Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department

Abstract

Introduction

The use of restraints to manage patients in the emergency department (ED) is controversial. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) and numerous advocacy groups have pushed for the use of alternatives to restraints. The need to protect the patients' rights while also reducing the risks they may pose to themselves, other patients, and medical staff is difficult to balance. The purpose of this study was to assess which agitation reduction techniques, if any, are used prior to restraints in the ED as recommended by the JCAHO. The second purpose was to determine the reasons for differing levels of usage and/or compliance with the JCAHO recommendations.

Methods

A survey tool was developed to include the new restraint and seclusion standards from Joint JCAHO. It was sent to a random sample of the EDs from a randomized list of hospitals in the United States and to all psychiatric EDs from the American Association for Emergency Psychiatrists (AAEP). A mailed survey allowed for institutions to review their yearly census for the information to questions. The survey included questions on the use of agitation reduction techniques, what are those methods, what methods are most effective for ED doctors, has staff received training in how and when to use those methods, and reasons why they do or do not use them in the ED. The study was IRB approved as exempt.

Results

A 40% response rate was obtained overall (391 out of 960). The majority, 70%, of general ED have no psychiatric unit vs. 87% of specialized EDs having a unit attached. The overwhelming majority of both, at 90% to 98%, do use alternatives to restraints prior to restraints. When restraints are used, 30% used physical and 30% used physical and chemical restraints combined. A management protocol is in place at 90% of the institutions to use alternative first and 76% of the staff is educated on the use of alternative methods. The methods in order of popularity are verbal interventions at 84%, one-to-one at 79%, decrease in stimulation at 74%, and food or drink at 69%. The rating of the effectiveness of those methods is low, with the following percentages feeling that the respective techniques were effective: one-to-one, less than 48%; verbal intervention, 36%; decreasing stimulation, 15%; and food or drink, 18%. However, 61% feel that chemical restraints were effective.

Discussion

The majority of respondents have training on alternatives to restraints. They do use alternatives to restraints, with one-to-one, food or drink, and verbal interventions being the most frequently used. These are seen as not very effective. The use of physical and/or a combination of physical and chemical restraints is used by 60% of respondents due to the perceived high level of effectiveness.

Introduction

Progress on how to deal with behavioral emergencies in the healthcare setting has been difficult. This is in part due to the potential danger these cases bring to the other consumers and healthcare workers in the emergency department (ED) [1], [2], [3], [4], [5]. This, according to Allen et al. [5], is due to the under operationalization of key determinants such as agitation, which has led to a lack of definable criteria that can be applied to behavioral emergencies. The lack of protocols was thought to have led to a percentage of patients who were restrained while in the ED. An expert panel felt that in 1% to 20% of the cases of behavioral emergencies, emergency interventions such as parenteral medications, restraints, and seclusion were necessary. They supported the use of alternatives first and involuntary medications only in limited cases such as to control aggressive behavior that emerged during treatment [5].

This was similar to the restraint and seclusion standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, which stated that the use of restraints and/or seclusion can only be used for emergency situations when there is imminent risk of physical harm to a patient or others [6]. The difference is that there must be documentation that alternative methods were considered prior to restraints. As of 2003, however, the question of what alternatives to restraints work and/or are being used was still unclear [7]. Verbal one-to-one interaction has been shown to be the most effective means to reduce anxiety and help patients regain control [8], [9]. Based on Brown and Tooke [10], there is a need to educate staff on the least restrictive methods, such as one-to-one, to prevent the overuse of restraints. There has been progress to train staff about alternative ways to treat violent patients; however, many of the less restrictive alternatives once tested have shown a wide variance in usefulness in day-to-day application [7]. The healthcare provider is often caught between their responsibility for all patient and staff safety and the use of the least restrictive methods to control psychiatric patient and administer treatment [11]. Nonpharmaceutical interventions should be used when possible; however, many psychotic episodes require anti-psychotic treatment once it has been shown that behavior and environmental interventions are not effective [12].

As EDs are more frequently asked to care for patients who exhibit threatening or violent behavior the issues of when and how to control the individual will arise [13]. The patient often has been referred by the police for psychiatric evaluation [14]. It is often necessary to restrain the patient during their assessment in order to reduce harm to themselves, other patients, and healthcare staff [13]. An understanding of what is being done and its level of effectiveness is needed in order to control symptoms enough to diagnose, treat, and/or admit the patient while also balancing the issues of safety and effectiveness [14], [15].