Leslie S. Zun, MD, MBA

Dr Leslie Zun discusses factors associated with accessing services for patients undergoing psychiatric challenges during the pandemic. He also elaborates on the 

Joint Statement for Care of Patients with Behavioral Health Emergencies and Suspected or Confirmed COVID-19

. The joint statement was compiled by by the American Association for Emergency Psychiatry, American College of Emergency Physicians, 

, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association.

Dr Zun is Professor and Assistant Dean for Faculty Talent Enhancement, Rosalind Franklin University of Medicine and Science, Chicago Medical School, and Chair for the Coalition for Psychiatric Emergencies.

Articles

Dr Leslie Zun discusses factors associated with accessing services for patients undergoing psychiatric challenges during the pandemic.

Addressing Behavioral Health Emergencies With COVID-19

The Sinai Health System in collaboration with Rosalind Franklin University of Medicine and Science/Chicago Medical School is presenting the “

Sixth Annual National Update on Behavioral Emergencies

,” December 2-4, 2015, at the Flamingo Las Vegas Hotel. This is the only conference in the country to address the behavioral emergencies in the acute care setting including emergency departments and PESs.

[[{"type":"media","view_mode":"media_crop","fid":"43095","attributes":{"alt":"","class":"media-image","id":"media_crop_3095174729560","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4690","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]Conference Update

The purpose of this conference is to increase the knowledge and collaboration among care givers in the emergency, PES, and acute care settings for patients who present with psychiatric symptoms. The target audience includes emergency physicians, psychiatrists, psychologists, nurses, nurse practitioners, mental health workers, social workers, and physician assistants.

There is an impressive array of presentations and speakers this year. The titles of this year’s presentations include:

• Ketamine and EMS
• Medical Clearance
• Disorders That Can Kill
• Treatment of Agitation
• Excited Delirium
• Violence in the ED/PES
• AMA and Other Risks
• Psychiatric Boarders

The speakers are national and international experts in the field. There is a preconference session sponsored by the Institute for Behavioral Healthcare Improvement. It is an all day seminar on i mproving care and flow and reducing board ing for people with behavioral health problems.

For more information regarding the conference, go to 

 or contact Jamie Doucet, conference coordinator at 1-773-257-6589 or jamie.doucet@rosalindfranklin.edu. For additional information regarding the IBHI pre-conference seminar, please contact Peter Brown at peter@ibhi.net or at 518 732-7178.

There is an impressive array of presentations and speakers at an upcoming meeting, the only one in the country to address behavioral emergencies in the acute care setting.

The Sixth Annual National Update on Behavioral Emergencies

The role of every emergency clinician is to determine whether the patient has a condition that threatens life or limb. Determining this in patients who malinger can be quite a challenge, because the malingering patient presents with false or exaggerated symptoms for secondary gain. The patient's motivation may be to obtain some type of compensation; acquire drugs; or avoid school, work, military duty, or even criminal confinement or prosecution.

It is interesting to note that malingering is not considered a form of mental illness or psychopathology; rather it is considered a deliberate behavior. Malingering is classified in the 

 as a "V" code (ie, other conditions that may be a focus of clinical attention).

The incidence of malingering in the emergency setting is unknown. Malingering should be considered when patients request certain evaluations or treatments that may or may not be recommended by their attorney or other legal counsel or when there is a marked discrepancy between patients' concerns and the physical findings. Clinicians may experience difficulty in evaluating these patients because of lack of cooperation or compliance. Often, persons who malinger are seen multiple times before the condition is diagnosed, if it ever is. These factors make it even more difficult to provide good care and treatment for malingering patients. This problem is confounded by the limited time, resources, and facilities that most emergency clinicians have.

The clinician is placed in a precarious situation when dealing with malingering patients. Should the physician confront patients about their behavior? Should the physician give patients whatever they ask for? Should the physician request or demand a psychiatric evaluation?

In the emergency setting, there is always a concern that a physician may miss a significant life- or limb-threatening condition. The burden of making the correct diagnosis can be onerous when dealing with patients who are not being candid about their symptoms. Physicians tend to err on the side of making a medical diagnosis. It takes much more energy and time to deal with malingering patients than it does to deal with patients who present with a typical medical or psychiatric condition.

The overall cost of dealing with malingering patients is magnified by their demands for testing, evaluations, and treatment that may not be appropriate in the emergency setting. Giving in to their demands may also expose patients to unnecessary radiation, blood draws, treatments, and medications. The costs related to malingering are part of the much larger cost of insurance fraud in the United States. Health care fraud from all sources amounts to 10% of all health care expenditures per year.

In his article, Dr Berlin eloquently presents a treatise on malingering, a difficult but important subject. He delves extensively into how to evaluate and deal with malingering patients once the behavior is identified and how to treat them. There is an interesting discussion of transference and countertransference in reference to the malingering patient. Most intriguing is the discussion of invention and intervention, which includes awareness, inevitability, circumstances, assessment, confrontation, and treatment. Dr Berlin also presents 3 cases that explore some of the quagmires that physicians must deal with when taking care of these patients.

In their commentary, Drs Hamilton and Feldman elaborate on the difficulty of dealing with a malingering patient. They also discuss the value of a brief inpatient admission for evaluation of a suspected malingerer. Although there is value in determining what, if any, the patient's underlying condition is, there is also a concern that the inpatient evaluation might validate the malingerer's secondary gain.

Together, Drs Berlin, Hamilton, and Feldman offer emergency clinicians some practical tools and useful insight into the evaluation and management of malingering in the emergency setting.

Leslie S. Zun, MD, MBA
Professor and Chair
Department of Emergency Medicine
Chicago Medical School at Rosalind Franklin University of Medicine and Science
Chair
Department of Emergency Medicine
Mount Sinai Hospital
Chicago

Diagnostic and Statistical Manual of Mental Disorders.

 4th ed, text revision. Washington, DC: American Psychiatric Publishing; 2000.2. Coalition Against Insurance Fraud. By the numbers: fraud stats. Available at: 

http://www.insurancefraud.org/stats_set.html

The role of every emergency clinician is to determine whether the patient has a condition that threatens life or limb. Determining this in patients who malinger can be quite a challenge, because the malingering patient presents with false or exaggerated symptoms for secondary gain.

Malingering in Acute Care Settings

Alcohol and substance use disorders take a tremendous toll on society as a whole and also require significant emergency department (ED) resources. Alcohol use and abuse in the United States accounts for over 100,000 deaths each year

 and costs more than $185 billion annually.

 A study of the effects of alcohol-related disease and injuries found that the number of patients who presented with these conditions increased by 18% from 1992 to 2000.

Unfortunately, most emergency care providers do little to reduce the incidence of alcohol and substance abuse. The major impediments to providing better service in the ED are associated with identification, intervention, and referral. In an ideal world, emergency clinicians would identify alcohol or substance abuse in patients, begin intervention in the ED, and ensure that care continues in an outpatient setting.

Many emergency physicians do not think that their role in the ED includes identifying persons with alcohol and substance use disorders, even though organized emergency medicine advocates for the screening of these patients.

 ED physicians who do little to identify patients with this problem probably either lack understanding or have time limitations. However, this condition is no different from any other medical condition that emergency physicians need to identify and manage.

Recognizing symptoms of alcohol or substance abuse in patients presenting to the ED is made more difficult by the subsets of patients who would not be thought of as having these disorders, such as pediatric and elderly patients. A significant number of pediatric and elderly persons who present to the ED with other disorders turn out to have underlying substance abuse or alcoholism that may have contributed to or caused their presenting problem. It is especially important that we do our utmost to identify substance or alcohol abuse in pediatric patients and that they receive treatment early so they are more likely to have success in later life.

Treatment interventions by emergency physicians are varied, if they occur at all. I had one colleague who thought that intervention in the ED was to instruct the patient to stop drinking (or using drugs, or both), get a job, and go to church. The effectiveness of these recommendations has not been tested. However, it has been demonstrated that short interventions in the ED may have a beneficial effect on both children and adults with alcohol problems who present to the ED.

Psychiatric Issues in Emergency Care Settings,

 Dr Maviglia has drawn an excellent road map addressing important factors related to alcohol and substance use disorders, including their incidence and manifestations, appropriate screening, performing an effective intervention, and identifying patients' levels of motivation for treatment. In addition, the development of management plans and referrals are discussed.

One rather unique aspect of this article is the review of our own feelings and possible biases concerning patients who are addicted to alcohol or illicit substances. Although a number of theories are presented on how health care providers might approach patients with alcohol and substance use disorders, it is probably most important that we focus on harm reduction for patients with these disorders. Dr Buckley's commentary discusses several complementary topics addressing polysubstance abuse and dual diagnosis.

Dr Maviglia also presents 3 cases that highlight some of the points central to his article. The first case illustrates the need to be culturally sensitive when screening patients. The second case focuses on the problems associated with missing the diagnosis. The third case discusses comorbidity and is about a patient with a dual diagnosis--something that we do not commonly think about in patients who present to the ED.

An interesting point brought out by this article is the importance of cultural sensitivity and competency. Unfortunately, the "one size fits all" philosophy does not apply to the treatment of patients who present to the ED with symptoms of alcohol or substance abuse. In the treatment of patients experiencing pain, we must understand how different persons react and respond to pain. This type of understanding should be similarly applied to persons with alcohol and substance use disorders.

The resources to treat patients with alcohol and substance use disorders are sorely underfunded. In my ED, we no longer tell the patient to stop drinking, go to church, and get a job; we now have a mental health care worker in the ED who determines the most appropriate inpatient or outpatient resource for each patient who presents with this condition. Unfortunately, many other EDs in the United States do not have this luxury and are at a loss to find available and adequate resources within their community. However, it is our responsibility to seek out and refer patients to affordable treatment options for their alcohol and substance use disorders.

Chicago Medical School at Rosalind Franklin   University of Medicine and Science

1. McGinnis JM, Foege WH. Actual causes of death in the United States. 

Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data.

 Rockville, Md: National Institute on Alcohol Abuse and Alcoholism; 2000.3. McDonald AJ 3rd, Wang N, Camargo CA Jr. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. 

. 2004;164:531-537.4. D'Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 1: improving detection. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine. 

. 1998;5:1200-1209.5. D'Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 2: intervention and referral. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine. 

Alcohol and substance use disorders take a tremendous toll on society as a whole and also require significant emergency department (ED) resources. Alcohol use and abuse in the United States accounts for over 100,000 deaths each year1 and costs more than $185 billion annually.2 A study of the effects of alcohol-related disease and injuries found that the number of patients who presented with these conditions increased by 18% from 1992 to 2000.3

Evaluating for Alcohol and Substance Abuse

ED staff should be trained to approach these patients in much the same manner as they would patients with physical problems. An appropriate evaluation consists of a directed history taking (medical and psychiatric history and reason for presentation) and an unclothed physical examination and testing, when indicated. This evaluation can help determine the cause of the psychiatric presentation, whether it is primarily medical or psychiatric, whether the patient will need treatment for an underlying medical condition, and whether a psychoactive agent is the treatment of choice.

Agitation can run the gamut from mild to severe, and the level may either change over time or be constant. Changes in the level of agitation may depend on the patient's environment and the treatment offered. Agitation can be measured by using various scales, but more frequently, the level of agitation is determined by the clinician's judgment. 

The following 4 cases illustrate the problems and frustrations associated with the use of restraint and seclusion in the emergency setting. 	

 A 37-year-old man was brought by the police to the ED for attempting to direct traffic at a local intersection. When approached by the police, he became violent and was handcuffed. When he was brought to the ED's psychiatric intake room, it took 4 hospital security staff members, assisted by the police, to place him supine on a cart. His handcuffs were replaced with 4 leather restraints, one on each extremity. The patient did not have any identification on his person and did not provide his name. He did not give any further history. He had no physical complaints and denied using drugs or alcohol. 	

The examination revealed a disheveled person who was having a conversation with a superior being and wrestling with his restraints. The patient was too combative for emergency personnel to determine vital signs or to perform an assessment using the Agitated Behavior Scale (ABS), page 15. The patient demonstrated to an extreme his short attention span, uncooperative attitude, explosive temperament, and loud voice; on later assessment, he was given a score of 43 on the ABS. Luckily, a mental health worker was able to identify the patient as someone with known schizophrenia.

 This patient would obviously meet the criteria, by whatever measurement used, for severe agitation. Although alternatives to restraint are required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS), in this case, staff members were concerned about their own safety and that of the patient. The patient was given a typical antipsychotic and a benzodiazepine for sedation. One hour later, the patient was sleeping on the cart. The nurse was now able to determine vital signs. 

The patient was arousable with painful stimuli but did not wake up enough to answer questions. The patient was approached every hour to obtain a history and perform a physical examination, but to no avail. Six hours later, the patient became communicative, relaying his history and agreeing to be examined. No physical problems were uncovered, and the psychiatric service was asked to assess him. After psychiatric evaluation, the patient was transferred to a state-operated psychiatric facility.

 Although restraint of patients is not preferred by hospital regulators, this patient was severely agitated and needed to be restrained immediately on arrival in the ED. Protecting the staff and the patient was the prime concern in this case. 

This patient's case illustrates the problems associated with conventional antipsychotic and benzodiazepine treatment. Patients who are given these medications frequently become overly sedated. This oversedation delays the patient's medical and psychiatric assessment and disposition. In busy emergency settings, patients waiting for evaluation delay the care of other patients and restrict the number of beds that can be turned around. Anything that can be done to reduce the patient's stay in the ED is valuable.

Atypical antipsychotic agents are thought to reduce the level of sedation and the need for benzodiazepine use. A limited number of studies demonstrate that patients do not become oversedated with the newer medications, but head-to-head studies of the use of the new atypical antipsychotic agents in the emergency setting are lacking. 

 A 26-year-old woman was brought to the ED by her family because she had not slept in 3 days. She had known bipolar illness, for which she had been treated sporadically. She denied recent drug or alcohol use and the possibility of pregnancy. Her history was otherwise unremarkable. The patient did not have any physical complaints. Her physical examination revealed an anxious- appearing woman with normal vital signs; the rest of the physical examination was unremarkable. Her level of agitation was assessed by the emergency staff with use of the ABS. She was uncooperative and demonstrated some degree of short attention span and low tolerance for frustration. Based on the assessment, the patient was given a score of 32 and was considered moderately agitated. 

Because the patient was only moderately agitated, alternative options were offered before restraint and seclusion were considered. The patient was placed in a quiet room and offered food. When she consented to receive medication, she was given the choice of an oral or intramuscular atypical antipsychotic agent. One hour after receiving the intramuscular injection, the patient was calmly sitting in bed and was appreciative that her discomfort was resolving. She was evaluated by a physician from the psychiatric service and received a diagnosis of bipolar disorder, manic phase. She was admitted to the psychiatric unit for medication stabilization.

Many psychiatric patients will agree to take medication if they are simply asked. In this case, the patient preferred the intramuscular form, but she could have taken an oral or oral-dissolving form of the atypical antipsychotic agent. The choice of medications depends on the patient's age, medical problems, psychiatric condition, and pregnancy status. 

Emergency care providers all too frequently ignore the mental plight of the agitated patient and therefore do not aggressively manage the patient's level of agitation. However, if asked, most patients will describe the psychic discomfort that they are experiencing. One could argue that this discomfort is no different from that experienced with pain. Perhaps one day, psychic discomfort will be measurable by a brief assessment tool. Periodic measurement of this discomfort could also provide the yardstick to modulate treatment in a stepwise fashion.

 A 45-year-old man came to the ED for help because he had been depressed for 3 weeks since his son died. In discussing his depression, he admitted to thoughts of suicide. He had a history of type 1 diabetes and injected insulin twice a day. The physical examination revealed a middle-aged man who appeared depressed. He had some abrasions on his arms and a small area of cellulitis on his left arm. Assessment of his vital signs demonstrated a resting tachycardia (110 beats per minute). Results of blood tests showed a blood glucose level of 240 mg/dL and normal electrolyte values. He had no evidence of diabetic ketoacidosis. On the ABS, the patient was given a score of 23 because of the absence or slight degree of many of the scale's criteria. A psychiatrist was called to evaluate the patient because of his depressed state.	

The patient met the criteria for a mild level of agitation, but more important, he needed treatment for his hyperglycemia. Because the patient was cooperative and only mildly agitated, it was decided that he would be placed under one-to-one supervision. The patient was given 2 L of normal saline intravenously and his normal dose of insulin to manage his high glucose level. After 2 hours of treatment, the patient's heart rate decreased to 88 beats per minute. When his heart rate normalized, he underwent psychiatric evaluation. The psychiatrist determined that the patient needed psychiatric hospitalization for depression because of his suicidal ideation.

In this case, management of the patient's medical conditions took precedence over management of his underlying psychiatric condition. When his medical conditions stabilized, a psychiatric evaluation was performed. 

Restraining or secluding this patient would not be appropriate, because the patient could easily be managed in the emergency setting with observation. Patients who do not have means to hurt themselves and who are not threatening the staff can be observed. The JCAHO and CMS are quite firm about reducing the use of restraints for staff convenience. In this case, staff members were available to perform one-to-one observation, which was successful in preventing harm to the patient. Other alternatives, such as offering the patient food, reducing stimuli, placing the patient closer to the nursing station, and talking with the patient, could be added or substituted to reduce the need for restraint and seclusion. However, these alternatives have not been studied, and their effectiveness is uncertain.

A 78-year-old woman was brought by her family to the ED with agitation and confusion that had lasted 3 days. The patient has multiple medical problems, including coronary artery disease, type 2 diabetes, and chronic obstructive pulmonary disease. The patient said that she takes medications for her cardiac and pulmonary conditions, but she was too agitated to give further information. When she was placed on a cart for evaluation and examination, she kept getting off the cart and refused to cooperate in her evaluation and care. During a quiet moment, the physical examination revealed an elderly woman with tachycardia, tachypnea, and leg edema. Pulse oximetry was measured at 83%. Her heart rate was 117 beats per minute, and her blood pressure was 170/100 mm Hg. The lung examination revealed rales and wheezes in both lung fields. The cardiac examination demonstrated a systolic ejection murmur. Further tests verified an acute myocardial infarction and resultant acute congestive heart failure. Because she was uncooperative, was wandering from the treatment area, and had repeti-tive behaviors, her score on the ABS was 26.

This patient obviously had a medical cause for her agitated behavior--her delirium was related to her low level of oxygenation. The patient did not qualify for behavioral restraint or seclusion; she rated mildly agitated on the ABS. If anything, the patient may need soft restraints, which may be ordered for a nonbehavioral reason, such as performing procedures for repositioning of a dislocated shoulder. The patient received treatment for her myocardial infarction and congestive heart failure. Her oxygenation status improved, as did her level of cooperation. She was admitted to a critical care unit.

Medical causes of agitated behavior should always be considered when agitated patients present to the ED and have abnormal physical examination results, with or without abnormal vital signs. Other determinants of the need for a medical evaluation include fever, new or changed psychiatric presentation, age over 45, incontinence, and focal neurologic deficit.

The JCAHO and CMS have significantly different standards for nonbehavioral restraints. The standards include limiting the use of restraint, reducing risks associated with the procedure, monitoring, ordering of restraint by an authorized person, and documentation. Nonbehavioral restraints are commonly used for patients who are having a medical or surgical procedure performed and who need to be restrained to be kept in a set position. In this case, the patient needed to stay on the cart to get appropriate medical treatment.

These 4 cases help illustrate some of the common problems in treating the agitated patient in the emergency setting. The institution's treatment protocol helps define the types of patients seen in the emergency setting, who may or may not need restraint and seclusion. There are limited indications for restraining or secluding a patient, and staff convenience is not one of them. The conventional antipsychotics have significant limitations in the management of agitation. Specifically, these medications commonly delay the disposition of the patients. Many times, patients will agree to take medications to reduce their level of agitation. Medical workup needs to be considered for all patients who present to the emergency care setting with psychiatric complaints. Not all of these patients need medical tests; clinical judgment can help differentiate patients who need medical from those who need psychiatric hospitalization.	*

Many physicians who work in the emergency department (ED) consider the agitated patient the bane of their existence. These patients are frequently difficult to deal with, are uncooperative, and can bring an already busy ED to its knees. Although it is easy to understand why severely agitated patients are commonly placed in restraints or seclusion, it is essential that cooler minds prevail when an agitated patient presents to the ED. The patient should be treated with dignity, respect, and understanding. Because these patients often cannot express their feelings adequately, many who work in the ED do not realize that these patients do not like the feeling of being out of control.

Deciding Appropriateness of Restraint and Seclusion

Seclusion and restraint are interventions that carry a degree of risk, as noted by the American Psychiatric Association (APA). The APA indicates that use of restraint and seclusion is allowable when, according to clinical judgment, less restrictive interventions are inadequate or inappropriate and the risks of these interventions outweigh the benefits.

 The American Academy of Pediatrics discourages the use of restraints and seclusion; rather, this organization recommends verbal interventions and therapeutic holding for children and adolescents in psychiatric facilities.

 Although their review did not specify location, the Cochrane Collaboration states that it is uncertain about the value of seclusion or restraint in persons with serious mental illness.

Most experts in the emergency field believe, however, that there is an essential role for these procedures in the care of patients in the acute care setting. This article will briefly define restraint and seclusion, lay the foundation for their restricted use, review studies on complications, discuss indications for restraint and seclusion and their application, and review combination drug therapy.

Restraint is defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

 as any chemical or physical method of restricting a patient's freedom of movement, physical activity, or normal access to his or her body. This definition does not include other interventions that are the usual and customary part of a medical diagnostic or treatment procedure performed with consent. The JCAHO defines chemical restraint as the inappropriate use of a sedating psychotropic drug to manage or control behavior.

 Seclusion is defined as the involuntary confinement of a patient alone in a room, with the patient physically prevented from leaving for any period. There are 4 variants to seclusion: placing a patient in a locked room; placing a patient in a room with the door held shut; placing a patient in a room in which freedom is restricted; and separation of a patient from the group.

Standards for Use of Restraint and Seclusion

JCAHO standards PC.11.10-11.100 and PC.12.10-12.190 state the requirements for the use of seclusion and restraint in all health care settings for behavioral and nonbehavioral reasons.

 In the "Hospital Conditions of Participation for Patients' Rights," the Healthcare Financing Authority (HCFA, now termed the Centers for Medicare & Medicaid Services [CMS]) presents standards for use of restraint and seclusion, including orders, assessment, monitors, reevaluation, and termination.

 Both orga- nizations require that a physician evaluate the patient within 1 hour of placement in restraint or seclusion.	 

The JCAHO standards include requirements for prevention, monitoring, training, documentation,  no- tification, preferred interventions, order limitations, assessment, and discontinuation. These rules were then followed in 2000 - 2001 by interim HCFA rules for children's residential treatment centers.

 American Psychiatric Nurses Association,

 National Association of Psychiatric Health Systems,

American College of Emergency Physicians,

 made policy statements and recommendations.	 

The chief indication for placing a patient in restraint or seclusion is prevention of harm to himself, other patients, or staff. Other, much less definite indications include patient requests; prevention of destruction of property; prevention of significant disruption of treatment programs; assistance in treatment as part of ongoing behavior therapy; and decreasing overstimulation, disruption of a treatment program, or chaotic behavior.

 The patient's chaotic or disruptive behavior is a prelude to danger. Reasons for which restraint and seclusion should 

 be used include punishment; convenience; preventing a voluntary patient from leaving; lack of resources to supervise the patient adequately; delirium or dementia; severe drug reactions; history of self-injury or aggression; maintaining an orderly treatment environment; a medically unstable state; and inability to perform one-to-one observation.

There are many anecdotal reports of restraint complications in acute care facilities. Complications of restraint included problems of elimination, aspiration pneumonia, circulatory obstruction, cardiac stress, skin breakdown, poor appetite, dehydration, and accidental death. In 1998, a series of articles describing the deaths of 142 patients across the nation appeared in the 

 These newspaper articles prompted governmental agencies and the JCAHO to regulate and control the use of restraint and seclusion.

The concern over complications and death prompted interim rules from the HCFA for the use of restraint and seclusion in 1999.

 Unfortunately, little good medical knowledge exists about restraint complications in the emergency setting. In a 1988 survey study of directors of emergency medicine residency programs, 13% of the respondents reported significant injuries during the restraint process at their institutions in the past 5 years, including fractures and head injuries.

 Deaths in the ED caused by use of restraint have been associated with cocaine-induced arrhythmias.

 The hogtie (hobble) restraint technique has been associated with multiple cases of cardiovascular collapse.

Articles related to the complications associated with use of restraint have not described in any detail the circumstances of these deaths or their relationship to patient age, process of applying restraint, or underlying medical conditions. One prospective trial found that the rate of complications was 5.4% among 298 patients, with no major injuries or mortality.

 This study was performed in an urban teaching ED and describes the rate and complications of restraint use over 1 year. Twelve complications were reported: getting out of restraints (6), injuring others (2), vomiting (1), injuring self (1), hostile or increased agitation (1), and other (1). This study was performed after the new standards by the HCFA and the JCAHO were issued. Complications that are more difficult to measure include psychological harm, loss of dignity, damage to the therapeutic alliance, and violation of personal rights.

Studies of Use of Restraint and Seclusion

Older studies have found that patients were frequently physically restrained in the health care setting. A review by Soloff and colleagues

 of 13 published studies involving adult inpatients found that 1.9% to 66% of the patients were secluded or restrained. Another study found that 25.2% of teaching EDs restrained at least 1 patient per day.

 An average of 3.7% of all ED patients needed restraint and seclusion or restraint alone. The use of seclusion in emergency medicine is limited to one small study. Lavoie and colleagues

 found that 61% (78 of 127) of the ED directors used seclusion in their department.

More recent information indicates that the use of restraint and seclusion has been significantly reduced. One survey of emergency medicine and pediatric emergency training programs found that 5% or less of the pediatric psychiatric patients were restrained.

 For hospitalized youths, the rate of seclusion has been reported as 61% and the rate of restraint as 49% after implementation of the federal regulations.

Figure 1 demonstrates the process we follow in the ED at Mount Sinai Hospital for placing a patient in restraint and seclusion. The flow diagram divides the patients into agitation-level categories. For patients with severe agitation, restraint and seclusion may be needed immediately after arrival at an acute care setting. For moderately agitated patients, restraint and seclusion would be considered after other interventions have failed. For those with mild agitation, it is unlikely that restraint and seclusion would ever be necessary. This flow diagram is predicated on the availability of some means to assess the patient's level of agitation. It is essential to reduce a patient's severe level of agitation to prevent the use of restraint and seclusion.

The 2 commonly used tests of agitation are the Overt Aggression Scale (OAS)

 and the Agitated Behavior Scale (Figure 2).

 Neither of these tests is tailored for use in the emergency setting. Both scales use observed behavior to rank the level of agitation that a patient exhibits, and the OAS has been tested  in children. Application of these scales in the severely agitated patient--for example, one who is brought in by the police in handcuffs--might place the staff at risk while someone is measuring the patient's behavior. The scales can be used during later assessment. There is a need for a short, reliable measure of agitation for use in the emergency setting.

Reducing Use of Restraint and Seclusion and Providing Alternatives

Many studies have examined the ways of reducing the frequency of restraint and seclusion used at their institutions.

 Most institutions have established some form of process improvement to accomplish such reduction, including frequent review of the number of patients placed in restraint and seclusion. Techniques used to reduce the use of restraint and seclusion include increased staff-to-patient ratios; improved management of problematic behavior; correction of inadequate monitoring; removal or addition of sensory-based treatment; intervention before loss of control; staff education on cultural differences in anger expression and control; and formal training of staff in crisis intervention, including alternatives to restraint and seclusion and how to talk to people in crisis.

A key concern is that reduced use of restraint and seclusion might lead to a greater number of assaults on staff. Indeed, one study in an inner-city community hospital with 3 inpatient psychiatric units did find that reduced use of restraint and seclusion led to an increased number of physical assaults on the staff, from 31 to 83, and assaults on patients, from 67 to 85, in a 12-month time frame compared with the previous 12 months.

 In general, however, it is thought that reducing restraint and seclusion reduces injuries rather than increases them.

In published studies of techniques for restraint and seclusion reduction in the hospital or long-term- care facility, the main focus has been on changes in staff education. In these settings, patients are stabilized and known by the staff and there is usually the luxury of time for use of techniques to prevent further escalation; in the ED or PES, patients may be unknown, they may have a more acute condition, and much less time may be available. However, it is still essential to attempt alternative techniques before resorting to restraint and seclusion if the clinical situation allows. Some alternatives are listed in Table 1.

Unfortunately, some of these techniques are just not practical or reasonable in the emergency setting. For example, it may be difficult to control the temperature, move the patient to a less chaotic environment, or provide for pastoral care in the ED. However, it would be reasonable to attempt to provide one-to-one observation, to negotiate with the patient, to reduce stimulation, to get the family involved when judged to be helpful, and to provide for the patient's basic needs.

Few studies have examined the effectiveness of these alternatives to restraint and seclusion in acute care settings, but there is more information available on measures used in the public psychiatric hospital setting. In a study covering the period from 1997 to 2002, many initiatives were tried.

 Changes in the process for identifying critical cases and initiating a clinical administrative case review were found to be effective in reducing the use of restraint and seclusion. One state hospital system viewed the use of restraint and seclusion as a treatment failure and reduced use dramatically in the inpatient population.

 reported that a large percentage of emergency medicine and pediatric emergency medicine residency programs do not teach their trainees about the application of restraints or the appropriate clinical situation in which to use restraints.

Application and Removal of Restraint and Seclusion

The process of applying and removing restraint and seclusion needs to be determined in each institution within the limits of the JCAHO and the CMS guidelines (Table 2). The APA guidelines

 stipulate that staff should be thoroughly trained and have demonstrated competence in the application of safe and effective techniques followed by each institution. The directives should address reasons for different types and degrees of seclusion and restraint; clinical indications and developmental considerations; monitoring frequency and duration of seclusion and restraint; qualifications of clinicians who can authorize, implement, monitor, and terminate seclusion and restraint; appropriate documentation; in-service training requirements for staff; and quality-improvement process.

Policies and procedures must be in place to stipulate the means by which patients are restrained. Unfortunately, many unanswered questions remain about the use of restraints: What is the proper number of restraints to be placed? What body position (supine, prone, side-lying, sitting) should be used? Are 4 restraints better than 3 or 2? Does the position that the patient is placed in or number of restraints interfere with the staff's ability to assess the patient or the patient's ability to meet his or her own needs? What is the level of training required for health care providers who place patients in restraints or seclusion? Procedures need to be developed to determine how and by whom restraints are applied.

There are certain requirements in the policies and procedures for restraint and seclusion. The JCAHO states that verbal and written orders for maximum time until reassessment for restraint and seclusion are age-dependent: 1 hour for children younger than 9 years, 2 hours for children aged 9 to 17 years, and 4 hours for adults. The HCFA states that a physician or other licensed independent practitioner must see the patient and evaluate the need for restraint and seclusion within 1 hour after initiation of the intervention. It is uncertain who is considered an independent practitioner, but physician assistants, registered nurses, nurse practitioners, psychologists, and masters-level nurses may be included.

 Social workers, licensed counselors, and unlicensed clinical staff do not qualify.

To accomplish restraint, it is usual to have a 5-person team: the leader secures the head, and each other person is responsible for securing an extremity to a cart, chair, or bed. It is recommended that all 4 extremities be restrained securely to the bed with 1 finger space between the extremity and the restraint. Leather restraints are commonly used. Rarely, plastic and Velcro restraint devices are used. Most experts favor placing the patient in a supine position, although one study demonstrated that the prone position calms patients more quickly. Prone restraint is generally viewed as more hazardous and is being eliminated in many facilities. 

There is always concern about aspiration. Some have suggested, therefore, that the head of the bed be elevated in supine patients. If the patient is still moving violently, one of the patient's hands may be placed above the head and one below, and additional straps may be placed on the knees and pelvis. Placement of chest straps or any other means of restraint on the patient's head is not recommended. The patient, parent, or significant other should be informed of the reason for restraint.

Patients in restraint and seclusion need frequent monitoring. Reevaluation of the need for continued restraint is essential. The appropriate monitoring of patients in restraints is continuous observation or audiovisual monitoring. The criterion for removal of restraints is simply that the reasons for placing a person in restraints no longer exist. The reason for restraint removal must be documented in the chart or in some procedural form.

Debriefing procedures have been recommended to reduce the use of restraint and seclusion. The purpose of debriefing is to analyze patient factors in the application of restraint and seclusion, plus the staff response to use of the techniques, and to review policies and procedures with an eye to reducing the future use of restraint and seclusion. However, no study has determined the effectiveness of debriefing in reducing the use of restraint and seclusion. Because the patient is only in the emergency setting for a set time, it is difficult to understand how to implement debriefing in the emergency setting to reduce the use of restraint and seclusion. However, debriefing may improve the individual patient's experience in future settings regardless of whether providers in a particular ED benefit. However, discussions with the staff are needed to reduce the overall use of restraint and seclusion.

The APA discourages the use of psychotropic medications for certain populations as first-line treatment of patients exhibiting dangerous behavior.

 In the emergency care setting, it is particularly difficult to distinguish between the uses of psychotropic medications as a therapeutic intervention that follows from a patient assessment and a written plan of care and the use of these medications to control agitated or violent behavior without a formal assessment and treatment plan. If the medication is used to control a patient's behavior without an assessment and treatment plan, it is considered "chemical restraint." There is a paucity of good ED studies  in the literature on the use of chemical restraints.

and there have been few comparative trials of different medications or combinations of medications.

The choice of an antipsychotic or antianxiety agent may be determined by the patient's medical or psychiatric diagnosis. Many times, however, it is difficult to make a firm diagnosis in the ED setting. In one consensus statement, 17 of 20 psychiatric medical directors stated that it is very difficult to determine the cause of violent behavior.

 In this report, high-potency conventional antipsychotics, a benzodiazepine, or a combination of both was recommended for initial treatment in the emergency setting of patients with a primary psychiatric disturbance or a general medical cause of agitation.

Benzodiazepines are best for patients with substance intoxication or withdrawal. In a study of 20 PES directors in 1999, 13 respondents said that they give the same acute medication regimen to all violent patients regardless of the eventual diagnosis.

 The most common regimen was the combination of haloperidol and lorazepam with or without benztropine. Likewise, the choice of agents to use in the ED has not been well studied. In an analysis of 24 studies, of which 3 were performed in an ED setting, lorazepam alone was found to be superior to haloperidol for agitation and combinations were better in the first hour.

 The studies looked at haloperidol, lorazepam, loxapine, chlorpromazine, molindone, phenobarbital, amobarbital, droperidol, flunitraz- epam, and combinations of these drugs.

The use of the newer antipsychotics is limited in the ED but increasing rapidly in the PES. Olanzapine and ziprasidone are approved by the FDA for the management of acute agitation. Risperidone is advocated for the management of acute agitation but does not have the FDA indication and does not come in an intramuscular form. The pivotal trials for the approval of these medications examined patients with a diagnosis of schizophrenia or bipolar mania, but diagnosis of either of these illnesses is rarely made early in the care of patients presenting to the ED. Use of ziprasidone is associated with a low incidence of dystonia and hypotension but has an association with prolonged QT intervals; ziprasidone can be administered orally or intramuscularly. Olanzapine is also available in oral or intramuscular form and may be associated with hypotension and postural hypotension. These side effects are of particular concern when olanzapine is coadministered with intramuscular lorazepam. 

Company-sponsored trials found that these new agents can be effective for the management of acute agitation.

 in his review of current medications, states: "These intramuscular atypical antipsychotics may represent a historical advance in the treatment of acute agitation." He comments on the need for well-designed studies of these medications for patients with severe agitation, drug intoxication or withdrawal, and comorbid medical problems.

The use of medications in special populations has not been studied. In children, low-dose benzodiazepines or antihistamines are recommended; the newer antipsychotics risperidone and olanzapine have been used in children, but such use is not FDA-approved. Mentally challenged patients and the elderly should be given low doses of atypical antipsychotics. Dorfman and Kastner

 found that benzodiazepines, butyrophenone, and antihistamines were regularly used for chemical restraint of children.

The use of all these medications has associated complications. The older medications are associated with a high frequency of sedation, dystonic reactions, hypotension, and QT prolongation. A study of 16 male schizophrenic patients whose symptoms were resistant to previous neuroleptic treatment with haloperidol found that they had significantly more violent episodes with haloperidol than with low-potency neuroleptics (chlorpromazine or clozapine) or placebo.

 This adverse effect was thought to occur from akathisia or drug-induced behavioral toxicity. Most would agree that the rate of difficult complications is lower with the newer medications; however, some complications are still problematic (Table 3).

 Some have recommended that these newer agents be considered first-line treatment for agitated patients.

Although there is some information on the rate and type of complications associated with restraints, less information is available on seclusion. In one study of complications of seclusion, Mattson and Sacks

 found a high rate of complications. In 63 patients, assaultiveness (32 episodes), destructiveness (5 episodes), and deterioration of mental status (7 episodes) were commonly found. A recent unpublished study found that 28% of the responding ED directors used seclusion.

 In this study, the authors found that inadequate physical plant and restrictions imposed by regulations were frequently cited as the reason for not using seclusion in the EDs. This study also pointed out several areas of concern: the high complication rate (38.5% of sites had at least 1 complication per month); the number of sites reporting the use of seclusion for children (32.5% of all sites); the fact that many of the patients are also given chemical restraints; the limited number of staff members trained to place patients in seclusion rooms; and the number of hospitals that lack a formal policy and procedure regarding the use of seclusion.

It is clear that seclusion is used in the pediatric setting. However, the American Academy of Child Psychiatry states that seclusion should be used only as an emergency intervention to maintain safety and should be implemented in a manner sensitive to the child's particular developmental level, any specific vulnerabilities, and the overall treatment goals.

 The latter requirements may be difficult to accomplish in the acute care setting.

As with restraint use, all aspects of seclusion use must be defined. There need to be policies and procedures in place defining who may place a patient in seclusion, length of time of seclusion, the monitoring process, time until reevaluation, removal from seclusion, and the need to meet the patient's physiologic needs. Appropriate physical space and location with monitoring and communication abilities need to be established in each institution. There is little information about the best physical space and equipment for secluding a patient. Seclusion rooms include wooden platform beds glued to the floor instead of stretchers, with handrails and other equipment removed. Constant observation is probably necessary because of the rate of self-injury in seclusion.

Therapeutic holding is considered a means of redirecting a person's activities by holding him or her for 30 minutes or less.

 This technique is used in the child and adolescent psychiatry arena but has little place in the emergency setting because it assumes that a therapeutic alliance has already been established with the staff, which is not the case in the emergency setting. This method is not regulated under JCAHO or CMS. No controlled studies of the holding technique versus other techniques could be found in the literature.

Little information can be found in the medical literature about the combination of therapies; thus, there is no scientific basis for answering the question of whether it is better to restrain a patient physically and then chemically treat him or to place him in seclusion and physically restrain him. A consensus document noted that 14 of 20 medical directors reported that their protocol was to restrain patients physically and medicate them before a medical workup.

 Although chemical and physical restraints are commonly used in combination in the ED, there are no known studies on the effects and complications of combination therapy.

Unfortunately, the use of restraint and seclusion has not been well studied, and little evidence-based information is available. The Cochrane Collaboration has reviewed the literature on the continuing use of seclusion or restraint.

 The authors of the Cochrane Collaboration review state that the use of these techniques must therefore be questioned in well-designed and -reported randomized trials. Ethical concerns make carrying out such studies very difficult, however. Although the rate of complications may be related to the number of restraints, type of restraint, age of the patient, application process, and underlying medical conditions, studies analyzing such correlations with the rate of complications are lacking.

There is little information on the immediate and subsequent effects of restraint and seclusion on a patient's psychiatric condition that we can use to determine the relative psychiatric safety of restraint and seclusion. Even more concerning is the frequency of use of combination therapy: physical restraints and chemical restraints. One could easily envision numerous studies to address all these concerns. However, significant resources would need to be devoted to answering these questions in a research area that has traditionally had low funding priority.

The use of restraint and seclusion in the emergency setting is a procedure associated with a high degree of emotions at all levels, from government regulators down to the patients themselves. Restraint and seclusion do have a place in controlling the behavior of patients when no other option is evident. The lack of good data on the application and use of restraint and seclusion limits the ability to draw evidence-based conclusions and make proper recommendations.

Even with these limitations, most experts in the field agree that use of physical restraint is necessary to protect the patient and the staff and that when properly performed, it has a low rate of complications. Once physical restraint is used in cases of extreme agitation, chemical treatment of the patient with the newer agents early in the course of treatment is essential to remove the physical restraints as quickly as possible. Seclusion is a selective treatment option for agitated patients who may benefit from a limited environment in selected EDs.	*

1. American Psychiatric Association Task Force on Patient Safety. 

. Avail-able at: www.psych.org/edu/other_res/lib_archives/ archives/tfr/tfr200301.pdf. Accessed June 8, 2005.2. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint interventions for children and adolescents in the acute care setting. 

 1997;99:497-498.	3. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. 

 2000;2:CD001163.4. Joint Commission on Accreditation of Healthcare Organizations. 

Restraint and Seclusion Standards for Behavioral Health.

 May 3, 2000.5. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Refresher Course. January 2005. GL-20.6. Fassler D, Cotton N. A national survey on the use of seclusion in the psychiatric treatment of children. 

 1992;43:370-374.7. Joint Commission on Accreditation of Healthcare Organizations. 2005 

Comprehensive Accreditation Manual for Hospitals: The Official Handbook.

 Oak Brook, Ill: JCAHO; 2005. Available at: www.jcaho.org/ accredited+organizations/hospitals/standards/ hospital+faqs/faq+index.htm. Accessed June 13, 2005.8. Health Care Financing Administration. 

Hospital Conditions of Participation for Patients' Rights.

 Available at: http://permanent.access.gpo.gov/websites/ www.hcfa.gov/quality/4b.htm. Accessed June 6, 2005.9. United States General Accounting Office. 

Mental Health: Improper Restraint or Seclusion Use Places People at Risk

. Washington, DC: US Government Accounting Office; 1999. GAO.HEHS-99-176.	10. National Association of State Mental Health Program Directors. HCFA releases new rules on seclusion and restraint. Available at: www.nasmhpd. org/general_files/HCFAREGS.HTM. Accessed June 12, 2005.11. Medicare and Medicaid programs: hospital conditions of participation: clarification of the regulatory flexibility analysis for patients' rights. Department of Health and Human Services. Centers for Medicaid and Medicare Services. 

. 2002;67:61805-61808.12. American Psychiatric Nurses Association. 

Position Statement on the Use of Seclusion and Restraint.

 Available at: www.apna.org/resources/ positionpapers.html. Accessed May 20, 2005.13. National Association of Psychiatric Health Systems. 

Statement on the Use of Restraints and Seclusion in Psychiatric Facilities

. Available at: www. naphs.org/news/sec41399.html. Accessed May 20, 2005.14. American College of Emergency Physicians. 

ACEP Policy Statement: Use of Patient Re- straints.

 Available at: www.acep.org/webportal/ PracticeResources/PolicyStatementsByCategory/ PracticeManagement/UseofPatientRestraints.htm. Accessed June 8, 2005.15. Child Welfare League of America. 

The Use of Restraints and Seclusion in Residential Care Facilities for Children.

 Available at: www.cwla.org/advocacy/ secres000531.htm. Accessed June 8, 2005.16. Hillard R, Ziteck B. 

 New York: McGraw-Hill; 2004:54-55.17. Weiss EM. Deadly restraint: a nationwide pattern of death. 

. October 11-15, 1998.18. Lavoie FW, Carter DL, Danzl DF, Berg RL. Emergency department violence in United States teaching hospitals. 

 1988;17:1227-1233.	19. Pudiak CM, Bozarth MA. Cocaine fatalities increased by restraint stress. 

 1994;55:PL379-PL382.20. Roeggla G, Roeggla H, Moser B, Roeggla M. Cardiorespiratory consequences of the hobble restraint. 

 1999;6:1076-1077. 21. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. 

 2003;24:119-124.22. Soloff PH, Gutheil TG, Wexler DB. Seclusion and restraint in 1985: a review and update. 

Restraints and seclusion have been used for many years in emergency departments (EDs) and psychiatric emergency services (PESs), but anecdotal case reports and newspaper investigations as well as clinical advances have led to restrictions in their use.