The Role of Race on Restraint Use: Background, Guidelines, and Adverse Outcomes (Part 1 in a 3-Part Series)

June 25, 2021
hand restraints

Background

Restraints serve as a means to manage agitation and other behavioral disorders when attempts at de-escalation fail. National trends show a 50% increase in the number of ED visits for behavioral disorders from 2006 to 2011 (Capp et al., 2016). EDs in the United States see nearly 1.7 million agitated patients per year (Zeller et al., 2010). Both physical and chemical restraints, as well as seclusion, are used in the ED to protect staff and prevent self-harm to patients.

Before further exploring restraints, it is important to define these terms and understand what warrants their use. As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a restraint is “any chemical or physical method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body” (Zun, 2005). The most common utilization of restraints is to prevent harm to the patients themselves, other patients, or staff. Other less common reasons that warrant the use of restraints include requests from the patients themselves, to prevent serious disruption to treatment programs, and to decrease overstimulation. One study found that 61% of ED patients were restrained because they presented a danger to themselves or others, whereas 28% were restrained because they were unwilling or unable to follow orders (Wong et al., 2019).

Guidelines for Restraint Use

Restraints can be classified into three broad categories: (1) physical, (2) chemical, and (3) seclusion. Physical restraints, which are the most frequent of the three types, use physical devices and techniques to restrict the movement of patients. Examples of this include head straps, restraining sheets, two-point restraints (where the patient’s wrists are strapped), and four-point restraints (where the patient’s wrists and ankles are strapped). Chemical restraints, which are less frequently used and even prohibited in some facilities, restrict the movement or behavior of patients through the administration of medications, such as benzodiazepines (i.e. lorazepam) or antipsychotic (neuroleptic) medications (i.e. haloperidol and olanzapine) (Coburn & Mycyk, 2009). A national survey found that 30% of EDs use only physical restraints whereas another 30% use physical and chemical restraints. (Downey et al., 2007). Finally, seclusion, which conventionally is used as a last resort method of restraint, is the involuntary confinement of a patient who is either behaving violently or in a self-destructive manner in an area from which they are not able to leave (Knox & Holloman, 2012).

Hospital protocols exist to ensure that the use of restraints is clinically justified and implemented in a safe manner. These protocols should be derived from the JCAHO’s Restraint and Seclusion Standards since they are the organization responsible for tracking the use of restraints. Under these national guidelines, a physician must evaluate a patient within an hour of placing him or her in either restraint or seclusion. The decision to use restraint or seclusion must only be made after considering alternative treatment options. By the JCAHO standards, restraint orders are time-limited, with a limit of four hours for individuals who are older than 17, two hours for individuals between the ages of nine and 17, and one hour for children younger than nine. After being placed in restraint or seclusion, the patient must be continually monitored and evaluated by medical staff (Zun, 2005). When the restraint order expires, the physician has the option to discontinue or renew the order only upon re-evaluation of the patient. However, regardless of the length of time specified in the restraint order, the intervention must be discontinued at the earliest possible time by periodic evaluations. Any complications that result from these interventions must be documented thoroughly (Zun, 2005).

While there are instances where the use of restraints is warranted, such as to prevent harm to the patients themselves or others, there are also instances where they are not. Restraints should not be used for mere convenience, punishment, or a lack of resources to supervise a patient (Coburn & Mycyk, 2009). Moreover, patient history or medical conditions (i.e. delirium, dementia, or history of self-injury) are not sufficient on their own to warrant the use of restraints.

Adverse Outcomes Associated with Restraint

When de-escalation strategies fail, physicians commonly use restraints, which are associated with both physical and psychological adverse outcomes. Physical restraints are associated with lasting physical injuries such as skin breakdown, circulatory obstruction, aspiration pneumonia, and cardiac stress. Struggling against physical restraints can also lead to dehydration, poor appetite, psychological trauma, and exacerbation of existing psychiatric conditions. In more severe cases, it can even lead to asphyxiation, cardiac arrest, or accidental death (Nissen et al., 2012).

In a qualitative study of 25 patients who were physically restrained in an ED, several emotional and psychological effects were identified. The restraint process was described as dehumanizing for patients, both physically and verbally, leading to feelings of loss of freedom and personal dignity. The use of restraints often led patients to conclude that the staff in the ED did not care for them, leading to a general distrust and avoidance of interactions with healthcare workers (Wong et al., 2020). In fact, a survey found that 66% of ED patients reported lasting consequences with regards to care-seeking behavior after physical restraint (Knox & Holloman, 2012).

Although chemical restraints can minimize the complications associated with physical restraints and struggling against them, they can have adverse outcomes as well. The most common side effects associated with medications such as benzodiazepines are sedation, confusion, nausea, and ataxia. Patients using these medications must also be carefully monitored for respiratory depression and cognitive impairment.

While seclusion avoids the adverse outcomes associated with physical and chemical restraints, it can lead to psychological harm if the patient feels isolated or rejected. Although seclusion only allows for limited freedom of movement, it can still be dangerous for patients who can harm themselves or others. Ideally, the rooms used for seclusion should include indestructible walls, immovable furniture, and unbreakable windows that allow for continuous monitoring (Coburn & Mycyk, 2009).

References

Capp, R., Hardy, R., Lindrooth, R., & Wiler, J. (2016). National Trends in Emergency Department Visits by Adults With Mental Health Disorders. The Journal of Emergency Medicine51(2), 131–135. https://doi.org/10.1016/j.jemermed.2016.05.002

Coburn, V. A., & Mycyk, M. B. (2009). Physical and Chemical Restraints. Emergency Medicine Clinics of North America27(4), 655–667. https://doi.org/10.1016/j.emc.2009.07.003

Downey, L. V. A., Zun, L. S., & Gonzales, S. J. (2007). Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. General Hospital Psychiatry29(6), 470–474. https://doi.org/10.1016/j.genhosppsych.2007.07.006

Knox, D., & Holloman, G. (2012). Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine13(1), 35–40. https://doi.org/10.5811/westjem.2011.9.6867

Nissen, T., Rørvik, P., Haugslett, L., & Wynn, R. (2012). Physical Restraint and Near Death of a Psychiatric Patient. Journal of Forensic Sciences58(1), 259–262. https://doi.org/10.1111/j.1556-4029.2012.02290.x

Wong, A. H., Ray, J. M., Rosenberg, A., Crispino, L., Parker, J., McVaney, C., Iennaco, J. D., Bernstein, S. L., & Pavlo, A. J. (2020). Experiences of Individuals Who Were Physically Restrained in the Emergency Department. JAMA Network Open3(1), e1919381. https://doi.org/10.1001/jamanetworkopen.2019.19381

Zeller, R. (2010). Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clinical Therapeutics32(3), 403–425. https://doi.org/10.1016/j.clinthera.2010.03.006

Zun, L. S. (2005, August 1). Use of Restraint and Seclusion in the Emergency Department. Psychiatric Times. https://www.psychiatrictimes.com/view/use-restraint-and-seclusion-emergency-department

Latest News

June 25, 2021
Restraint use, like other disparities in healthcare, can stem from the impact of racial bias in clinical encounters. A disparity, according to the Institute of Medicine in its Unequal Report, is a difference in the quality of healthcare provided to patients that is not attributable to the patients…
July 14, 2020
Today, emergency room physicians see too many patients who have delayed treatment for heart attacks, strokes, and other serious conditions because of COVID-19 fears. In some cases, the results are needlessly catastrophic.
July 7, 2020
Just like NASA’s mission control analyzes data and provides feedback to optimize a mission in space, a hospital command center does the same for the nurses and clinicians caring for patients on the wards.1  In the past, “incident command centers” were established to temporarily assist health…