Restraint Episodes Research Articles

An analysis of nurses’ post‐incident manual restraint reports

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

The Conceptualization of Physical Restraint as a Nursing-Sensitive Adverse Outcome in Acute Care Psychiatric Treatment Settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Use of Pulse Oximetry During Restraint Episodes

Back to table of contents Previous article Next article LettersFull AccessUse of Pulse Oximetry During Restraint EpisodesKim James Masters, M.D., and Deborah Wandless, L.P.N.Kim James MastersSearch for more papers by this author, M.D., and Deborah WandlessSearch for more papers by this author, L.P.N.Published Online:1 Oct 2005https://doi.org/10.1176/appi.ps.56.10.1313AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I read with interest the special section in the September issue on the use of seclusion and restraint in psychiatric treatment settings. Physical restraint—the holding of an individual by staff to contain dangerous behavior—is used at many different levels of care, from hospitals and residential facilities to group homes and schools, especially with children and adolescents (1,2).Unpublished data for 1995 to 2004 from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) indicate that among 3,000 sentinel events that involved severe injury or death, 115 restraint-related fatalities occurred. Fourteen percent of the restraint-related deaths involved "take-down and hold" maneuvers. Death resulted from asphyxia because of inability to expand the chest or from obstruction of the airway, usually with a face towel to prevent spitting or biting (personal communication, Croteau R, 2005). A JCAHO study of 20 restraint-related deaths found that chest compression had limited the patients' air exchange, which led to inadequate oxygenation (3). Similar problems have been noted for sitting restraints, such as the basket hold.Currently, when a person is restrained, adequacy of oxygenation is assessed through pulse, blood pressure, and respiration measurements, which are confounded by anxiety and anger. Pulse oximetry is a noninvasive direct measure of oxygenation that has been used in medical facilities to measure the oxygen saturation of hemoglobin. Portable oximeters are accurate and reliable (4).To determine the usefulness of pulse oximetry during restraint procedures, baseline pulse oximetry readings were obtained for all patients at our residential treatment facility, which has an average daily census of 84. The residents were given information by a licensed practical nurse about the use of pulse oximetry readings to decrease the possibility of suffocation during restraint. Residents included male and female adolescents aged 12 to 18 years who had psychiatric and behavior problems and who lived in seven separate units in the facility.Oxygen saturation was measured during 31 physical restraint episodes (12 patients) over 70 days (March 10 to May 19, 2005) by using a probe from a portable oximeter that was clipped to a finger or toe (2) by licensed practical nurses. The oximeter used was the 503 DX model from Criticare Systems Mini SPO2T. In seven of the restraint episodes, the patients were prone; in the remainder, the patients were in standing positions. The mean±SD duration of an individual episode was 9±6 minutes.Baseline oxygen saturation readings were 96 percent or greater; readings during restraint episodes were 95 percent or greater. No incidents of respiratory distress were noted either by the staff or by the residents during restraint. Oximetry was well accepted by staff and patients. In fact, we found that placing the finger probe on the adolescent's hand and asking him or her to turn on the oximeter, if interested, sometimes distracted everyone involved, diffused tension, and ended the restraint.It will be necessary to see how oximetry performs under conditions of impaired oxygenation. There is concern that it might give an inaccurate reading during acute dyspnea, making repeat readings and clinical correlation essential (4). In addition, in one study when volunteer staff of a mental health facility were restrained in either a prone or a supine position and then directed to exercise, those subjected to prone restraint showed prolonged pulse recovery after exercise, which may suggest a link with sudden death during prone restraint (5). Although the oximetry measures for the volunteers did not show abnormalities, measurements during clinical situations could help clarify any role that oxygenation plays in pulse abnormalities.Our investigations suggest that oximetry in medical settings, such as hospitals, and nonmedical settings, such as group homes, may be a viable, cost-effective tool that could protect persons who are subjected to physical restraint from respiratory embarrassment, suffocation, and death.Dr. Masters is affiliated with the psychiatry department at Pines Residential Treatment Center, Midlands Campus, in West Columbia, South Carolina, and Charleston Campus. Ms. Wandless is director of nursing at New Hope Treatment Center in Rock Hill, South Carolina.

Inhibition of restraint stress‐induced neural and behavioural activation by endogenous cannabinoid signalling

The role of endocannabinoid (eCB) signalling in restraint stress-induced neuronal activation was studied. Male mice exposed to 30 min of restraint exhibit increased Fos protein within prefrontal cortex (PFC), lateral septum (LS), nucleus accumbens (Acb) and medial amygdala. SR141716 (2 mg/kg) itself had no effect on Fos but pretreatment with SR141716 significantly potentiated restraint-induced Fos expression in cingulate, LS and Acb. SR141716 also significantly increased the time spent in active escape behaviours during the restraint. In restraint-habituated mice (mice exposed to four previous restraint episodes), the fifth restraint exposure resulted in decreased expression of active escape behaviours compared to the first exposure and only induced Fos protein in the central and medial amygdala. Administration of SR141716 prior to the fifth restraint episode resulted in greater potentiation of restraint-induced Fos induction than the first; significant increases occurred within all regions of PFC examined, LS and Acb. Brain regional eCB content was measured immediately after restraint. N-arachidonylethanolamine content within the amygdala was significantly decreased after both restraint episodes. 2-Arachidonylglycerol content was significantly increased in both the limbic forebrain and amygdala after the fifth restraint but not the first. Restraint had no effect on cerebellar eCB content. These data suggest that eCB activation of CB(1) receptors opposes the behavioural and neuronal responses to aversive stimuli. Because repeated homotypic stress increased both limbic 2-AG and resulted in a greater effect of SR141716 on limbic Fos expression, we hypothesize that increased CB(1) receptor activity contributes to the expression of habituation to homotypic stress.

Association Between Seclusion and Restraint and Patient-Related Violence

This study assessed the effect of an intervention designed to reduce the use of seclusion and restraint on reported episodes of patient-related violence on an acute inpatient psychiatric service. Results showed a significant decrease in the total number of episodes of seclusion and restraint between the 12 months before and after the intervention. However, the number of episodes of assault on patients and staff increased significantly. Efforts to decrease seclusion and restraint may be accompanied by an increased risk of harm to psychiatric patients and staff, and intensive safety monitoring and staff training should accompany all such efforts.

Reduction of episodes of seclusion and restraint in a psychiatric emergency service.

The authors developed a comprehensive plan focusing on the early identification and management of problematic behaviors in an effort to reduce seclusion and restraint in a psychiatric emergency service and to increase adherence to hospital standards for its use. Hospital data for nine months before and nine months after the implementation of the plan were retrospectively reviewed. Two key factors that were believed to increase the likelihood of episodes of seclusion and restraint were ineffectual management of problematic behavior and inadequate monitoring. The plan, when instituted, was associated with a 39 percent reduction of instances of seclusion and restraint. Compliance with hospital standards increased to 100 percent.

Acute and delayed restraint stress-induced changes in nitric oxide producing neurons in limbic regions

Rationale: Microinjection into the dentate gyrus of the hippocampus of N ω-nitro- l-arginine methyl ester hydrochloride ( l-NAME), a nitric oxide synthase (NOS) inhibitor, induces antinociceptive effect 5 days after a single restraint episode. The mechanisms of this stress-antinociceptive modulatory effect have not been investigated but may involve plastic changes in the hippocampal formation (HF). Objective: The objective of the present study was to investigate possible mechanisms of the stress-modulating effect on antinociception induced by NOS inhibition in the hippocampus. We analyzed the effects of restraint stress on neuronal NOS (nNOS) expression and nicotinamide adenine dinucleotide phosphate-diaphorase histochemical activity (NADPH-d) in the HF and related brain regions. Methods: Male Wistar rats ( n=6–11/group) were submitted to a single (acute stress) or repeated (5 days) episodes of 2-h restraint. Control animals remained in their home cages being all animals daily handled during this period. In the fifth day, animals received unilateral microinjection of l-NAME (150 nmol/0.2 μl) or saline (control) into the dentate gyrus of the dorsal hippocampus (DG). Immediately before and after drug microinjection tail-flick reflex latency or hotplate licking reaction was measured. Animals were killed i. immediately; ii. 5 days after acute stress; or iii. after repeated stress. NADPH-d and nNOS expression were quantified in the HF, caudate-putamen, secondary somatosensorial, entorhinal and piriform cortices and amygdaloid complex. Results: Five days after one or five restraint episodes l-NAME microinjection into the DG elicited antinociceptive effect (analysis of variance [ANOVA], P<0.05). Acute restraint stress induced a significant increase in the density of neurons expressing NADPH-d and nNOS in the amygdaloid nuclei. nNOS expression increased also in the DG and piriform cortex. Five days after a single or repeated restraint stress there was an additional increase in NADPH-d- and nNOS-positive neurons in CA1, CA3, and entorhinal cortex. No changes were seen in non-limbic regions such as the caudate-putamen and secondary somatosensorial cortex. Conclusion: The results confirm that the dorsal hippocampus participates in the modulation of stress consequences. They also show that a single stress episode causes acute changes in nitric oxide system in the amygdala complex and delayed modifications in the HF. The delayed (5 days) antinociceptive effect of NOS inhibition in the HF after a single restraint episode suggests that those latter modifications may have functional consequences. It remains to be tested if the acute amygdala and delayed hippocampal changes are causally related.

Achieve emergency department restraint reduction.

Reduce restraint episodes without compromising safety by implementing process-oriented, behaviorally based practice tools. Learn how one trauma center minimized restraint use with intensive process management.

Two-year trends in the use of seclusion and restraint among psychiatrically hospitalized youths.

This study examined characteristics associated with the use of seclusion and restraint among 442 psychiatrically hospitalized youths and sought to quantify changing trends in the rates of these modalities of treatment over time after the 1999 implementation of federal regulations and an institutional performance improvement program. Demographic and clinical data related to all 5,929 incidents of seclusion and restraint that occurred during 2000 and 2001 at a child and adolescent state psychiatric hospital were analyzed. The two-year prevalence of use of seclusion was 61 percent and of restraint was 49 percent. Children and adolescents who were admitted on an emergency basis and those belonging to ethnic minority groups were more likely to undergo seclusion or restraint. Children aged 11 years and younger were more likely to undergo seclusion. The total number of episodes decreased by 26 percent and their cumulative duration decreased by 38 percent between the first quarter of 2000 and the last quarter of 2001. The decreases were the result of fewer seclusion and restraint incidents as well as shorter episodes of restraint. Over time, a concurrent increase was observed in the proportion of episodes associated with patient (but not staff) injuries and with as-needed use of medications. National reforms and institutional efforts can lead to downward trends in the use of seclusion and restraint among psychiatrically hospitalized youths. The active elements of these interventions warrant further study and replication.

Achieve ED restraint reduction.

Reduce restraint episodes without compromising safety by implementing process-oriented, behaviorally based practice tools.

Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital.

The aim of this study was to examine staff strategies for applying emergency procedures with patients who were violent or threatening. The study addressed those situations where verbal intervention, voluntary medication, and other interventions had been tried unsuccessfully and where staff found it necessary to apply emergency procedures in the shape of forced emergency medication (pharmacological restraint), physical restraint, and seclusion. The study was conducted in a 100-bed Norwegian university psychiatric hospital. By retrospectively examining hospital records we found there were 797 episodes of physical restraint, 384 episodes of pharmacological restraint, and 88 episodes of seclusion during a five and a half year period. The preferred emergency procedures varied significantly with patients' sex, age, and diagnoses. Physical restraint was preferred more often with male, younger, and nonpsychotic patients. Pharmacological restraint was preferred more often with female patients and older patients with a nonorganic psychotic disorder. Seclusion was preferred more often with older male patients with an organic psychotic disorder.

Change in the rate of restraint use and falls on a psychogeriatric inpatient unit: impact of the health care financing administration's new restraint and seclusion standards for hospitals.

This chart review of 767 patients treated on a psychogeriatric inpatient unit over a 2-year period examined the impact of the Health Care Financing Administration's (HCFA) new restraint standards for hospitals on the rate of restraint use and falls. There was a marked decrease in the number of restraint episodes in the year after the introduction of the new standards compared with the year before (44 vs 212 restraint episodes per 1,000 patient-days). However, no notable differences were found in the number of total falls (18 vs 21 falls per 1,000 patient-days) or serious falls (2 vs 1 serious fall per 1,000 patient-days). If replicated, these findings of decreased restraint use without a concomitant increase in the number of falls demonstrate a change in practice patterns as a result of HCFA's action.

Datapoints: use of restraint before and after implementation of the new HCFA rules.

138 T use of physical restraint in psychiatric settings is highly controversial, and the issue is all the more contentious for the lack of systematic data collection and careful evaluation of indications, methods, outcomes, and adverse events. In July 1999 the Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services, issued rules on restraint and seclusion for general and psychiatric hospitals that participate in Medicare and Medicaid (1). The rules require that a physician or a licensed independent practitioner make a face-to-face assessment of a patient within one hour of the initiation of restraint or seclusion. The “one-hour rule” has provoked tremendous debate as smaller and rural facilities struggle to comply with this “unfunded mandate.” The rules also shorten the interval between mandatory renewal orders, codify requirements for staff training, and create more stringent requirements for documentation. No data on the use of restraints on inpatient psychiatric wards have been published since these rules were put into effect. We report information about restraint episodes on four psychiatric units with a total of 80 beds at the University of Rochester Medical Center during the three months before Use of Restraint Before and After Implementation of the New HCFA Rules

The Use of Physical Restraints in Polish Psychiatric Hospitals in 1989 and 1996

The use of physical restraints in 11 locked psychiatric wards in Warsaw, Poland, was examined in 1989 and 1996 to determine whether the implementation of the Mental Health Act in 1995 and other political transformations changed this psychiatric practice. All episodes of restraint were documented during a one-month period in both years. Significantly more episodes of restraint occurred in 1996, but the average duration of each episode decreased, the number of episodes per patient fell, and the proportion of episodes due to patient aggression increased. Findings indicate that use of restraint was less arbitrary in 1996, which is likely attributable to the replacement of local institutional rules by national regulations controlling the use of restraint in psychiatric practice.

Impulsivity, dietary control and the urge to binge in bulimic syndromes

Objective Naturalistic studies on sufferers of bulimic syndromes suggest that binge episodes are often precipitated by episodes of dietary restraint. However, evidence also implies that binge eating may, in certain psychopathological contexts, have less direct connection with dietary control factors. Applying an 8- to 22-day experience-sampling procedure in individuals with bulimic syndromes, we explored possible moderating effects of trait impulsivity upon the ongoing association between cognitive dietary control and binge eating. Method Fifty-one women with bulimia spectrum eating disorders provided periodic daily observations on cognitive control over eating, urges to binge, and binge episodes. Impulsivity was assessed by self-report questionnaire. Hierarchical linear modeling techniques were used to assess relationships of interest. Results Urge to Binge was higher (on average) prior to eating binges than at comparable times on binge-free days, and thus seemed to signal the potential for binge eating. More importantly, scores on Urge to Binge and Dietary Control covaried systematically over time in most participants, but were desynchronous in highly impulsive individuals. Conclusions Binge eating is closely linked to dietary control in most bulimic individuals, but this may be less typical of individuals showing marked impulsivity. We discuss factors that may explain the disconnection between Dietary Control and Urge to Binge in impulsive binge eaters as well as the implications of such factors for the management of bulimic patients with marked impulsivity. © 1999 by John Wiley & Sons, Inc. Int J Eat Disord 26: 261–274, 1999.

Physical Restraint of Patients in a Psychiatric Hospital

Use of physical restraint occurs within British psychiatric hospitals yet there has been little evaluative research on current practice. The present study aims to describe a group of disturbed in-patients who had required physical restraint at some point during the course of their stay in hospital and to classify the reasons for its use. Cases were identified using Case Register data and information obtained from patients' records. In the 48 episodes of physical restraint identified, patients were predominantly schizophrenic (60%), male (67%) and had been restrained because of physical violence to others (44%) or because they were attempting to abscond (31%). Although the majority of patients were compulsorily detained prior to the use of physical restraint, three remained informal. The findings are discussed in the context of the legal justifications for use of restraint. Further research on current practice is required to enable formulation of clear guidelines.

Evaluating Staff Use of Crisis Prevention Intervention Techniques: A Pilot Study

The purpose of this pilot study was to evaluate staff use of crisis prevention intervention (CPI) techniques in averting crisis episodes at the various levels (anxiety, defensive, and acting out) of a crisis (resulting in reduction of seclusion and restraint episodes and patient/staff injuries). A descriptive correlational research design was used. Data were collected by nurse observers trained in CPI techniques through observation of patient incidents and staff interventions. A 51-item CPI instrument based on the CPI training program techniques was developed and used for data collection. Data were analyzed using descriptive statistics, Pearson correlation, t tests, ANOVA, and the Scheffe test. One hundred forty-six observations of patient incidents were completed on both day and evening shifts. The results of the study indicate that staff use of CPI training program techniques was effective in resolving crises in 84.2% of the episodes observed and over a wide variety of diagnostic and functional levels.

Effect of nonviolent self-defense training on male psychiatric staff members' aggression and fear.

Male staff members at two state psychiatric hospitals were trained in nonviolent self-defense skills for dealing with potentially assaultive patients to determine whether such training could reduce the number of assaults and episodes of patient restraint. Three groups of male staff received didactic training, didactic and physical skills training, or no training in the nonviolent self-defense skills of protective profile, repel, and push-off, as well as in evasive movement. Effects of the training were evaluated using the Buss-Durkee Hostility-Guilt Inventory; a questionnaire about clinical experience and sports training; judges' evaluations of physical skill, aggression, and fear; a self-report questionnaire about the value of nonaggressive responses and felt fear and aggression; and a follow-up questionnaire about posttraining assaults. Behaviorally expressed fear and aggression were significantly reduced among staff who received both didactic and physical skills training. The other two groups showed no significant changes in this area. During the two weeks after training, subjects trained in physical and didactic skills were involved in 23 percent fewer assaults than those who received only didactic training and 20 percent fewer assaults than those who received no training. The development of increased skill in nonviolent physical techniques of self-defense was strongly correlated with an increase in the value placed on the use of the skills and on nonviolent outcomes.

Clinical review of clozapine treatment in a state hospital

Medical records of the first 37 patients to begin clozapine treatment at a state hospital in Oregon were reviewed for six months before clozapine treatment and six months after. Patients had a long history of schizophrenia and had responded poorly to antipsychotic medication. Clozapine treatment was generally well tolerated, although the rate of seizures (8 percent) was slightly higher than expected. Psychotic symptoms decreased as measured by the Brief Psychiatric Rating Scale, as did symptoms of tardive dyskinesia as measured by the Abnormal Involuntary Movement Scale. Thirty-four patients remained hospitalized after six months of treatment. However, indicators of social function (hospital privilege level, community passes, violent episodes, and episodes of seclusion and restraint) all showed that patients improved markedly after receiving clozapine.

Initial evaluation of reorganized hospitalization services in a community mental health center.

Two locked inpatient units at an inner-city community mental health center were reorganized as a hospitalization service consisting of a 22-bed intensive care inpatient unit, an acute-treatment day hospital for 20 patients, and a 23-bed transitional residence program. Levels of functioning of hospitalized patients treated before and after the reorganization were compared to determine if the reorganized program as a whole was more effective clinically than the two inpatient units had been. The authors retrospectively compared levels of functioning at discharge of random samples of 10 percent of patients treated in the ten months before the reorganization (N = 66) and 10 percent of the intensive care and day hospital patients treated in the same ten calendar months afterward (N = 78). They also compared data on episodes of seclusion and restraint and on patient flow in the two time periods. The mean functional level of intensive care and day hospital patients treated in the reorganized service was significantly higher than the level of inpatients treated before. The mean duration of episodes of seclusion, but not of restraint, decreased significantly. Total service admissions and readmissions increased from 493 to 603. The reorganized service encouraged patients to function at higher levels. However, such a program must be affiliated with a diversified and well-functioning outpatient service that can divert some potential inpatients to appropriate alternative treatments and help move patients out of the day hospital-residential program when they are stabilized.