Use Of Chemical Restraints Research Articles

Emergency Psychiatry

Back to table of contents Previous article Next article Book ReviewsFull AccessEmergency PsychiatryDouglas H. Hughes, M.D.Douglas H. HughesSearch for more papers by this author, M.D.Published Online:1 Jul 2003https://doi.org/10.1176/appi.ps.54.7.1046AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail It is a testament to the coming of age of emergency psychiatry that a text of this caliber can be produced. Michael H. Allen, the editor of Emergency Psychiatry, assembled national experts in the field of emergency psychiatry to concisely write about the acute evaluation and care of psychiatric patients. This text, which is part of American Psychiatric Publishing's "Review of Psychiatry" series, will be valuable to both inpatient units and emergency services, because the topics it covers are germane to both. For example, the focus on managing patients' aggression is timely for both settings because of current efforts by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) to decrease the use of physical and chemical restraints. The authors provide a practical review of acute psychopharmacology and behavioral intervention techniques to assist the clinician in this endeavor.The text is divided into five chapters and is succinct. All the chapters are well written. In the first chapter, "Structure and Function of Psychiatric Emergency Services," Richard E. Breslow enumerates the multiple existing and evolving delivery models for emergency psychiatric care—consultation, specialized psychiatric services, crisis hospitalization, and mobile units. The staffing of these various models is also diverse. The second chapter, by Glenn W. Currier and coauthors, explores medical, psychiatric, and cognitive assessment in the psychiatric emergency service. The authors note the high incidence of comorbid medical illness among patients in the psychiatric emergency service—50 percent of the patients have major medical illnesses—and review the literature to determine how to best assess for these illnesses in the acute care setting. These authors also comment on the Accreditation Council on Graduate Medical Education's scant four-month general medical requirement for psychiatric residents, suggesting that residents may be poorly equipped to handle even routine medical problems.The book's final chapter, "Psychosocial Interventions in the Psychiatric Emergency Service: A Skills Approach," by Ronald C. Rosenberg and Kerry J. Sulkowicz, rather than offering a reductionistic view that presents the patient's out-of-control behaviors as a product of neurochemical processes, emphasizes the complexity of the patient's internal world, the importance of ongoing familial interactions, and the patient's accrued experiences and psychological processes. The authors offer several therapeutic models for working with these patients. They accurately portray the psychiatric emergency service environment and its limitations: "The milieu of the PES is noisy, with minimal privacy and overlapping staff roles that can be confusing to the patient. Referrals to the PES typically have a coercive component…. There is little time for the building of therapeutic relationships; nor is there always consistency of approach among staff…nevertheless, …some aspect of virtually every therapeutic approach can be useful in the PES, particularly if the clinician remains flexible and has modest goals."Given the current prominence of emergency psychiatry, it is easy to forget that this field is still in its infancy; nearly all its founders are still vital and productive. Emergency Psychiatry will serve as valuable documentation of the current state of the field for those of us who are employed by inpatient units, psychiatric emergency services, and medical emergency departments.Dr. Hughes is vice-chair in the department of psychiatry of Boston Medical Center.edited by Michael H. Allen, M.D.; Washington, D.C., American Psychiatric Publishing, Inc., 2002, 216 pages, $31.95 softcover FiguresReferencesCited byDetailsCited byNone Volume 54Issue 7 July 2003Pages 1046-1047 Metrics History Published online 1 July 2003 Published in print 1 July 2003

A prospective study of the complication rate of use of patient restraint in the emergency department

Patients are frequently involuntarily, physically restrained in the emergency department (ED). The purpose of this study was to determine the type and rate of complications experienced by patients physically restrained in the ED. A prospective, observational study was performed on consecutive patients who were restrained in a community, inner-city teaching hospital ED for a 1-year period. The ED nurses or physicians completed a restraint study checklist. The checklist included the reasons for restraints, restraint duration, method and number of restraints, use of chemical restraint, and complications resulting from the use of restraints. The 298 patients were accumulated during a 1-year period. The mean age was 36.5 years (range 14–89). Sixty-eight percent were men; 73% were African-Americans, 16% Hispanic, and 11% Caucasian. One hundred six patients had more than one indication for patient restraint. Patients were restrained for a mean of 4.8 h (range 0.2–25.0 h), with psychosis being the most frequent discharge diagnosis (33%). Patients were most frequently restrained on a cart with two restraints (59%), in the supine position (86%), and 27.5% had chemical restraint added. There were 20 complications (7%); getting out of restraints was the most common (10) and the remainder included vomiting (3), injured others (2), spitting (2), injured self (1), increased agitation (1), and other (1). These complications were not correlated with age, gender, race, number of restraints, use of chemical restraint, diagnosis, or duration of restraint. This study demonstrates a low rate of minor complications. We found that male patients were most often restrained for violent and disruptive behavior. Most commonly, two restraints were used in combination with chemical restraints for a duration of almost 5 h.

Improving outcomes requires more, not less, from psychology.

Over the past 15 years, many public and private providers of inpatient psychiatric services have reduced the availability and sophistication of psychological and behavioral interventions while the concentration of people with comorbid psychiatric and behavior disturbances has increased. This has resulted in a move away from providing direct treatment of behavior dysfunction and an increase in the use of high dosages of psychoactive medications, leading in many cases to unnecessary chemical restraints, mechanical restraints, and seclusion (see Hunter, 1995; Hunter, 1999; Hunter, 2000). ********** An overdependence on neurobiological and biochemical theories of mental disorders, a society oriented to quick-fix medical and chemical solutions to complex problems (Hunter, 2000), and beliefs advanced by the massive promotion of by the pharmaceutical industry (Valenstein, 1998; Glenmullen, 2000) have contributed to restricted case formulation strategies that have been described as little more than drugs and TV therapy (Hunter, 1999; Hunter, 2000). These limited case formulation strategies have resulted in poor outcomes and increases in restrictive and coercive interventions. Deaths and other adverse reactions from, often unnecessary, restraints and seclusion have led to action by Congress and several public and private organizations (e.g., HCFA, DOJ, JCAHO, SAMSHA). During 1999 and 2000 there was much legislative activity on Capitol Hill attempting to regulate the use of restraints and seclusion. Numerous bills and legislative proposals, at one time or another, contained language that would have eliminated many psychological and behavioral interventions (e.g., Time-Out, hand-over-hand guidance, graduated guidance, redirection) and excluded psychologists from providing the necessary leadership for case formulation decisions, writing orders, or training and directing staff in implementing appropriate psychological and behavioral interventions. The American Psychological Association's Practice Directorate took an active role in advocating for appropriate inclusion of psychologists and attempted to protect psychological interventions when they were unintentionally (or intentionally) impacted by various definitions of terms. For example, the wording in several definitions of seclusion would have impacted the procedure Time-Out in a way that in order to use Time-Out, the behavior would have had to rise to the level of imminent dangerousness. In September 2000 the restraint and seclusion language of various bills and amendments were rolled into the Children's Health Act of 2000 (HR 4365), which passed the Senate on September 22nd and the House on September 27, 2000. President Clinton signed the bill into law on October 17th. This law, although not entirely written as APA or its consultants would have preferred, contained language allowing for physicians or other licensed practitioners (psychologists) to write seclusion or restraint orders, required staff of facilities using restraints or seclusion to train staff in alternatives to the use of these restrictive procedures, exempted Time-Out from the definition of seclusion, attempted to limit the use of chemical restraints, and exempted physical escort from the restraint stipulations. Prior to the legislative activity in 1999 and 2000 resulting from the reports of deaths from restraints and seclusion, HCFA was revising its children's residential facility regulations. After HR 4365 passed, HCFA completed its revisions on its RTF

The use of physical and chemical restraints in the pediatric emergency department.

Restraining patients is potentially dangerous and should be viewed as a last resort, to be used when no other modality of care is sufficient or when other efforts to calm the patient have been exhausted. Protocols and staff training are essential to limit inappropriate use of restraints and to protect both the patient and staff. Further clinical studies are needed in the area of chemical restraint of children and to evaluate the safety and efficacy of different methods of physical restraint.

Redesign in the Long-Term Care Industry: A Restraint Reduction or Restraint Elimination Program in the Nursing Home

The Nursing Home Reform Act of 1987 required nursing homes in the United States to modify their use of physical and chemical restraints in the provision of care to the residents. Nursing home staff members can restrain only if a medical professional determines that they must temporarily restrain residents in order to provide care for them. The author employs the Kast and Rosenzweig model of systems theory to describe the approaches that nursing homes have taken to implement a restraint-free or restraint-elimination program. He then describes the benefits that residents and staff members receive when they participate in a restraint-reduction of restraint-elimination program.

Emergency psychiatry: physical and chemical restraint in the psychiatric emergency service.

In recent years we have witnessed a markedly increased sensitivity to the potential for abuse of the socalled police powers of physicians. The criteria for involuntary admission have shifted from a treatment model to a dangerousness model, while the philosophical shift toward treatment in the least restrictive setting has been accelerated by hard economic reality. Between 1970 and 1994, the number of episodes of psychiatric care more than doubled, while the number of inpatient beds was cut by more than half (1). Payment for psychiatric hospital care has also become entwined with dangerousness. Lack of access may now be more of a rights issue than is deprivation of liberty. Consequently, the concentration of aggressive patients in the hospital has risen (2), and hospitals have become increasingly dangerous places. Concern has also heightened about violence committed by mentally ill persons in the community. Emergency services are an increasingly important component in a process with very serious consequences for the consumer and the community. In this complex situation where emergency mental health professionals are asked to weigh a number of clinical, legal, and economic issues, debate now arises about the use of physical and chemical restraint or seclusion. Although restraint may well be justifiable in many instances in the psychiatric emergency service, its ultimate value remains unclear. In an extensive review of the literature, Fisher (3) underscored the utility and clinical efficacy of restraint and seclusion in maintaining patient and staff safety in a variety of psychiatric treatment settings. However, that review and others also convincingly point to deleterious effects of restraint and seclusion on patients, who perceive them to be coercive and traumatic (4,5). Early scrutiny of use of restraint in

Managing aggressive psychotic patients

Back to table of contents Previous article Next article LetterFull AccessManaging Aggressive Psychotic PatientsDouglas H. Hughes, M.D.Douglas H. HughesSearch for more papers by this author, M.D.Published Online:1 Mar 2000https://doi.org/10.1176/appi.ps.51.3.391-bAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: I thank Drs. Fichtner, Durgin, and Chacko for their interesting comments on my article. Dr. Fichtner raises the conceptual question of the use of chemical restraints. I agree with his comments and do not have a clear answer to this escalating debate. Clinically, the use of pyschopharmacological interventions cannot be equated with chemical restraints. When restraints are needed, I recommend physical restraints. Once the patient is in restraints, medications may be required to treat and manage the patient safely. However, other clinicians may view my definitions as only semantic distinctions. As Dr. Fichtner mentions, the issue of chemical restraints is increasingly being tested in public policies and legal forums.Concerning Dr. Durgin's comments, I agree that intramuscular preparations generally do reach their peak concentrations sooner than oral medications and hence have a more rapid onset of action. However, achieving optimal antipsychotic properties of all neuroleptic drugs requires one to three weeks, which of course is not possible in the emergency situation. The sedative (muscarinic) effect of the neuroleptic medication occurs much more rapidly and is clinically relevant in an emergency. Rapid tranquilization can be safely and quickly achieved by using higher doses of benzodiazepines intramuscularly alone or in combination with neuroleptic medication. In the chaser approach, neuroleptic medications are not used to sedate, so oral administration is not an issue. The benefit of this approach may be improved neuroleptic compliance.Dr. Chacko questions my recommendation for using cogentin to treat akathisia. Most experts would agree that lowering the dose of the neuroleptic medication could relieve the symptoms, though the effect is not immediate. Acute relief is often attempted by employing one of the following medications: anticholinergic drugs, beta blockers, or benzodiazepines. Dr. Chacko may be referring to the Schatzberg and Nemeroff text (1) that recommends benzodiazepines and propranolol, as opposed to cogentin, for the treatment of akathisia. Yet in the same textbook Stanilla and Simpson (2) recommend trying anticholinergic agents before using benzodiazepines or beta blockers. Researchers vary on their recommendations (3), and others see these agents as equivalent (4).

The use of chemical restraint in helicopter transport

Introduction: Helicopter transport of the combative patient is a major safety hazard facing air medical teams. Although physical restraints alone are helpful, the addition of chemical restraint (CR) often is necessary to control these patients while in flight. Methods: A survey was conducted to determine the current practices of using nonparalyzing CR in air medical transport programs nationwide. The survey consisted of 24 questions on the use of CR during transport. Each U.S. program belonging to the Association of Air Medical Services was contacted by telephone, and a flight nurse or paramedic provided answers based on personal experience and statistics compiled by his or her individual program. Results: Of the 100 programs responding, benzodiazepines were used most commonly to control agitation with 51% using midazolam. Patients with a head injury required CR more frequently than any other condition (73%). Crews flying larger aircraft reported less need for CR. A physician order was required by only 30% of the programs, but delays infrequently endangered the patient (2%). Only 7% of the responding programs had a patient whose condition deteriorated because of CR. Conclusion: CR is necessary in air medical transport. Most programs use short-acting benzodiazepines. Crews in smaller aircraft use CR more frequently, and head injury is the most common condition requiring such restraint.

Nurses' perceptions of chemical restraint use in long-term care

The purpose of this pilot study is to validate the use of the Perceptions of Restraint Use Questionnaire (PRUQ) in assessing chemical restraint perceptions among nurses working in long-term care. The convenience sample includes 60 licensed nurses working in six long-term care facilities in Illinois. The reliability analysis for a modified version of the PRUQ, based on the research sample chosen, was found to have a Cronbach's coefficient alpha of .9450. Study findings reflect a moderately positive attitude toward chemical restraint use by nurses in long-term care.

An exploratory account of registered nurses' experience of patient aggression in both mental health and general nursing settings.

Until relatively recently, aggression and violence in nursing has been an area of little discussion (Poster & Ryan 1993). Today, concerns are rising about escalating levels of violence towards nurses (Wykes 1994, Whittington 1997). In response, this paper explores registered nurses' experiences of patient aggression encountered in the acute inpatient general and mental health settings. Critical incidents from registered nurses in both areas are examined and analyzed in relation to existing literature. The aim of the research is to ascertain if differences exist or similarities prevail. Findings reveal that the two areas have similar problems in terms of types of aggression. Verbal and 'minor' types of aggression are the most problematic. Also, the 'biomedical model' of care is evident in both settings and possibly underpins chosen approaches to aggression management. The repeated use of chemical and physical restraint is apparent. The main comparison identified between the two groups relates to nursing control over situations involving violent patients. Mental health nurses seem to consistently take control of aggressive situations whilst general nurses tend to rely more heavily upon the input of others (medical staff, mental health teams and the police) when intervening. These two nursing specialties therefore have much to learn from each other in terms of nursing experience and possible future approaches to the management of aggressive patients.

The effect of natural environments upon agitation and aggression in late stage dementia patients

Agitated aggressive behavior in late stage dementia occurs in 30 to 50 percent of patients. This behavior often results in the use of chemical and physical restraints (which have a high degree of untoward side effects) and caregiver burnout. Interventions for agitated aggressive behavior are needed that do not have these side effects, which are readily available in nursing homes and are effective and acceptable to caregivers. Environmental psychologists have proposed that natural elements within the environment decrease agitation in the nondemented as well as the demented Since the shower bath is often a time of great agitation in dementia patients, natural elements were used to modify care during the shower bath (n = 31). There was a significant decrease in mean difference scores from baseline to treatments one and two, with the treatment group demonstrating an overall decline in agitated aggressive behavior Additional randomized trials of the effects of natural environments upon agitation and aggression in dementia are needed.

The use of restraint in the care of elderly patients.

The use of physical and chemical restraint in elderly care settings to restrict mobility and control behaviour is not a new concept. However, until the 1980s, it was an area that was neglected in nursing research. In 1989, Evans and Strumpf carried out an extensive literature review on restraint in an attempt to consolidate the state of knowledge regarding its use in care of the elderly settings. This article aims to evaluate how far the discussion surrounding restraint has progressed since that time and in what direction. It also reviews the extent of restraint use and rationale for its application, the consequences of restraint and progress in developing alternatives.

Physical aggressive resident behavior during hygienic care.

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

Clinical techniques in rabbits

Rabbits are very popular house pets and they require the same level of veterinary care as the canine or feline patient. It is often necessary to perform a variety of clinical procedures for both routine preventative care and when attempting to diagnose and treat illness in these patients. Many practitioners are wary of handling rabbits and attempting these procedures due to their fragile nature. However, armed with a good understanding of the rabbit's behavior and physical limitations and with the use of appropriate manual or chemical restraint, the veterinarian can accomplish necessary clinical procedures without harm to the patient.

Clinical techniques in domestic ferrets

The popularity of the domestic ferret has increased dramatically over the past 5 years in the United States. In addition, the ferret has become a legal pet in all but a few locations. Ferrets are prone to a variety of diseases, particularly as they age, with neoplasia being the most commonly encountered. Routine and frequent veterinary attention is often necessary to manage disease in these patients. Because of the ferret's historical reputation for being vicious and hard to handle, many veterinarians are reluctant to see these pets in their practice. Fortunately, domestic ferrets are docile and easy to handle animals that make excellent patients due to their stoic nature and natural tenacity. With an understanding of ferret behavior and the use of appropriate manual or chemical restraint, the veterinary practitioner can perform most clinical procedures in this species with ease.

Appropriate Use of Chemical and Physical Restraints With Elderly Nursing Home Residents

This article describes the history and practice of using restraints (chemical and physical) in elderly nursing home residents, and the effect of the new Omnibus Budget Reconciliation Act regulations affecting these practices. Copyright © 1996 by W.B. Saunders Company

Behavioral management of agitation in the traumatically brain-injured person

This paper outlines general management strategies used to prevent and control agitation throughout the continuum of recovery from traumatic brain injury. These include environmental management, alterations in the behavior of staff and family, use of physical and chemical restraints, redirection and substitution, time out, operant procedures, self monitoring and relaxation training. The need for both flexibility in choice of strategies and consistency in application is emphasized, along with the importance of staff training and patient and family participation.

Innovations in dementia care.

Creating a homelike environment in an institutional setting that caters for dementia sufferers requires flexibility, understand and insight. A homelike environment frequently only addresses the physical appearance of the facility without over considering what was homelike for the resident prior to coming into care. The use of chemical and mechanical restraints to overcome adverse behaviour has been the accepted norm in many nursing homes without consideration being given to the diverse effects of these management tools. The use of the clinical type setting for routines and policies has been in place for many years, yet it is these very routines that have been found to cause the most distress to dementia sufferers. The challenge of change is the greatest reason for maintaining the status quo but change can bring its rewards with the improved quality of life experienced by those residents who lived in a nursing home. This paper describes a programme that addresses the advantages of changing the environment for dementia sufferers and demonstrates that an improved quality of life can be achieved by removing the need for chemical and mechanical restraints.

Omnibus Budget Reconciliation Act of 1987 and Its Implications for the Medical Director

The nursing home reform amendments passed by Congress in 1987 (known as OBRA 87) have several sections that are relevant to medical practice and medical direction in the nursing home. The regulations and interpretive guides specify the medical director's role, physician services, resident assessments, resident rights, and restrictions on the use of chemical and physical restraints. This article provides the nursing home attending physician and medical director with basic information to help bring medical services into regulatory compliance.

SPECIAL CARE UNITS Meeting the Needs of Cognitively Impaired Persons

1. Alzheimer's disease (AD) is the fourth leading cause of death of older persons. Families frequently turn to nursing homes to provide the care that they are unable to provide during the later stages of the disease. 2. Sloane and Mathew concluded that special care units resulted in better care based on appearance, little difference in weight loss, similar range of services to traditional units, higher amount of interaction with residents more often out of their room, greater mobility, fewer medications, less physical restraint, and similar use of chemical restraints. 3. Alzheimer's disease does not affect an individual only; it affects a family. Effective programming includes the family. From the initial contact with the institution through placement on the special care unit--and often beyond the death of the resident--families are supported by the staff.