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.
Table 1
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 |
| Offer medication |
| 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:
- pregnant
- history of breathing problems
- head or spinal injuries
- history of recent fractures or surgeries
- seizure disorder
- history of sexual or physical abuse.
Table 2
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 |