Deciding Appropriateness of Restraint and Seclusion

August 1, 2005

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.

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.

Case Presentations

Patient A: 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.

Treatment plan: 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.

Analysis and teaching points: 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.

Patient B: 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.

Treatment plan and follow-up: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.

Analysis and teaching points: 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.

Patient C: 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.

Treatment plan and disposition: 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.

Analysis and teaching points: 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.

Patient D: 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.

Treatment plan and disposition: 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.

Analysis and teaching points: 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.

Summary

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. *