What are the considerations for using psychiatric restraints?

Considerations with Psychiatric Restraints

Psychiatric restraints should only be used when a patient presents an acute danger to themselves or others, or causes significant disruption to the treatment program, and only after less restrictive interventions have failed or are impractical. 1

Strict Indications for Use

Restraints have only two legitimate indications 2:

• Imminent danger: To prevent dangerous behavior to self or others 2, 1
• Severe disruption: To prevent disorganization or serious disruption of the treatment program, including serious property damage 2, 1

Less restrictive measures must be attempted first or documented as impractical before restraints can be applied. 2, 1

Absolute Prohibitions

Restraints must never be used for 2, 1:

• Punishment of patients 2, 1
• Staff convenience or program convenience 2, 1
• Compensation for inadequate staffing patterns 2
• By untrained staff 2

Pre-Restraint Requirements

Initial Assessment and De-escalation

Before considering restraints, conduct a thorough evaluation 2:

• Identify cognitive limitations, neurological deficits, and learning disabilities during intake that may require modification of restraint procedures 2
• Complete medical evaluation to identify factors requiring procedural modifications 2
• Implement unit-specific de-escalation protocols including verbal prompting, modeling, negotiating, and time-out interventions 2

Hierarchical Intervention Approach

Use a three-level escalation system 2:

• Level 1 (Nonrestrictive): Verbal prompting, de-escalation, modeling, negotiating, contingency contracting, time-out <30 minutes 2
• Level 2 (Restrictive): Ignoring behavior, time-out ≥30 minutes, room restriction—requires documented failure of Level 1 2
• Level 3 (Most restrictive): Seclusion, physical restraint, mechanical restraint, chemical restraint—only after documented failure of less restrictive options 2

Critical Safety Protocols During Restraint

Physical and Mechanical Restraint Safety

Airway protection is paramount 2:

• Never use restraints that cause airway obstruction (choke holds, covering face with towel/bag) 2
• Supine restraints: Patient's head must rotate freely 2, 1
• Prone restraints: Airway must be unobstructed at all times, no excessive pressure on back 2
• Preferred positioning: Supine with head of bed elevated to decrease aspiration risk 1

Monitoring Requirements

Continuous monitoring is mandatory 1:

• Licensed independent practitioner must evaluate the patient in person within 1 hour of restraint placement 1
• Monitor nutrition, hydration, elimination, physical and psychological status continuously 2
• Restraint order renewal varies by age: Every 1 hour for patients <9 years, every 2 hours for ages 9-17 years, every 4 hours for patients >18 years 1

Chemical Restraint Considerations

Chemical restraint is the involuntary use of psychoactive medication in crisis situations to contain out-of-control aggressive behavior, distinct from ongoing psychiatric treatment. 2, 1

Administration Protocol

• Offer oral medication before parenteral administration 1
• Benzodiazepines (e.g., lorazepam) are preferred due to fast onset and rapid absorption 1
• Consider combination of benzodiazepine plus antipsychotic for acutely agitated patients 1
• Review medical and psychiatric history, including concurrent medications, before ordering 2, 1
• Oral medication must be given sitting up or standing to avoid aspiration 2

Special Consideration for Stimulant Intoxication

In suspected illicit stimulant use, chemical restraint may be preferable to physical restraint due to risk of rhabdomyolysis causing rapid serum potassium increase and potential cardiac arrest 1

Mandatory Documentation and Oversight

Facilities must have a committee providing oversight of seclusion and restraint practices 2:

• Review of restrictive interventions and equipment 2
• Staff training and retention monitoring 2
• Patient and parental concerns review 2
• Peer review of application and use 2

Family notification is required when seclusion or restraint is used 2

Special Population Modifications

For children and adolescents with trauma history, physical and mechanical restraints are discouraged; seclusion may be used preferentially. 2

Staff Training Requirements

Repeated training in aggression management is necessary 2:

• Updated information on seclusion and restraint practices 2
• Frequent practice with restraint equipment 2
• Annual certification in cardiopulmonary resuscitation 2
• Annual education updates from academic, regulatory, patient advocacy, and professional resources 2

Known Complications

Deaths have been associated with physical restraint use, particularly prone positioning 1:

• Skin breakdown 1
• Neurovascular damage 1
• Rhabdomyolysis and potential kidney failure 1

Remove smoking materials from physically restrained patients to prevent burns 1

Termination Criteria

Once the patient is settled and has regained self-control, the restraint must be terminated immediately. 2 Preserving patient autonomy and dignity throughout the process is mandatory 2