Restraint and monitoring of psychotic or suicidal patients
Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.
The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.
Psychotic man breaks neck jumping into window
Dane County (WI) Circuit Court
A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.
The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.
In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.
- The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
Dr. Grant’s observations
The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.
I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.
When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.
One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).1,2 Predictably, patients respond negatively to restraints, preferring medication instead.4 When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.
Possible alternatives to restraints
Allow the patient to vent his or her feelings one-on-one with staff
Offer use of a quiet area or provide privacy if patient is upset
Provide alternate activities such as relaxation therapy or art therapy
Set firm, clear limits
Source: Reference 3
Security personnel asphyxiate woman
Pima County (AZ) Superior Court
A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.
The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.
- A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
Dr. Grant’s observations
This case shows how improper use of restraints may result in a successful lawsuit.
In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.5 State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.6
Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:
- history of breathing problems
- head or spinal injuries
- history of recent fractures or surgeries
- seizure disorder
- history of sexual or physical abuse.
In this case, these guidelines were not followed and the patient asphyxiated, suggesting improper training or blatant disregard for her welfare.
Guidelines for proper restraint use
Ensure the restrained patient’s safety and observe him or her continuously:
Keep the patient as comfortable as possible
Provide frequent opportunities for eating, drinking, and elimination, and continually assess physical comfort
Assess the continuing need for restraint, and consider alternatives when possible
Source: Reference 6
Unmonitored suicidal man suffocates himself
Tarrant County (TX) District Court
A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.
For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.
The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.
At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.
- A settlement of $1.1 million was reached.
Dr. Grant’s observations
Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective7 and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.7 Frequently document the patient’s location, activities, and behavior.
To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.8 For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.
1. Richmond I, Trujillo D, Schmelzer J, et al. Least restrictive alternatives: do they really work? J Nurs Care Qual 1996;11:29-37.
2. Donat DC. Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital. Psychiatr Serv 2005;56:1105-8.
3. American Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems. Learning from each other: Success stories and ideas for reducing restraint/seclusion in behavioral health 2003. Available at: http://www.psych.org/psych_pract/patient_safety/sandr.cfm. Accessed September 27, 2005.
4. Frueh BC, Knapp RG, Cusack KJ, et al. Patients’ reports of traumatic or harmful experiences within a psychiatric setting. Psychiatr Serv 2005;56:1123-33.
5. Appelbaum PS. Seclusion and restraint: Congress reacts to reports of abuse. Psychiatr Serv 1999;50:881-2.
6. Joint Commission on Accreditation of Healthcare Organizations. Behavioral Healthcare Standards FAQs on special interventions. Available at: http://www.jcaho.org/. Accessed September 27, 2005.
7. Sullivan AM, Barron CT, Bezmen J, et al. The safe treatment of the suicidal patient in an adult inpatient setting: a proactive approach. Psychiatr Q 2005;76:67-83.
8. Lieberman DZ, Resnik HL, Holder-Perkins V. Environmental risk factors in hospital suicide. Suicide Life Threat Behav 2004;34:448-53.