Restraint Events Research Articles

Predicting Agitation Events in the Emergency Department Through Artificial Intelligence

Agitation events are increasing in emergency departments (EDs), exacerbating safety risks for patients and clinicians. A wide range of clinical etiologies and behavioral patterns in the emergency setting make agitation prediction difficult in this setting. To develop, train, and validate an agitation-specific prediction model based on a large, diverse set of past ED visit data. This cohort study included electronic health record data collected from 9 ED sites within a large, urban health system in the Northeast US. All ED visits featuring patients aged 18 years or older from January 1, 2015, to December 31, 2022, were included in the analysis and modeling. Data analysis occurred between May 2023 and September 2024. Variables that served as potential exposures of interest, encompassing demographic information, patient history, initial vital signs, visit information, mode of arrival, and health services utilization. The primary outcome of agitation was defined as the presence of an intramuscular chemical sedation and/or violent physical restraint order during an ED visit. A clinical model was developed to identify risk factors that predict agitation development during an ED visit prior to symptom onset. Model performance was measured using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (PR-AUC). The final cohort comprised 3 048 780 visits. The cohort had a mean (SD) age of 50.2 (20.4) years, with 54.7% visits among female patients. The final artificial intelligence model used 50 predictors for the primary outcome of predicting agitation events. The model achieved an AUROC of 0.94 (95% CI, 0.93-0.94) and a PR-AUC of 0.41 (95% CI, 0.40-0.42) in cross-validation, indicating good discriminative ability. Calibration of the model was evaluated and demonstrated robustness across the range of predicted probabilities. The top predictors in the final model included factors such as number of past ED visits, initial vital signs, medical history, chief concern, and number of previous sedation and restraint events. Using a cross-sectional cohort of ED visits across 9 hospitals, the prediction model included factors for detecting risk of agitation that demonstrated high accuracy and applicability across diverse patient populations. These results suggest that clinical application of the model may enhance patient-centered care through preemptive deescalation and prevention of agitation.

Behavioral Outcomes for Students with Disabilities Attending Specialized Charter Schools for Students Qualifying for Special Education Services

ABSTRACT We examined the behavioral outcomes of students with disabilities attending non-charter public, specialized charter, or non-specialized charter public schools. Data from the 2020 to 2021 Civil Rights Data Collection were analyzed. There were statistically significant differences in behavioral outcomes according to type of school. Specialized charter schools for students with disabilities had similar levels of restraint events for students with disabilities as compared to specialized public schools, which was significantly higher than all other charter schools and non-charter public schools. Specialized charter schools for students with disabilities also had similar levels of seclusion events for students with disabilities.

Monitoring Psychiatric Inpatient Coercion in India – A 6-Month Prospective Evaluation of Incidence, Patterns, and Factors Affecting Restraint Use at a Tertiary Care Center

Background: The use of restraint in psychiatric inpatient settings is a contentious issue, balancing patient safety with ethical concerns. Despite India’s Mental Healthcare Act of 2017, which prohibits seclusion and mandates stringent restraint regulations, restraint remains a critical intervention in managing acute behavioral crises. This study investigates the prevalence, patterns, and determinants of restraint use in a tertiary care psychiatric facility in Northern India. Materials and Methods: This hospital-based, observational, prospective study was conducted over 6 months in a 32-bedded psychiatry ward. Data were collected from ward registers, treatment charts, and patient records, documenting restraint events. Sociodemographic and clinical factors were analyzed using descriptive statistics, comparisons, and logistic regression. Results: Among 128 admissions (5,518 inpatient days), 35.1% of patients experienced restraint, yielding a restraint patient rate of 8.15 per 1000 inpatient days and an event rate of 26.1 per 1000 inpatient days. Chemical restraint was predominant (74.3% of events), followed by combined (22.9%) and physical restraint (2.8%). Restraint occurred primarily in young adults with mood and psychotic disorders, with no significant association between restraint use and sociodemographic or clinical factors. Most restraints were applied within the 1st week of admission. Conclusions: Restraint, primarily chemical, remains common in managing acute agitation and violence, especially early in hospitalization. The findings underscore the importance of balancing clinical needs with patient rights while striving for noncoercive, patient-centered psychiatric care. The findings also highlight the need for standardized reporting and continued training to minimize restraint use and promote ethical healthcare delivery.

Teacher Experiences of Restraint Events and School District Policies on the Use of Restraint with Children With Disabilities

Physical restraint is an emergency procedure restricting the movement of an individual and is used in events where students pose an imminent threat of physical harm to themselves or others. Students with disabilities are subjected to these procedures seven times more than typically developing students. Over the past decade, there has been substantial policy reform on the use of restraint; however, policies still vary across the country. Additionally, research on experiences of the use of and policy on restraint in school settings is incredibly limited. The current study expands the body of literature by investigating teachers’ experiences, and factors associated with experiences, of restraint events and district policy utilizing a multiple-methods survey design. One hundred eighty Prekindergarten through 12th-grade teachers working in a variety of school settings across the country completed a self-report online survey. Results revealed variability in experiences of restraint events and school district policies. While most participants reported following the district policy as written, level of education significantly impacted teachers’ adhering to the policy, wherein those with higher levels of education were less likely to follow the policy. Implications for policy and practice are provided.

Reducing Physical Restraint Use in the Medical Behavioral Unit.

Children with behavioral health conditions often experience agitation when admitted to children's hospitals. Physical restraint should be used only as a last resort for patient agitation because it endangers the physical and psychological safety of patients and employees. At the medical behavioral unit (MBU) in our children's hospital, we aimed to decrease the weekly rate of physical restraint events per 100 MBU patient-days, independent of patient race, ethnicity, or language, from a baseline mean of 14.0 to <10 within 12 months. Using quality improvement methodology, a multidisciplinary team designed, tested, and implemented interventions including a series of daily deescalation huddles led by a charge behavioral health clinician that facilitated individualized planning for MBU patients with the highest behavioral acuity. We tracked the weekly number of physical restraint events per 100 MBU patient-days as a primary outcome measure, weekly physical restraint event duration as a secondary outcome measure, and MBU employee injuries as a balancing measure. Our cohort included 527 consecutive patients hospitalized in the MBU between January 2021 and January 2023. Our 2021 baseline mean of 14.0 weekly physical restraint events per 100 MBU patient-days decreased to 10.0 during our 2022 intervention period from January through July and 4.1 in August, which was sustained through December. Weekly physical restraint event duration also decreased from 112 to 67 minutes without a change in employee injuries. Multidisciplinary huddles that facilitated daily deescalation planning safely reduced the frequency and duration of physical restraint events in the MBU.

Nursing Interventions during Seclusion and Mechanical Restraint: A Video-Observation Study in Inpatient Psychiatric Care

Purpose. To understand nursing practice in seclusion and mechanical restraint events in psychiatric inpatient care. Design and Methods. Non-participant video observation was used to collect data from seclusion and mechanical restraint events. Nursing interventions were analysed using deductive content analysis. Findings. Video recordings (n = 36) showed that nurses were present for 4.1% of the duration of seclusion and mechanical restraint events. The nursing interventions focused on meeting patients’ basic needs, maintaining safety, and interaction. Practice Implications. Nursing must be founded on a thorough assessment of patients’ physical and psychosocial needs and meeting those needs with appropriate nursing interventions.

Race-Based Disparities in the Frequency and Duration of Restraint Use in a Psychiatric Inpatient Setting.

Patients' race and age have each been identified as risk factors for experiencing restraint events during psychiatric hospitalization. Restraint duration is also an important variable in determining disparities in treatment. To the authors' knowledge, no studies to date have examined the effect of the interaction of race and age on restraint use and duration in inpatient psychiatric settings. This retrospective chart review of electronic medical records of patients admitted between 2012 and 2019 sought to examine whether race and age interacted in predicting differences in the use and duration of restraints in a psychiatric inpatient setting. Logistic and hierarchical regression analyses were conducted on data from a sample of 29,739 adolescent (ages 12-17 years) and adult (ages ≥18 years) inpatients to determine whether the interaction of race and age group (adolescent or adult) significantly predicted a restraint event or differences in restraint duration. Black (adjusted OR [AOR]=1.85) and multiracial (AOR=1.36) patients were more likely to experience a restraint event than were their White peers. Black race was also significantly (p=0.001) associated with longer restraint duration. No significant interaction was detected between race and age in predicting restraint events or duration. Although the interaction between race and age did not predict restraint events or duration, the findings indicate racial disparities in the frequency and duration of restraint events among Black and multiracial individuals and may inform efforts to reduce these events.

Association of Long-acting Injectable Antipsychotics with Inpatient Seclusion and Restraint Events at a Public Psychiatric Hospital

Objective: Seclusion and restraint (S/R) are emergency safety measures to manage aggressive behaviour and prevent physical harm to self and others during psychiatric hospitalisations. Antipsychotics have been reported to reduce the incidence of S/R events during psychiatric hospitalisation. This study explores factors associated with inpatient S/R events and investigates whether long-acting injectable (LAI) antipsychotic prescription is associated with a reduction of S/R events. Method: Data on the number of S/R events during hospital stay were collected from the medical records of 741 psychiatric inpatients admitted between 2012 and 2017, and categorised into groups of 0, 1–2 and recurrent (≥3) S/R. Multinomial logistic regression analysis was performed to find the association between S/R events and several demographic and clinical variables, including the time to initiation of LAI (TLAI). Results: TLAI was not significantly associated with S/R events. Antipsychotic medication prescription was associated with a decreased risk of recurrent S/R events (OR = 0.47; 95% Cl = 0.24–0.92), however, it was not significant for the group having 1–2 S/R events (OR = 0.74; 95% Cl = 0.37–1.49). Individuals with recurrent S/R events were more likely to have forensic admission, transfer from jail or supervised facility, higher psychiatric comorbidity, and higher inpatient medications and prescription changes. Conclusion: Early initiation of LAI antipsychotics was not associated with S/R events; however, routine oral antipsychotic medication prescription was associated with decreased risk of S/R events. Specific predictors of S/R episodes may be used in preventative efforts aimed at decreasing S/R events.

Patients' and staff members' experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis.

Recent guidance has called for the reduction of restrictive practice use owing to growing concerns over the harmful physical and psychological effects for both patients and staff. Despite concerns and efforts, these measures continue to be used regularly to manage challenging behaviour in psychiatric in-patient settings. To undertake a systematic review of patients' and staff members' experiences of restrictive practices in acute psychiatric in-patient settings. A systematic review and thematic synthesis was conducted using data from 21 qualitative papers identified from a systematic search across three electronic databases (PsycInfo, Embase and MEDLINE) and citation searching. The protocol for the review was pre-registered on PROSPERO (CRD42020176859). The quality of included papers was examined using the Critical Appraisal Skills Programme (CASP). Four overarching themes emerged from the experiences of patients: the psychological effects, staff communication, loss of human rights and making changes. Likewise, the analysis of staff data produced four themes: the need for restrictive practices, the psychological impact, decision-making and making changes. Patient and staff experiences of restrictive practices were overwhelmingly negative, and their use carried harmful physical and psychological consequences. Lack of support following restraint events was a problem for both groups. Future programmes seeking to improve or reduce restrictive practices should consider the provision of staff training covering behaviour management and de-escalation techniques, offering psychological support to both patients and staff, the importance of effective staff-patient communication and the availability of alternatives.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study.

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 Dec. 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit.

To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns. We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day. The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001). Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

Post-incident reviews after restraints-Potential and pitfalls. Patients' experiences and considerations.

WHAT IS KNOWN ABOUT THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and care providers. Several countries have implemented seclusion and restraint (S/R) reduction programmes in which post-incident reviews (PIRs) including patients and care providers are one of several strategies. Existing knowledge indicates that PIRs have the potential to contribute to S/R prevention, but knowledge of the patients' perspectives on PIRs is scarce. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides in-depth knowledge about patients' experiences of being participants in PIRs after restraint events. Patients experience PIRs to result in being strengthened and developing new coping strategies. The paper reveals pitfalls when planning and conducting PIRs that make patients experience PIRs as meaningless, feel objectified or long for living communication and closeness. The patients' mental state, the quality of the relationships and the services' care philosophies, influence patients' experiences of PIRs as supporting their personal recovery processes or as continuation of coercive contexts. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Patients' vulnerability during the PIRs must be acknowledged. Trusted persons or advocacy must support the patient in the PIR and thus reduce the power-dependence imbalance. The PIR must be conducted in a supportive, non-punishing atmosphere. Patients must influence planning for the PIR concerning time point and participants and themes to be discussed. The PIR forms should be extended to support the patients' empowerment and well-being. ABSTRACT: Introduction Post-incident reviews (PIRs), including patients, nurses and other care providers, following incidents of restraints are recommended in mental health services. Few studies have examined patients' experiences and considerations concerning PIRs. Aim The study aims to explore patients' perspectives on PIRs in relation to how they experience participation in PIRs and further view PIRs' potential for care improvement and restraint prevention. Method We conducted a qualitative study based on individual interviews. Eight current and previous inpatients from two Norwegian mental health services were interviewed. Results The patients experienced PIRs as variations on a continuum from being strengthened, developing new coping strategies and processing the restraint event to at the other end of the continuum; PIRs as meaningless, feeling objectified and longing for living communication and closeness. Discussion PIRs' beneficial potential is extended in the study. The findings highlight however that personal and institutional conditions influence whether patients experience PIRs as an arena for recovery promotion or PIRs as continuation of coercive contexts. Implications for practice We recommend patients' active participation in planning the PIR. PIRs should be conducted in a supportive atmosphere, including trusted persons, emphasizing and acknowledging a dialogical approach.

A Visual Dashboard to Monitor Restraint Use in Hospitalized Psychiatry Patients

A Visual Dashboard to Monitor Restraint Use in Hospitalized Psychiatry Patients

The use of mechanical restraint in Pacific Rim countries: an international epidemiological study—Corrigendum

In the above article the abstract incorrectly states, “International rates of mechanical restraint in 2017 varied from 0.03 (New Zealand) to 98.9 (Japan) restraint events per million population per day”. The rate in Japan has been corrected to 98.8 as is found in the text of the article.

Association Between Sleep Times and Seclusion and Restraint Events in an Inpatient Pediatric Psychiatric Hospital: A Retrospective Chart Review.

To examine demographic characteristics of patients who experience seclusion and restraint (S&R) events in a pediatric psychiatric inpatient setting and assess whether sleep time 24 hours prior and after the occurrence of an S&R event was different from average sleep time during hospitalization. Charts from an acute care inpatient child and adolescent psychiatric unit from 2012 to 2014 were reviewed. A paired samples t test was performed to look for significant differences in sleep time 24 hours prior to S&R versus average sleep times for the same patients during hospitalization. A total of 232 S&R events occurred between 2012 and 2014. Of the incidents, 172 involved children who were ≤ 12 years old, and 178 incidents involved male patients. A paired sample t test revealed a significant mean (SD) decrease in sleep time prior to S&R (9.5 [2.24]) compared to average sleep time during hospitalization (10.07 [1.08], t₂₀₅ = -3.722, P < .01). The study results reveal a statistically significant reduction in sleep time 24 hours prior to an S&R event compared to average sleep duration during hospitalization. The association between sleep times and subsequent problem behaviors in an inpatient setting require further evaluation.

Predictors of Injury to Youth Associated with Physical Restraint in Residential Mental Health Treatment Centers

The restraining of children is a pervasive but controversial practice that has resulted in the injury and death of children. Despite this threat of harm, little research has explored what factors contribute to the risk of a child becoming injured during a restraint event. This study examined multiple child and restraint factors to better understand what predicts the injury of a child during a restraint event. Longitudinal data (794 youth, 13,339 restraint events) from six residential treatment centers in the Midwest were utilized to predict injury associated with restraint using nested hierarchical logistic regression models. Injuries to the child are a frequent outcome following the use of restraints on a child. Findings show that a child being male and older contributed to the likelihood of an injury, but the race of the child did not predict injury. In addition, three physical hold types—prone, supine, and settle—were associated with a greater likelihood of injury. Results suggest those who use restraints on children should reevaluate their behavior management plans to reduce their risk of hurting children by restraints. Eliminating or greatly reducing the use of prone, supine, and settle holds will likely lead to a drop in injuries of children.

Post-incident reviews\u2014a gift to the Ward or just another procedure? Care providers\u2019 experiences and considerations regarding post-incident reviews after restraint in mental health services. A qualitative study

Public guidelines in many western countries recommend post-incident reviews (PIRs) with patients after restraint use in mental health care. PIRs are one of several elements of seclusion and restraint reduction in internationally used programmes. PIRs may improve restraint prevention, patients’ recovery processes and care providers’ ethical mindfulness. The knowledge base on PIRs is, however, vague. This qualitative study explores professional care providers’ experiences and considerations regarding PIRs that included patients after restraint use in a Norwegian context.MethodsWithin a phenomenological hermeneutical framework, 19 multidisciplinary care providers were interviewed about their experiences and views regarding PIRs that included patients after restraint events. The interviews were performed over the period 2015–2016. Data analysis followed a data-driven stepwise approach in line with thematic content analysis. A group of two patient consultants in mental health services, and one patient’s next of kin, contributed with input regarding the interview guide and analysis process.ResultsCare providers experienced PIRs as having the potential to improve the quality of care through a) knowledge of other perspectives and solutions; b) increased ethical and professional awareness; and c) emotional and relational processing. However, the care providers considered that PIRs’ potential could be further exploited as they struggled to get hold on the patients’ voices in the encounter. The care providers considered that issue to be attributable to the patients’ conditions, the care providers’ safety and skills and the characteristics of institutional and cultural conditions.ConclusionHuman care philosophies and a framework of care ethics seem to be preconditions for promoting patients’ active participation in PIRs after restraints. Patients’ voices strengthen PIRs’ potential to improve care and may also contribute to restraint prevention. To minimise the power imbalance in PIRs, patients’ vulnerability, dependency and perceived dignity must be recognised. Patients’ individual needs and preferences should be assessed and mapped when planning PIRs, particularly regarding location, time and preferred participants. Care providers must receive training to strengthen their confidence in conducting PIRs in the best possible way. Patients’ experiences with PIRs should be explored, especially if participation by trusted family members, peers or advocates may support the patients in PIRs.

Nurses' and consumers' shared experiences of seclusion and restraint: A qualitative literature review.

Seclusion and restraint are coercive practices associated with physical and psychological harm. International bodies have called for an end to these practices. However, these practices continue to be used. Elimination programmes have had some success in reducing the rates of these practices. Understanding coercive practices through the perspectives of involved individuals may facilitate a complete cessation of seclusion and restraint from the practice. Therefore, this qualitative review explored how nurses and consumers experienced seclusion and restraint events in mental health care. Five databases were searched. The search strategy resulted in the inclusion of fourteen qualitative papers. A thematic analysis was used to synthesize the findings. Six themes emerged under three main categories; shared experiences: disruption in care, disruption in the therapeutic relationship and shared negative impacts; nurses' experiences: Absence of less coercive alternatives; and consumers' experiences: overpowered, humiliated and punished. Considering these experiences during planning for seclusion and restraint prevention might facilitate more effective implementation of seclusion and restraint elimination programmes. Our findings suggested that consumers should receive recovery-oriented, trauma-informed and consumer-centred care; while nurses should be better supported through personal, professional and organizational developmental strategies. Further research should focus on investigating shared interventions among consumers and nurses and exploring carers' experiences with coercive practices.

Effects of the Psychiatric Care Concept "Weddinger Modell" on Mechanical Coercive Measures

The aim of the present study was to analyze the effects of the implementation of the Recovery-orientated psychiatric care concept "Weddinger Modell" on mechanical coercive measures. A retrospective case-control study design was implemented, investigating 375 patients treated in in-patient care on three acute psychiatric wards who were selected at four different reporting dates. The study compared two groups of patients, one treated according to the Weddinger Modell (intervention group; n = 122) and the other one conventionally (control group; n = 235). The results show a significant reduction of the maximum frequency of restraint events as well as the duration of seclusion incidents in the group of patients treated according to the Weddinger Modell. In conclusion, the results indicate that the implementation of the Weddinger Modell and similar treatment concepts in inpatient psychiatric setting can help reduce coercion.

Nurses' perceptions of risks for occupational hazards in patient seclusion and restraint practices in psychiatric inpatient care: A focus group study.

Seclusion and restraint are regularly used to manage patient aggression events in psychiatric inpatient care, despite occupational safety concerns. There is currently a lack of information on how nurses perceive the use of patient seclusion and restraint as a risk for occupational safety. The aim of this study is to describe the risks for occupational hazards in patient seclusion and mechanical restraint practices as well as ideas for improvement identified by nurses. A qualitative descriptive design was adopted, using focus groups comprising nurses (N=32) working in psychiatric inpatient care. The data were analysed using inductive content analysis, and the results were reported using the consolidated criteria for reporting qualitative studies (COREQ). Four themes of risk for occupational hazards were identified: patient-induced, staff-induced, organization-induced, and environment-induced risks. One significant finding was that nurses described that their actions can strongly contribute to occupational hazards during seclusion and mechanical restraint practices. The nurses gave various ideas for how occupational safety could be improved during seclusion and mechanical restraint events, ideas involving staff, the organization, and environmental enhancements.