Mechanical and pharmacological restraints in acute psychiatric wards—Why and how are they used?

Restraint use has been reported to be common in acute psychiatry, but empirical research is scarce concerning why and how restraints are used. This study analysed data from patients' first episodes of restraint in three acute psychiatric wards during a 2-year study period. Logistic regression analyses were used to identify predictors for type and duration of restraint. The distribution of restraint categories for the 371 restrained patients was as follows: mechanical restraint, 47.2%; mechanical and pharmacological restraint together, 35.3%; and pharmacological restraint, 17.5%. The most commonly reported reason for restraint was assault (occurred or imminent). It increased the likelihood of resulting in concomitant pharmacological restraint. Female patients had shorter duration of mechanical restraint than men. Age above 49 and female gender increased the likelihood of pharmacological versus mechanical restraint, whereas being restrained due to assault weakened this association. Episodes with mechanical restraint and coinciding pharmacological restraint lasted longer than mechanical restraint used separately, and were less common among patients with a personality disorder. Diagnoses, age and reason for restraint independently increased the likelihood for being subjected to specific types of restraint. Female gender predicted type of restraint and duration of episodes.     

Length of time spent in seclusion and restraint by patients at 82 VA medical centers.

Analysis of data from 82 Veterans Affairs medical centers showed that during a one-year period in 1987-88, VA psychiatric inpatients spent about 240,000 hours in seclusion or restraint, with about half of that time in mechanical restraints. The median length of time patients in each medical center spent in seclusion and restraint was used to classify centers as having "higher" or "usual" rates of use of those techniques. In the 20 centers classified as higher users, patients spent two to three times longer in seclusion and restraint per incident than patients in the 62 centers classified as usual users. Time spent by patients in seclusion and restraint in centers with usual rates of use was consistent with reports from other U.S. studies. The longer time in seclusion and restraint per incident in higher-user centers may be due to characteristics of the medical center or of the patient population.     

Prevalence and Precursors of the use of Restraint and Seclusion in a Private Psychiatric Hospital: Comparison of Child and Adolescent Patients

The use of restraint and seclusion is highly regulated in psychiatric inpatient settings. However, the majority of studies of restraint and seclusion are based on public hospitals serving adult patients, with some limited data available on adolescents and children. This paper presents prospectively collected data on restraint and seclusion over a 2-year period at a private psychiatric hospital whose patients include large numbers of both adolescents and pre-adolescent children. 2 years of restraint and seclusion data were analyzed on a total of 2,411 unique patients. Types of seclusion included in-room seclusion on the treatment unit and off-unit seclusion in a separate seclusion annex. Restraints consisted solely of short term (<15 min) and longer term (>14 min) manual restraints. The use of IM medication was also recorded. The precipitants of these events were examined. These included physical and verbal threats, stabbing or throwing objects, attempts to elope, attempts to hurt one’s self or another, or property destruction. Out of 2,411 child and adolescent in-patients admitted during the period under review, only 703 (29%) experienced restraint or seclusion. Among these, the modal number of events per patient was one (n = 156), but the maximum number of occurrences was 163. Child patients had a much higher frequency of events (n = 396, 53%) than adolescents (n = 307, 19%). There were notable differences in the types of seclusion events, with children typically experiencing in-room seclusion on the unit. When age was examined as a continuous variable, younger patients had a higher prevalence of restraint and seclusion, significantly more restraint and seclusion, and these restraint and seclusion events were significantly shorter than those seen in older patients. Multiple other potential determinants of these events were examined, including diagnosis, symptom severity at admission, age, and gender, but none of these predicted these events. Restraint and seclusion events were more common for children and less so for adolescents, with robust age effects for the likelihood of any seclusions, the number of seclusions and restraints, and the duration of seclusions and restraints. Patients who experienced restraint or seclusion typically required it only once during their hospitalization. Only age was found to be a predictor of the restraint and seclusion variables. Given these findings, it appears that management of agitated behavior in children and adolescents may be a qualitatively different phenomenon. Future research should be directed at understanding the determinants of high frequency agitated behavior and developing alternatives to seclusion or restraint.     

Use of holding,restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment

The aim of the study was to analyse the use of holding, restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment in Finland. The study included 504 child and adolescent psychiatric in-patients in the year 2000. Time-out had been used for 28 %, holding for 26 %, seclusion for 8 %, and mechanical restraints for 4 % of the in-patients. In multivariate analysis, aggressive acts were the strongest factor associated with all kinds of restraint practices. Psychosis, suicidal acts and older age (13–18 years) were associated with seclusion and mechanical restraints. Younger age (< 13 years), attachment disorder and autism were associated with holding. The longer children had been in treatment, the more likely they were to have been restrained. The high prevalence of restraint techniques used indicates a need for guidelines of restraint and seclusion which take into account the child's need for protection from his/her own impulses and the legal rights of the child. Accepted: 22 February 2002 Correspondence to: A. Sourander     

Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review

Seclusion and restraint are frequent procedures to intervene in aggressive and potentially dangerous patients in psychiatric settings. However, little is known about their utilization and effectiveness in pediatric populations. We aimed to examine the prevalence and determinants of seclusion and restraint utilization in children and adolescents in psychiatric settings. Using PubMed, PsychInfo and Cinahl, we performed a systematic literature review of studies published in the last 10 years reporting on the prevalence of seclusion and restraint use in psychiatrically ill youth (<21 years old) treated in psychiatric settings. Only seven publications addressed the topic. Primary outcomes were prevalence rates, reported either as the proportion of patients restrained/secluded or as the number of restraints/seclusions per number of patient days. All studies found relatively high baseline rates of seclusion (26% of patients; 67/1,000 patient days), and restraints (29% of patients; 42.7/1,000 patient days). In four studies, an intervention, implemented to reduce seclusion and restraints, resulted in a dramatic weighted mean reduction in the more restrictive use of restraints by 93.2%, with a 54.2% shorter duration. There was a small, weighted mean reduction in the use of less restrictive seclusions (−0.6%), but results were heterogeneous (−97.2 to +71.0%), with the only increase in seclusions being reported in one study in which the intervention-based padded seclusion room was utilized more frequently instead of more restrictive measures. Otherwise, seclusion episodes reduced by 74.7%, including a 32.4% shorter duration. Few studies reported on risk-factors and predictors, consisting of past or current aggression and/or violence, suicidal behavior, more severe psychopathology, non-White ethnicity, emergency admissions, out-of-home placement, and poorer family functioning, while findings regarding age were inconsistent Except for duration, data about the effectiveness of seclusion and restraints were missing, although there is some indication that seclusion and restraints can lead to severe psychological and physical consequences. Future research should focus on indications, predictors, preventive and alternative strategies, as well as on clinical outcomes of seclusion and restraints in psychiatrically ill youth. In addition, there is a clear need for transparent policies and guidelines.     

Use of constraints and their correlates in Norwegian nursing homes

OBJECTIVE: To analyse the effect of patient and ward characteristics on the use of constraints in nursing homes. METHOD: Primary carers in 222 wards in Norwegian nursing homes were asked about use of constraints towards 1926 patients during seven days. Constraints were grouped as mechanical restraints, non-mechanical restraints, electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in ADL. The patients' mental capacity (CDR score), activity in daily living (ADL) and behaviour (BARS score) were rated. Type and size of ward, staffing level and educational level of the staff was recorded. RESULTS: In all 758 of the patients were subjected to any constraint. Degree of dementia, aggressive behaviour and loss of function in ADL had significant impact on all types of constraint except for electronical surveillance. The strongest associations were found between degree of dementia and mechanical restraint (OR 5.14), impaired ADL and mechanical restraint (OR 9.23) and aggression and force or pressure in ADL (OR 3.75). Mechanical restraint was less used towards patients in special care units for persons with dementia (SCU) (OR 0.38) compared to patients in regular units (RU), whereas non-mechanical restraint was more frequent used in SCUs (OR 2.28). Type of ward had no significant impact on use of other types of constraints. Staff level and education level of the staff had no significant impact on the use of constraint. CONCLUSION: Constraint is frequently used in nursing homes, and most frequent toward patients with severe dementia, aggressive behaviour or low ADL function.     

Managing Treatment Resistant Violent Adolescents: A Step Forward by Substituting Seclusion for Mechanical Restraint?

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint. Dr. Kraus is now a full-time employee of GlaxoSmithKline.     

Reducing patient restraints: a pilot approach using clinical case review

PURPOSE. This study aims to reduce the incidents of restraints by applying a nontraditional consultation process in which a university-based team focused on patient consultations to collect data on treatment interventions and milieu approaches and conditions, as well as staff interactions. CONCLUSIONS. The efforts resulted in restraint reduction from 36 episodes per month to 0 episodes per month as well as precipitating a change in unit climate and care approaches on a specialized unit for patients with developmental disabilities and mental illness. PRACTICE IMPLICATIONS. Reducing the use of restraints involving multiple restraint incident patients is possible with a team-based approach and a specific intervention plan.     

Reduction of restraint of people with intellectual disabilities: an organizational behavior management (OBM) approach

We used an organizational behavior management (OBM) approach to increase behavior intervention plans and decrease the use of mechanical restraint. First, recipients were tracked as a member of the priority group if they engaged in frequent self-injurious behavior or physical aggression toward others and/or if they had been placed in mechanical restraint as a result of the problem behaviors. Second, a behavior data monitoring and feedback system was put in place. Third, organizational contingencies for the use of mechanical restraint or the occurrence of frequent self-injurious behavior or physical aggression toward others were initiated. Over the course of 17 months, behavior intervention plans were more than doubled to 124 and mechanical restraints decreased by almost 80%. This study represents the first to use an organizational behavior management (OBM) to reduce restraint with people who have intellectual disabilities.     

Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review

PURPOSE: To identify interventions preventing mechanical restraints. DESIGN AND METHODS: Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention. FINDINGS: Implementation of cognitive milieu therapy, combined interventions, and patient‐centered care were the three interventions most likely to reduce the number of mechanical restraints. PRACTICE IMPLICATIONS: There is a lack of high‐quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.     

The Impact of ‘Being There’: Psychiatric Staff Attitudes on the Use of Restraint

The practice of mechanically restraining psychiatric patients is constantly under debate, and staff attitudes are considered a central factor influencing restraining practices. The aim of this study was to explore associations between psychiatric staff members’ presence and participation in incidences of restraint and attitudes towards mechanical restraints. Methods: Staff members (psychiatrists, nurses, paramedical staff; N = 143 working in a government psychiatric hospital in Israel) completed a questionnaire including personal information, participation in incidents of restraint and attitudes towards mechanical restraints. Items were categorized into the following categories: security and care; humiliation and offending; control; order; education and punishment. Results: Compared to those who were not present during restraint, staff members who were present agreed significantly less with statements indicating that restraints are humiliating and offending and agreed more with statements indicating that restraints are used primarily for security and care (p < .05). Among those present in incidences of restraint, staff members who physically participated in restraint agreed significantly more with statements indicating that restraints are a means for security, care and order, and less with statements indicating restraints are humiliating and offending, compared to those present but not physically participating in restraint (p < .05). Conclusions: These findings highlight the importance of proximity of staff members to incidences of restraints. This may have implications in understanding the professional and social discourse concerning mechanical restraints.     

Beyond emergencies: the use of physical restraints in medical and psychiatric settings

Physical restraints, such as locked-door seclusion and two- or four-point leather restraints, are frequently used in both the medical and psychiatric settings. Efforts are currently under way to reduce the use of physical restraints in psychiatric settings; various institutional, state, and federal policies are place. However, using these same restraints in the context of providing medical care for psychiatric patients is more complicated, as it is uncertain which principles and regulations apply in a particular setting. For example, is the restraint governed by the policies that regulate the psychiatric application of restraints, by those that regulate the medical application of restraints, or by both? This article reviews the principles and regulations governing the use of restraints on psychiatric patients, with specific attention to the use of restraints in providing medical treatment to that patient population. Also addressed are general principles of risk management to help avoid negative outcomes and to reduce the risk of litigation for unauthorized or unlawful restraint. A case example is used to illustrate these concepts.     

Physical restraints in an Italian psychiatric ward: clinical reasons and staff organization problems

PURPOSE: To analyze physical restraint use in an Italian acute psychiatric ward, where mechanical restraint by belt is highly discouraged but allowed. DESIGN AND METHODS: Data were retrospectively collected from medical and nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint rate and relationships between restraints and selected variables were statistically analyzed. FINDINGS: Restraints were statistically significantly more frequent in compulsory or voluntary admissions of patients with an altered state of consciousness, at night, to control aggressive behavior, and in patients with “Schizophrenia and other Psychotic Disorders” during the first 72 hr of hospitalization. PRACTICAL IMPLICATIONS: Analysis of clinical and organizational factors conditioning restraints may limit its use.     

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.     

ECT as a form of restraint

ECT is controversial as a form of therapy, with lay and psychiatric objectors. Restraint is also controversial, though often necessary. The Ontario Mental Health Act of 1978 allows the psychiatrist to restrain patients without consent if there is risk of physical danger. The act mentions "chemical and mechanical" means. ECT is not dealt with as a form of restraint. A case is described of a manic male who during 2 episodes of psychosis presented a serious threat of assault to staff. The next of kin was reluctant to sign consent for "treatment" because of fear of the patient's later resentment. An application to the Review Board for permission to treat would have taken a week. On both occasions attempts to control the patient with chemotherapy were totally unsuccessful despite the use of rapid neuroleptization, paraldehyde, barbiturates and mechanical restraints. In both admissions 4 ECT given over 2 days produced rapid behavioural control. ECT was then discontinued because the patient declined to give consent for ECT as treatment and he no longer presented a threat. Medical and legal consultation were necessary and the consensus was that ECT as restraint may be justified on the basis of clinical judgment. In such cases ECT is safer, more reliable and more humane than chemotherapy or mechanical restraints. The authors discuss the current public and professional antipathy towards ECT. There is risk of death for the patient in circumstances where legal barriers prevent the appropriate use of electro-shock and a U.S. case is mentioned.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of staff training on the use of restraint in dementia: a single-blind randomised controlled trial

BACKGROUND: Use of restraint amongst institutionalised elderly with dementia and problem behaviour not only remains widespread, but also appears to be accepted as inevitable. OBJECTIVE: The aim of this study was to reduce problem behaviour and the use of restraint in demented patients using a staff training program as intervention. METHODS: The study was a randomised single-blind controlled trial and took place in Stavanger, Norway. Four nursing homes were randomised to a control or an intervention group after stratification for size. The intervention consisted of a full day seminar, followed by a one-hour session of guidance per month over six months. The content of the educational program focused on the decision making process in the use of restraint and alternatives to restraint consistent with professional practice and quality care. The primary outcome measures were number of restraints per patient in the nursing homes in one week and agitation as measured with the Brief Agitation Rating Scale (BARS). These were rated before and immediately after the intervention was completed. The assessments were performed blind to design and randomisation group. RESULTS: Clinical and demographic variables did not differ between the intervention and control groups at baseline. After the intervention period, the number of restraints had declined by 54% in the treatment group, and increased by 18% in the control group. The difference between the two groups was statistically significant ( p = 0.013). There was a trend towards higher BARS score in the intervention compared to the control group at follow up ( p = 0.052). CONCLUSION: Although the level of agitated behaviour remained unchanged or increased slightly, the educational program led to a significant reduction of the use of restraint in institutionalised elderly with dementia. These results suggest that educational programs can improve the quality of care of people with dementia.     

eLearning course may shorten the duration of mechanical restraint among psychiatric inpatients: A cluster-randomized trial

Abstract

Background: The management of psychiatric inpatients exhibiting severely disturbed and aggressive behaviour is an important educational topic. Well structured, IT-based educational programmes (eLearning) often ensure quality and may make training more affordable and accessible. Aims: The aim of this study was to explore the impact of an eLearning course for personnel on the rates and duration of seclusion and mechanical restraint among psychiatric inpatients. Methods: In a cluster-randomized intervention trial, the nursing personnel on 10 wards were randomly assigned to eLearning (intervention) or training-as-usual (control) groups. The eLearning course comprised six modules with specific topics (legal and ethical issues, behaviour-related factors, therapeutic relationship and self-awareness, teamwork and integrating knowledge with practice) and specific learning methods. The rates (incidents per 1000 occupied bed days) and durations of the coercion incidents were examined before and after the course. Results: A total of 1283 coercion incidents (1143 seclusions [89%] and 140 incidents involving the use of mechanical restraints [11%]) were recorded on the study wards during the data collection period. On the intervention wards, there were no statistically significant changes in the rates of seclusion and mechanical restraint. However, the duration of incidents involving mechanical restraints shortened from 36.0 to 4.0 h (median) (P < 0.001). No statistically significant changes occurred on the control wards. Conclusions: After our eLearning course, the duration of incidents involving the use of mechanical restraints decreased. However, more studies are needed to ensure that the content of the course focuses on the most important factors associated with the seclusion-related elements. The eLearning course deserves further development and further studies. The duration of coercion incidents merits attention in future research.     

Restraint, seclusion, and clozapine.

BACKGROUND: The effects of clozapine, an unconventional neuroleptic drug, on the use of restraint and seclusion in patients have not been extensively reported on in the United States. METHOD: The records of 107 patients receiving clozapine in Missouri state mental hospitals were reviewed over a 13-month period for frequency and duration of restraint and seclusion. RESULTS: During clozapine treatment, patients had fewer episodes of restraint and seclusion than previously. The duration of restraints and seclusions also decreased, starting the second month after the initiation of clozapine treatment. CONCLUSION: For patients who were restrained or secluded before clozapine treatment, the decrease in the number and duration of restraint and seclusion episodes was dramatic.     

A quasi-experimental study on the effect of electrical aversion treatment on imposed mechanical restraint for severe self-injurious behavior

Eight individuals with mental retardation and imposed mechanical restraints due to severe, life-threatening self-injurious behavior received electrical aversive treatment. Eight other individuals, who had been matched with the treatment group in terms of the degree of imposed mechanical restraint due to the above problem behavior, had not received electrical aversion treatment. A comparison of imposed mechanical restraint scores, as a measure of severity of self-injurious behavior, between both groups over a period of three years, revealed that electrical aversion treatment significantly reduces the degree of imposed mechanical restraint.