26 - Use of Physical Restraints as an Emergency Treatment

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

Copyright 2003 Lippincott Williams & Wilkins

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26

Use of Physical Restraints as an Emergency Treatment

Thomas G. Gutheil

Richard I. Shader

The use of physical restraints is perhaps the most controversial treatment method described in this text. Because it can be both protective and life saving for patients and staff, this chapter provides a brief discussion of physical restraint in the following four most common forms: the geriatric chair, the Posey belt, plastic handcuffs, and four-point restraints (wrist and ankle bracelets). All forms of physical restraint require constant monitoring and consideration of a patient's physical needs and status. Adequate numbers of staff are essential both for patient monitoring and for safe placement of patients in restraints. As with the use of seclusion (see Chapter 25), restraints should not be ordered by a physician when other safe and effective methods of temporary control are available that have not been used (see also section IV.C). A persuasive clinical argument involving safety to the patient, other patients, or staff must be documented each time a decision is made to use restraints. Most jurisdictions have laws governing the use of restraints in hospitals, nursing homes, and other settings. Some believe that the movement toward more restrictive laws was prompted by perceptions that restraints were not being used primarily for the benefit of patients (see also section VI.C in Chapter 25 for information about proposed interim rules from the Health Care Financing Administration).

I. Geriatric Chair

The geriatric chair is used most often with demented elderly patients. It is a broad-based chair (rarely, a wheeled chair) that is fitted with a lap desk secured to its arms. The chair prevents the confused, agitated, and disoriented patient from wandering around or off the ward or intruding on other patients, either to their detriment or so as to provoke an aggressive reprisal or response.

A. Advantages

The advantages of this method are that the patient sits in a comfortable position; most activities of the hands such as occupational therapy, eating, writing, and taking medication are possible; and the device is generally safe for the occupant as long as the chair cannot be tipped over. In addition, ongoing staff contact can be readily maintained.

B. Possible Hazards

• Contact hazards

  • Skin abrasion.

  • Abdominal compression.

  • Chair sores.

  • Impairment of circulation, including (in rare instances) venous stasis, thrombosis, or embolism. These complications are the result of problems with the use of the chair, including a failure to adjust the chair to the patient, faulty chair design, insufficient supervision, or inadequate hygienic monitoring of the patient.

• Treatment hazards

  • Deliberate avoidance and neglect of the patient after placement in the chair, leading to failures of feeding, toileting, and interpersonal contact.

  • Sensory deprivation, leading to agitation.

  • The creation of a false sense of security; the patient is supposedly all right and is no longer in need of nursing staff attention.

• Other hazards. Severe increases in agitation resulting in injury from the chair itself or by its tipping over.

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II. Posey Belt

A Posey belt is a broad canvas, leather, or web belt that is secured around the patient's waist and fastened to the bed frame or chair. Used with side rails in a bed, it may help to keep a wandering demented patient in the bed when rest is required by the patient's medical condition. This method may also be used when specially designed geriatric chairs are not available. The hazards are circulation impairment; abdominal compression; abrasion; and, if the patient tries to slide out of the belt, strangulation, a hazard that severely limits the value of the Posey belt.

III. Plastic Handcuffs

A patient who, because of dangerous assaultiveness or terror, is judged incapable of being evacuated from an area or a building for clinical or administrative purposes (e.g., fires, fire drills, or emergency evacuations) can be temporarily restrained by plastic handcuffs. These plastic cuffs resemble metal handcuffs, but they are made of noninjurious plastic, often with additional padding. The cuffs facilitate ambulation and add a degree of safety for other patients being evacuated. After the emergency or drill is over, the cuffs should be removed immediately.

IV. Four-Point Restraint

Four-point restraint usually consists of foam-padded leather wrist and ankle bracelets attached securely to the frame of a hospital bed or to a specialized bed frame that is sometimes secured to the floor. Sufficient slack should be left in the placement of the restraints to permit needed positional changes, especially side to side movement and toileting. The use of this method of restraint is an intensive and specialized medical procedure that requires specific training and careful monitoring and supervision.

A. Indications

In general, restraints are considered when a patient's loss of control is of dangerous proportion, and little or no response is seen with medication, temporary isolation or seclusion (see Chapter 25), or verbal intervention. Under certain circumstances, patients with toxic psychoses, such as those induced by phencyclidine or lysergic acid diethylamide (LSD), that promote violence toward the self or others may be protected and treated in restraints until the offending agent is metabolized or is countered by an effective antidote. Deliria, especially delirium tremens or other drug-withdrawal deliria, also may be so treated, especially if the patient must be briefly left unattended. A patient ill enough to be restrained should in no instance be left unattended for more than 10 to 15 minutes; some jurisdictions require that the patient never be left unattended.

Severe paranoid and manic states may require emergency restraint when other methods, such as seclusion or medication, have been ineffective or have not yet had time to work. Agitated depressions involving severe unremitting self-injury (e.g., self-mutilation, eye enucleation, self-strangulation) may mandate the use of restraints to keep the patient safe until emergency electroconvulsive therapy can be initiated or medications have taken effect. In addition, violent patients with comorbid medical disease in a combination that prohibits other treatment measures may need restraints to allow time for safe medical treatment or nursing care. Although the following is controversial, some clinicians advocate restraints instead of medication in psychotic women who are pregnant, believing that the temporary use of restraints gives time needed for the consideration of the risks of medication exposure during pregnancy. In any patient, the clinical benefits of restraints must exceed or outweigh the risks, both psychologic and physical.

B. How Do Restraints Help?

Restraints are thought to act through direct physical control of the patient's ability to harm the self or others. In addition to preserving life and bodily safety, restraints communicate to patients who may fear loss of control that they do not need to rely only on their own fragile internal controls. Some clinicians believe that the inherently calming effect of this message is a likely factor in the efficacy of restraint. In certain clinical states, a period in restraints may be the only time an acutely agitated patient can relax.

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Physical restraint also allows disturbed patients a period of safe interpersonal contact. Medication, other treatments, and diagnostic procedures may be achieved in an atmosphere of safety for the patient and staff; the patient obtains crucial human contact without fearing the effect of his or her own impulses.

A third mechanism is the induction of a state of relative sensory sameness, which is advantageous, as with seclusion, in aiding patients prone to sensory overload and stimulus generalization. This latter mechanism is especially relevant when a patient requires physical restraints while in the seclusion room.

C. Contraindications

Restraints should not be used (a) when other effective treatment measures are available; (b) as a replacement for staff attention; (c) except for brief emergency situations for the habitually violent, those with impulse disorders or explosive personalities, or very angry nonpsychotic patients (these patients should receive other types of treatment or, when appropriate, legal or administrative controls); or (d) in place of transfer to a secure facility when this is indicated and is possible.

D. Technique

Restraints should be used only by physicians, nursing staff, or treatment teams familiar with and trained and practiced in their use. All staff must be thoroughly oriented to the theory of restraints and should be comfortable with their use, especially because a positive nonpunitive attitude, when communicated to the patient, should reassure him or her about being controllable. Annual retraining is strongly recommended. For pregnant patients whose level of dyscontrol requires restraints, placing the patient on her left side or using a pillow to raise the right hip to avoid aortocaval compression has been recommended (see Additional Reading). In general, patients should be restrained in a supine position; some authorities further suggest elevation of the head of the bed to decrease the likelihood of aspiration.

The patient should be offered restraints on a voluntary basis whenever possible. The possible future use of restraints and a review of alternative aids to control should also be discussed. A request for restraint that is initiated by a patient should almost always be honored. All patients in restraint should be told as clearly as possible that this is occurring for their own protection or the protection of others; that they will be carefully observed and followed closely; and that, when their control returns, they will be released promptly. Once the patient is in restraints, he or she must be viewed as being under intensive care and requiring more observation, not less. Attention to feeding, toileting, vital signs, concurrent medical conditions, the careful use of medications, and body position changes must be regular and systematic. At the same time, the staff must continue to assess the beneficial effects of restraint and whether the patient's self-control has been reestablished.

Recent guidelines from the American Academy of Child and Adolescent Psychiatry (see Additional Reading) largely track the recommendations provided in this chapter and emphasize the alertness to any potential for airway obstruction and avoidance of this as a possibility.

E. Hazards and Risks

These are mostly short term, and they include abrasion or injury from the straps, cuffs, or bed; asphyxiation or aspiration from vomiting or while feeding; and bladder and bowel disturbances secondary to position. In pregnant patients, compression of venous return through the inferior vena cava must be avoided. With prolonged use, restraints may cause bed sores, muscle atrophy, bone demineralization, and other metabolic disturbances. Attention to exercise and metabolic needs is essential. Psychologic hazards are posed particularly for the types of patients described in section IV.C, who may regress when placed in restraints, and for those with cognitive disorders (e.g., dementias) for whom excessive sensory deprivation could worsen their mental state.

Limited data are available on the rates of accidental deaths attributable to the use of restraints. One recent survey examined 1,403 incidents of restraints

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use in a 150-bed county psychiatric facility over a 5-year period, with the following two findings. First, in keeping with national trends, annual use rates fell steadily from 9.2 per 1,000 patient days in 1994 to 1.5 per 1,000 patient days in 1999 for an average rate over the 5 years of 4.6 per 1,000 patient days. Second, more importantly, no deaths were attributable to the use of restraints.

F. Termination

The decision to terminate restraint is as critical, and requires as much clinical care, as the decision to initiate it. As with the termination of seclusion (see Chapter 25), restraints must be removed in a graduated stepwise manner that has been negotiated with patients as part of an ongoing assessment of their clinical state. The staff must be ready to resume restraints at a certain stage after release to allow the patient to acclimate; nevertheless, an inconsistent, impulsive, nongraduated, or non-negotiated on-again, off-again approach should be studiously avoided.

G. Forensic Issues

These are similar to those with seclusion (see Chapter 25). Some authorities suggest that when a voluntary patient must be restrained involuntarily, involuntary commitment proceedings should be initiated immediately. The use of physical restraint is a sensitive and controversial subject. It is a source of potential distress to patients, families, and staff, so its use must be the subject of active review and discussion. To ensure high standards of practice, each episode of restraint must be the subject of careful internal review and documentation of indications and response; the review itself must be documented.

Additional Reading

Bursten B. Using mechanical restraints on acutely disturbed psychiatric patients. Hosp Commun Psychiatry 1975;26:757 759.

Carmel H, Hunter M. Compliance with training in managing assaultive behavior and injuries from inpatient violence. Hosp Commun Psychiatry 1990;41:558 560.

Department of Health and Human Services, Health Care Financing Administration. Medicare and Medicaid Programs: hospital conditions of participation: patients' rights: Interim Final Rule. 42 CFR 482 Federal Register 1999;64:36069 36089.

Fisher WA. Restraint and seclusion: a review of the literature. Am J Psychiatry 1994;151:1584 1591.

Guirguis EF, Durost HB. The role of mechanical restraints in the management of disturbed behavior. Can Psychiatr Assoc J 1978;23:209 218.

Hay D, Cromwell R. Reducing the use of full-leather restraints on an acute adult inpatient ward. Hosp Commun Psychiatry 1980;31:198 200.

Mallya AR, Roos PD, Roebuck-Colgan K. Restraint, seclusion, clozapine. J Clin Psychiatry 1992;53:395 397.

Masters KJ, Bellonci C, Bernet W, et al. Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions with special reference to seclusion and restraint. J Am Acad Child Adolesc Psychiatry 2002;41:4S 25S.

Miller WH, Resnick MP. Restraining the violent pregnant patient. Am J Psychiatry 1991;148:269.

Pinninti NR, Rissmiller D. Incidence of restraint-related deaths. Psychiatr Serv 2001;52:975.

Raskin VD, Dresner N, Miller LN. Risks of restraints versus psychotropic medication for pregnancy. Am J Psychiatry 1991;148:1760 1761.

Rosen H, DiGiacomo JN. The role of physical restraint in the treatment of psychiatric illness. J Clin Psychiatry 1978;39:228 232.

Soloff PH. Behavioral precipitants of restraint in the modern milieu. Compr Psychiatry 1978;19:179 184.

Tardiff K, ed. The psychiatric uses of seclusion and restraint. Task Force Report No. 22. Washington, D.C.: American Psychiatric Press, 1984.

Tardiff K. Concise guide to assessment & management of violent patients. Washington, D.C.: American Psychiatric Press, 1989.