Portable pulse oximeters are inexpensive ($150 to $600), are noninvasive, and can measure a patient's oxygen saturation in 5 to 10 seconds. Use of these devices has the potential of being a preventive strategy that can be used to identify patients who have acute oxygen deficits, which can occur during physical (eg, patient held by staff) or mechanical restraint.
The Joint Commission's 1994-2005 summary of sentinel events—deaths or serious injuries in its accredited facilities—found that 130 deaths were related to the use of restraints in adults and children.1 The proximate cause of morbidity or mortality in many of these cases was asphyxiation (R. Croteau, MD, personal communication). In another study of the deaths of 45 children and adolescents during physical restraint, 29 (64%) were found to be associated with asphyxiation.2
We had hoped that pulse oximetry might detect oxygen saturation deficits when we began using it routinely in all restraints in 6 adolescent and child residential and hospital programs during the past 3 years.3-5
Oximetry was measured in patients at admission to obtain a baseline level, during restraint to assess cardiorespiratory status, and several minutes after the restraint ended to detect possible bronchospasm. Additional oxygen saturation measurements were obtained on the patient's request, if staff members were concerned about the patient's cardiorespiratory status, or when a patient fell asleep or became quiet. We set acceptable oximetry saturation as 95% or above.
To date, 6 abnormally low saturation readings have been reported. In the most worrying case, an adolescent in a standing physical hold had a 70% (critical) saturation level. When oximetry was unable to be performed during restraint because of patient agitation, we were usually able to obtain measurements within a few minutes after the restraint ended. It will be important to find out with further oximetry data collection how easily and reliably respiratory or cardiac compromise can be detected.
We found no increase in the length or number of restraints when oximetry was used. Instead, it appeared that there were psychological restraint prevention benefits to the procedure. Admission discussion of oximetry increased patient and family awareness of potential medical risks of restraint, and the use of oximetry sometimes ended a restraint, particularly when the patient was permitted to take his or her own saturation reading.
The availability of pulse oximetry also heightened staff concerns about medical complications. Patient resistance to oximetry measurements was sometimes a sign of underlying depression or, as in 1 case, of suicidal wishes that had not been previously detected.
Pulse oximetry should always be incorporated into restraint reduction programs to prevent it from being used to justify restraints as safe procedures, since its purpose is to prevent asphyxiation and emphasize the medical dangers associated with restraint. Our protocol requires explanation of the use of oximetry to patients during restraint, and in the case of minors, to guardians. The protocol also requires baseline oxygen saturation measurements. Both of these elements can help increase public awareness of the dangers of restraints, what monitoring should occur, and what restraint reduction efforts are currently being used.
We recently completed an American Psychiatric Association (APA) grand round online on a seclusion and restraint case which included a discussion of pulse oximetry. Dr Frank Guerra, professor of anesthesiology and psychiatry, provided very helpful clinical information on the importance of pulse oximetry and indicated that its use in monitoring oxygen saturation during restraint is clinically appropriate. The case and the discussion are available at the APA Web site, under "Members Corner" and after login at APA grand rounds.
In summary, the monitoring of behavioral restraints has really not incorporated the modern technology that is available to us. Indeed, one could have taught King Tutankhamen how to count pulse and respiration rates! Blood pressure monitoring is a newer technology, but it is often difficult to apply to an agitated person. Furthermore, all these procedures are only secondary measurements of oxygen saturation deficit and would be a delayed indicator of it. Pulse oximetry is a primary measure of oxygen saturation deficit and therefore should provide more timely information that might prevent medical catastrophe.
There is no funding for the pulse oximetry initiative nor is there a research network that can provide supportive data. However, oximetry to monitor oxygen saturation is used in many hospital settings, from emergency departments to pediatric units. For oximetry to be made available to patients who are restrained in the context of psychiatric care, the impetus will have to come from individual psychiatrists, groups, district branches, and maybe even the APA assembly. Please consider joining me in this effort.
I would be pleased to share our center's protocol as well as other information with the hope that it might be of interest to readers and to collect anecdotal information from those who use this procedure.
1. Joint Commission. Sentinel event statistics. December 31, 2006. Available at: http://www.jointcommission.org/SentinelEvents/Statistics/. Accessed July 11, 2007.
2. Nunno MA, Holden MJ, Tollar A. Learning from tragedy: a survey of child and adolescent restraint fatalities. Child Abuse Negl. 2006;30:1333-1342.
3. Masters KJ, Wandless D. Use of pulse oximetry during restraint episodes. Psychiatr Serv. 2005;56:1313-1314.
4. Masters K, Crocker S. Pulse oximetry use during restraints: can it save lives? J Am Acad Child Adolesc Psychiatry News. 2007;37:318-319.
5. Masters K. Pulse oximetry use during restraints. Letter to the editor. J Emerg Med. 2007;33.