What is the best approach for transporting an aggressive patient with a history of psychosis or schizophrenia?

Transporting Aggressive Patients with Psychosis or Schizophrenia

For aggressive patients with psychosis or schizophrenia requiring transport, use trained staff (minimum 2 per patient), ensure adequate sedation before movement, avoid prone positioning and airway-compromising restraints, and employ mechanical transport devices (papoose boards, body carriers) rather than prolonged physical holding when moving distances exceed 15 minutes. 1

Pre-Transport Preparation and Team Assembly

Staffing Requirements

• Assign a minimum of two trained staff members per patient for physical restraint during transport 1
• Ensure all transport personnel have completed annual training in restraint techniques, airway management, and recognition of medical emergencies during restraint 1
• Relieve the transport team of all other clinical duties to maintain focus on patient safety 1
• Notify hospital security and the receiving unit before initiating transport 1

Communication and Handoff

• Implement a structured huddle process between the sending and receiving teams before transport begins 2
• The sending nurse should initiate contact with the receiving unit to alert them that a potentially violent patient is being transferred 2
• Both teams should participate in a joint handoff call to discuss the patient's aggressive behaviors, triggers, and management strategies 2
• This huddle process improved staff safety perception from 54.7% to 100% in one quality improvement study 2

Medical Stabilization Before Transport

Pharmacological Management

• Administer appropriate sedation or chemical restraint before initiating transport to minimize the need for physical restraint during movement 1
• Chemical restraint is defined as medication used to control behavior or restrict movement that is not standard treatment for the underlying psychiatric condition 1
• For patients with functional or organic psychosis, mechanical restraint combined with appropriate sedation is recommended to control aggressive behavior 1
• Ensure the patient is medically stable with adequate oxygenation and hemodynamic parameters before departure 1

Medical Contraindications to Physical Restraint

• Avoid physical restraint in patients with obesity, drug intoxication, or conditions that may cause airway or diaphragm restriction 1
• These conditions increase the risk of fatal cardiovascular interactions, airway obstruction, or arrhythmias during restraint 1

Transport Method Selection

Mechanical Transport Devices (Preferred for Longer Distances)

• Use papoose boards, body carriers, or holding blankets (calming blankets) to transport patients from the site of aggressive outburst to the destination as an alternative to prolonged physical holding 1
• These devices are particularly appropriate when transport distance or time exceeds what can be safely managed with physical holding alone 1
• All mechanical restraint equipment must be reviewed annually by the medical staff and appropriate committees 1
• Equipment must have protocols for decontamination when stained with body fluids (saliva, blood, urine) 1

Physical Holding Technique (For Brief Transports)

• Physical restraint for 30 minutes or less does not require the extensive monitoring required for longer restraint episodes 1
• When physical holding exceeds 15 minutes, reassessment by nursing staff and the attending psychiatrist is clinically indicated 1
• Transport the patient in a quiet environment away from other patients 1

Critical Safety Measures During Transport

Airway Protection (Highest Priority)

• Never use choke-holds, face coverings (towels, bags), or any restraint technique that causes airway obstruction 1
• Absolutely avoid the prone wrap-up position (immobilizing face-down), which has been associated with injuries and deaths 1
• If prone restraint is used, the patient's airway must remain unobstructed at all times (not buried in bedding) and lungs must not be restricted by excessive pressure on the back 1
• With supine restraint, the patient's head must rotate freely, and elevate the head of the bed when possible to prevent aspiration 1
• Staff may use gloves, gowns, and face masks if the patient is anticipated to bite, spit, or inflict injury 1

Positioning Considerations

• Some training programs advocate prone restraint while others oppose it; there is no empirical data favoring one approach over another 1
• The National Alliance for the Mentally Ill and some states oppose prone restraint due to safety concerns 1
• Prone positioning is believed to restrict diaphragm motility in obese patients and has contributed to deaths during restraint 1

Monitoring During Transport

Continuous Assessment

• Maintain the same standard of monitoring during transport as the patient would receive in the referring unit 1
• Continuously assess for signs of respiratory compromise, particularly airway obstruction or restricted chest expansion 1
• Monitor for signs of physiological decompensation related to emotional hyperarousal, which may inhibit compensation mechanisms and result in airway obstruction, arrhythmias, or vasovagal hyperactivity 1

Equipment Requirements

• Ensure all battery-operated equipment is fully charged before departure 1
• Have emergency airway equipment immediately available during transport 1
• Equip the transport team with a mobile telephone to enable contact with the receiving facility and base hospital en route in case of clinical deterioration 1

Documentation and Quality Assurance

Required Documentation

• Document all restraint episodes, including the method used, duration, staff involved, and patient response 1
• Review all physical holding episodes lasting 1 hour or longer by the medical director and facility committee on seclusion and restraint 1
• Maintain written policies and procedures addressing communication, personnel, equipment, and monitoring for aggressive patient transport 1

Quality Improvement

• Evaluate and refine the transport plan regularly using a standard quality improvement process 1
• Track adverse events during transport to identify areas for improvement 1
• Retraining of all staff in restraint techniques should occur annually 1

Common Pitfalls and How to Avoid Them

• Using untrained staff for restraint: Always ensure personnel have completed formal training before participating in aggressive patient transport 1
• Rushing transport without adequate sedation: Stabilize the patient pharmacologically before movement to minimize physical restraint needs 1
• Inadequate staffing: Never attempt transport with fewer than two trained staff members per aggressive patient 1
• Ignoring medical contraindications: Screen for obesity, drug intoxication, and respiratory conditions before applying physical restraint 1
• Prolonged prone positioning: If prone restraint is necessary, continuously monitor airway patency and avoid excessive back pressure 1