Educating Staff Key to Curbing Use of Restraints

The use of physical and chemical restraints remains a thorny issue, despite great strides that are being made to improve, reduce, and eliminate the practice.

An investigative series by the Hartford Courant in 1998 prompted a federal investigation and report confirming that the use of seclusion and restraint was largely ungoverned, erratically monitored, and underreported, and had caused injury and death to both children and adults.

That same report from the U.S. General Accounting Office (now known as the Government Accountability Office) went on to say that some states had been able to reduce–and even eliminate–seclusion and restraint use. Just how clinicians are expected to accomplish that is the topic of much debate and little scientific research.

Eliminating the use of restraints in the emergency department, for example, isn't possible because, by its very nature, the ED isn't as controlled a setting as are other units, said Douglas Kupas, M.D., director of the emergency residency program at Geisinger Medical Center, Danville, Pa. Emergency departments have to consider the safety of the patient, staff, and other patients who are often in close proximity.

“Although there are deaths in patients who have been restrained, the restraint frequently has nothing to do with the cause of death. We must always work to improve our training and to use best practices when restraining patients, but many emergency medical services systems and EDs do an excellent job in restraining these very difficult patients,” he said.

Patients should be restrained in a way that maintains their dignity and permits evaluation of underlying medical conditions, he said. The staff needs both to be educated on the use of verbal de-escalation and physical and chemical restraints, and to be prepared to use the appropriate techniques.

To point to a single practice as hazardous oversimplifies the issue, Dr. Kupas said.

In particular, critics posit that restraining patients in the prone position predisposes them to suffocation. Although his practice is to avoid the prone position, Dr. Kupas said it can be helpful in the initial restraint or “take-down” of a patient.

“The key is that [restraint] is multifaceted,” he said. “There isn't a silver bullet answer, but there are many best practices that EDs should incorporate into their policies and procedures.”

Educating staff about the appropriate time to administer and remove restraints is essential, agrees David H. Dorfman, M.D., a pediatrician with the division of pediatric emergency medicine at Boston Medical Center and the department of pediatrics at Boston University.

A study led by Dr. Dorfman found that a large percentage of emergency medicine residency programs (52% of 48 respondents) and pediatric emergency medicine fellowships (82% of 33 respondents) do not teach their trainees about the application of restraints, and 35% of responding emergency medicine residencies and 64% of pediatric emergency medicine fellowships did not teach appropriate situations in which to use restraints (Pediatr. Emerg. Care 2004;20:151–6).

Chemical restraints were used in pediatric psychiatric patients in the emergency department by almost three-fourths of the respondents, but few reported having formal policies on chemical restraint.

Benzodiazepines and butyrophenones were the most commonly used agents. But both responding groups often misclassified butyrophenones as phenothiazines.

Cascading to Arrhythmia

A situation ripe for improvement is the misinterpretation of the cascade of events leading to fatal arrhythmias, particularly when patients are restrained in the prone position, said Tracy G. Sanson, M.D., assistant medical director in the department of emergency medicine at Brandon (Fla.) Regional Hospital.

In a typical scenario, a patient may be brought in by police, handcuffed to a bed after being chased for 10 blocks for selling cocaine, and administered a second intramuscular injection under restraints because nothing else is working, she said. Staff or police may increase the pressure of their hold until the patient stops resisting, at which point they assume either that the patient is “playing possum” or that the medication has taken effect.

“Essentially that is the [moment]–if you would recognize it–that if you flipped them over, defibrillated them, [and] gave them bicarb and fluids, you could get them back,” Dr. Sanson said.

The actual causes of cocaine-associated sudden death and excited delirium are unknown. But studies have suggested that the vast majority of such patients die after a struggle, which may increase the level of circulating epinephrine and may result in metabolic acidosis.

In the ED, chemical restraint should be used more aggressively, Dr. Sanson said. It must be accompanied by ongoing monitoring because of the risk of respiratory arrest and because of the cumulative effect of drugs that may have been used by the patient prior to arrival and/or those administered by ED staff.