controlled emergency department access during high-risk periods.[6]
• Alarm systems — Alarms can enhance patient and staff safety. Some alarms include pressure-sensitive bed alarms, patient room alarms, and staff panic alarms.

Negative Consequences of Restraint and Seclusion

Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy, justice, beneficence, and non-maleficence. Per beneficence - the act of doing good - and non-maleficence - do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort. A 2019 meta-analysis on the effects of restraint and seclusion estimated that the precipitation of posttraumatic stress disorder following restraint interventions ranged from 25% to 47%.[10] 

Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious effects such as pressure ulcers, skin breakdown, abrasions, asphyxia, strangulation, incontinence, depression, social isolation, and drug overdose or interaction.[11][12]

Clinical Significance

Interview Preparation 

Before the interview, all patients need to be searched and disarmed.[13] Metal detectors, as well as the routine practice of gowning the patient, act as non-confrontational strategies to uncover weapons. Once the patient has been appropriately searched, the interview can commence. The evaluation should occur in privacy but not in isolation.[14] The common practice is for the interviewer to locate the patient between the door and the door. Ideally, in the case of a high-risk patient, the provider should have proximal access to a panic button. 

Recognition of Violence Escalation

Violence history remains the best predictor for future violence. The classic escalation of patient violence progresses from anger, resistance, and finally to confrontation. Signs of impending violent behavior include provocative behavior, posturing, pacing, angry demeanor, and aggressive acts.[15] It is also plausible that violent behavior erupts impulsively and without warning, especially in the setting of organic disease. Alternative tools to assess violence include the following batteries: 

• Coburn and Mycyk describe 3 phases of violence escalation: (1) anxiety, (2) defensiveness, (3) physical aggression. As individuals move through these stages, they typically get closer to violence. It is a useful tool for clinicians to initiate de-escalation techniques at earlier phases to prevent progression quickly.[11]
• The STAMP (Staring, Tone, and Volume of Voice, Anxiety, Mumbling, and Pacing) tool for use in the emergency department details behavior observed in patients, family, and friends that can indicate impending violence.[16]
• The Overt Aggression Scale (OAS) is a rating scale to measure the aggressive behavior of inpatient children and adults. It is divided into 4 sections: verbal and physical aggression against objects, self, and others.[17]

De-escalation Techniques

Once an agitated patient has been identified, staff must allow the patient to calm down before physical intervention. Often, agitated but cooperative patients are amenable to verbal de-escalation. Guidelines recommend an honest and straightforward approach with the implementation of friendly gestures, which proves most beneficial in the setting of an agitated patient. Ten key features for verbal de-escalation as provided by the American Association for Emergency Psychiatry De-escalation Workgroup include:[18]

• Maintain a distance of 2 arm's lengths 
• Maintain a relaxed and non-confrontational posture
• Establish verbal contact
• Use simple and concise language.
• Identify requests and feelings.
• Actively listen to what the patient is saying.
• Do not be afraid to agree to disagree.
• Set clear boundaries
• Attempt to offer choices
• Debrief the staff and patient

Indication for Emergency Seclusion and Restraint

Following fruitless de-escalation techniques, emergency seclusion and restraint can be indicated. The following list suggests incidences when such measures should be administered.

• Imminent danger to others
• Imminent danger to the patient
• Profound disruption of treatment or damage

Types of Restraints

The least restrictive method necessary to correct the issue should always be used. Physical restraints encompass hand mitts, soft cloth, leather limb restraints, enclosed beds, belts, and vests. Ideally, a restraint team should include at least 5 people, including the team leader. If the patient is female, at least 1 member should be female to minimize the potential of sexual assault allegations. Chemical restraint (sedatives/hypnotics/neuroleptics/dissociatives) can be administered alone or with physical restraints. The medication used must have a rapid onset with minimal side effects. The 3 primary drug classes used are benzodiazepines, first-generation antipsychotics, and second-generation antipsychotics. If the patient is only minimally responsive following the administration of the chemical restraint, it may be fruitful to administer a subsequent psychotropic from an alternate class. The pharmacological agent administered can vary on the scenario: 

Severely violent (rapid tranquilization)

• First-generation or second-generation antipsychotics (eg, haloperidol [2.5 to 10 mg IM], olanzapine [5-10 mg IM])
• Benzodiazepines (eg, lorazepam [0.5 to 2 mg IV/IM], midazolam [2.5 to 5 mg IV/IM]) 
• A combination of first-generation antipsychotics and benzodiazepines

Agitation from drug intoxication or withdrawal

• Benzodiazepines (contraindicated in the setting of intoxication with CNS depressant)

Agitation due to an unknown cause

• Benzodiazepines (preferred) or
• First-generation antipsychotics

Agitation in a patient with a psychiatric condition

• First-generation antipsychotics or
• Second-generation antipsychotics [19][20]

Lorazepam can be given in doses of 0.5 to 2mg IV or IM every 10 to 30 minutes, depending on the severity of agitation. The half-life is 10 to 20 hours. Midazolam works more rapidly than lorazepam; however, it lasts a shorter period (one to 2 hours). The dose for midazolam is 2.5 to 5 mg IV or IM and can be given every 3 to 5 minutes, depending on severity. The dose for haloperidol is 2.5 to 10 mg IM or IV (although the FDA does not approve IV administration) every 15 to 30 minutes as needed. Haloperidol has an onset of action of about 28 minutes IM and 3 to 20 minutes IV. Olanzapine can be given in a 5 to 10 mg IM dose with an onset of action of 15 to 45 minutes and a half-life of 2 to 4 hours. Take caution when giving a patient first-generation antipsychotics as they have a propensity to induce extrapyramidal side effects, as well as QT prolongation, which can potentially lead to dysrhythmias like torsades de pointes.[19] Obtain an EKG before administering the medication; otherwise, an EKG should be obtained once the patient has been sedated. Per the US Food and Drug Administration, higher doses and IV administration of haloperidol increase the incidence of QT prolongation. In the setting of a lowered seizure threshold (eg, alcohol or benzodiazepine withdrawal, epilepsy, anticholinergic toxicity), first-generation neuroleptics should be avoided, as they can further increase seizure diathesis. Regarding benzodiazepines, the clinician should be wary of CNS depression and, less commonly, paradoxical disinhibition. Generally, heuristic models suggest that the provider moves to an alternate class when the initial attempt is ineffective. An alternative to benzodiazepines and antipsychotics is ketamine. Ketamine is a dissociative anesthetic with minimal adverse effects. Off-label uses include management in the setting of excited delirium, acute-on-chronic substance abuse, and when first-line measures have been ineffective.[21]

Active Restraint Monitoring 

Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly to prevent sequelae such as pressure ulcers, rhabdomyolysis, and paresthesias.[11] Once it is safe, the patient should also be evaluated for medical causes of agitation. Generally, patients above the age of 40 experiencing new-onset psychiatric symptoms are more likely to be suffering from an organic pathology, whereas elderly patients are more likely to experience delirium secondary to a medical illness or iatrogenic etiology. Seclusion is an environmental restraint that prevents the patient's free movement and decreases environmental stimulation. Depending on the indication, it can be used involuntarily or voluntarily. There are circumstances when restraint and seclusion are contraindicated. Seclusion is inappropriate if a patient requires constant monitoring. Examples include patients presenting with suicidal ideation, self-injurious behavior, hemodynamic instability, or overdose. Restraint and seclusion should not be used as punishment or convenience. Generally, restraints and seclusion cannot be administered longer than 4 hours for adults (> 18 years), 2 hours for children and adolescents (9 - 17 years), or 1 hour for children (<9 years) unless state laws are more restrictive. 

Removal of Restraints

When the patient is no longer a danger to themselves or others, the restraints should be removed immediately.

Other Issues

Legal Ramifications

Patients typically sign a document that legally details their consent to treatment. When the decision to treat becomes involuntary, as in most instances of patient restraint and seclusion, the physician is put at risk of common legal ramifications about false imprisonment, battery, the duty to do no harm, the duty to warn, and competence.[22] For this reason, physicians must be sure that their decision to restrain or seclude is fully justified and thoroughly documented to explain the details behind the decision. To illustrate this topic, picture a scenario where a patient is being emergently evaluated for a serious condition that can alter his level of competency. During the evaluation, the patient is lethargic and unaware of his location; he becomes agitated and desires to leave. At this point, the physician decides to restrain the patient because he is now a danger to himself. All aspects of the decision-making process should be documented to demonstrate the need for restraint. Documentation should include the emergent situation, why consent could not be obtained, and why the treatment benefited the patient.[15] The clinician should not permit the patient to leave if he is incompetent and a danger to himself, as this becomes an issue of negligence, which is significantly more difficult to defend in court. Additionally, the physician must be aware of any statement from the patient regarding the impending harm of a third party, as there is a duty to warn that party. The physician can face legal ramifications if the patient leaves without the staff notifying the third party and that third party is harmed. Knowledge of how certain cases can lead to legal consequences can help a physician document and take action to avoid liability appropriately.

Enhancing Healthcare Team Outcomes

It is of paramount importance to effectively train staff on how to appropriately care for agitated and at-risk patients requiring restraint or seclusion. If staff is not appropriately trained, patients and others are at higher risk of adverse outcomes. In addition to staff training, healthcare facilities must be equipped with means to protect individuals, such as continuous security presence, efficient operation of the business, access control, alarm systems, and availability of means to restrain and seclude. If de-escalation techniques are ineffective, restraint and seclusion must be considered as last-resort methods. The patient should be included as much as possible in the decision-making process. Staff must review restraint and seclusion situations to evaluate performance and provide feedback to ensure efficient, effective, and safe medical practice.