What is the rule against physical and pharmacological restraint?

Rules for Physical and Pharmacological Restraint

Physical and pharmacological restraints should only be used when a patient presents an acute danger to themselves or others, when significant disruption of the treatment program is occurring, and when less restrictive measures have failed or are not possible options. 1

Indications for Restraint Use

• Restraints are indicated only when the patient is an acute danger to harm themselves or others 1
• When there is significant disruption of the treatment plan including considerable damage to property 1
• Only after less restrictive measures have failed or are not possible options 1

Prohibited Uses of Restraint

• Restraints should never be used as punishment for patients 1, 2
• Never for the convenience of staff or the program 1, 3
• Never to compensate for inadequate staffing patterns 1
• Never where prohibited by state guidelines 1
• Never instituted by untrained staff 1

Physical Restraint Protocols

Types of Physical Restraint

• Physical restraints involve staff members in bodily contact with the patient without mechanical apparatus 3
• Mechanical restraints use leather or cloth restraints, papoose boards, and other implements 3

Safety Measures for Physical Restraint

• Proper staff training on alternatives and proper application is essential 1
• Continuous monitoring of restrained patients is required 1
• Supine positioning with head of bed elevated and free cervical range of motion is preferred to decrease aspiration risk 1
• Prone positioning may be used if other measures have failed but carries higher risk 1
• Monitoring for airway obstruction is critical, especially with prone positioning 1
• Minimize or eliminate pressure on the neck and back 1
• Discontinue restraints as soon as possible 1

Dangerous Physical Restraint Practices to Avoid

• Restraints that cause airway obstruction (e.g., choke holds, covering face) 1
• High neck vests, waist restraints, and beds with unprotected split side rails 1
• Restraining medically compromised or unstable patients 1
• Restraint by untrained staff 1

Pharmacological Restraint Protocols

Definition and Appropriate Use

• Chemical restraint is the involuntary use of psychoactive medication in crisis situations to help contain out-of-control aggressive behavior 1, 4
• Must be distinguished from the pharmacological management of underlying psychiatric illness 1, 4

Medication Selection and Administration

• Consider available medical and psychiatric history, including concurrent medications 1, 2
• Benzodiazepines (e.g., lorazepam) are preferred due to fast onset and rapid absorption 4
• Antipsychotics (e.g., haloperidol) are evidence-based options for acute agitation 4, 2
• Combination therapy of benzodiazepine plus antipsychotic may be used for severe agitation 4
• Oral medication should be offered prior to intramuscular administration 1, 2
• Administer oral medication only when patient is sitting up or standing to avoid aspiration 1

Monitoring Requirements

• Chemical restraints must be continuously monitored by trained nursing personnel 1, 2
• Monitor for allergic reactions, paradoxical reactions, dystonia, and extrapyramidal symptoms 4, 2
• A licensed independent practitioner must have face-to-face contact with the patient within 1 hour of the initial order 1

Regulatory Requirements

Evaluation and Ordering of Restraints

• Licensed independent practitioner must evaluate the patient in person within 1 hour of restraint placement 1
• Renewal of restraint orders varies by patient age: every 1 hour for patients <9 years, every 2 hours for patients 9-17 years, and every 4 hours for patients >18 years 1
• In-person evaluation by licensed independent practitioner to renew restraint order: every 4 hours for patients <18 years and every 8 hours for patients >18 years 1

Required Assessments

• Assessments every 15 minutes must include: vital signs, signs of injury, nutrition/hydration, extremities circulation and range of motion, hygiene and elimination, physical and psychological status/comfort, and readiness to discontinue restraint 1, 3
• The patient's family should be informed of use of seclusion or restraint 1

Complications of Restraint

• Deaths have been associated with physical restraint use, particularly prone positioning 1
• Common complications include skin breakdown, neurovascular damage, rhabdomyolysis, and potential kidney failure 1
• Other reported complications include accidental strangulation, brachial plexus injuries, electrolyte abnormalities, hyperthermia, deep vein thrombosis, pulmonary injuries, and asphyxia 1
• With chemical restraint, monitor for respiratory depression (especially with benzodiazepines), QT prolongation, extrapyramidal symptoms, and dystonic reactions 4, 2

Special Considerations

• In cases of agitation due to suspected illicit stimulant use, chemical restraint may be preferable to physical restraint due to risk of rapid increase in serum potassium from rhabdomyolysis potentially causing cardiac arrest 1
• Remove smoking materials from physically restrained patients 1
• For children and adolescents with trauma history, seclusion may be preferable to physical or mechanical restraints 3
• PRN (as needed) use of chemical restraints is prohibited 2