Question

  1. Am I right in thinking that, over there in North America, you sometimes use physical restraints (leather straps and the like) to control violent behaviour? If I am right, I'd like to know what your thoughts are about them, as I was debating this with some people the other day. Over here, it's four man restraint teams and medication. I was arguing that maybe there's some value in physical methods of restraint as opposed to chemical restraint, in that the physical restraint is over when it's over, whereas meds can hang around in the system for days, causing side-effects and what have you.

    I'd appreciate an American perspective on this.

    Thanks,

    Clive
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  2. 20 Comments

  3. by   Youda
    It depends on the setting. In nursing homes and long term care, leather or four-point restraints are forbidden by law. In an emergency room or psych unit, I think they are still used (someone help me here?) as a temporary measure to control violent patients until medication takes effect or they can be transferred to another setting. I've seen EMTs use leather 4-points to keep a violent patient on the guerny while being transferred to the ER . . .
  4. by   LilgirlRN
    Yes Youda you're right, we do use the leather restraints in the ED from time to time. There is so much paper work involved in using restraints that we try our best to not have to restrain anyone at all. The acutely psychotic patients are the ones who get them most often, we usually use medication in conjunction with the restrains. We wait until the meds have taken effect and try to remove the physical restraints. If you do use leathers you have an assessment sheet where you have to check every 15 mins to make sure that the circulation is good etc. We have to desparate to use them, fearing for our lives desparate.
  5. by   maureeno
    I work on an 'intensive psychiatric care unit' and people are sent to us often because they need physical restraints. Some come from nursing homes and other medical units. Some people are in them for days; we can even bind hands and legs to help them get a shower or ambulate.
    We use 5 pt. leather restraints, extremities and waist. We reduce them one point at a time to 2 pts. [always a waist] and then discontinue.
  6. by   sanakruz
    Restraints are routinely used in acute psych settings. The person is strapped to a bed at 4(sometimes 5) points.There is much debate about this: Face up or face down? Face down appears to be less dangerous for the pt. With meds or without? Usually with meds. How much decision-making power does the floor staff have?(read RN) Always an MD's order must be obtained- but it happens after the fact. At the last acute facility I worked it was not acceptable to have a standing order for restraints. Yet in reality there was an unwritten unspoken standing order cuz if someone acted out we would restrain them first, call md later. How can you walk the fine line between keeping someone safe and punishment?
    Once a very psychotic man received some unpleasant news while he was hospitalized. This news made him angry and he said so. He walked into his room and returned to the nurses station with a towel, which he began to wrap around his right hand. Several of us began to plead with him not to do what we correctly anticipated. He punched out a window. He calmly removed the towel from his hand and sat on the floor. We were split on how to deal with this. Half the staff said the incident was over, no physical intervention needed ;half said he was unpredicatble and needed seclusion, restraints and emergency medication. This man had alot of the negative symptoms of schizophrenia, poverty of speech, social isolation. The restraint camp won. I disagreed but am a team player.
    It seemed to me more like punishment than tx at that point.

    I hate this intervention. If I personally were restrained I'm sure it would escalate whatever problem I was having.

    I have seen children restrained day after day because they like the drama and negative attention.

    I realize confused nursing home pts are restrained for saftey reasons but I still see it as cruel, and I believe a restraint free environment is possible WITH ADEQUATE STAFFING LEVELS.


    Violence is never ok. Physical violence happens. Gotta act. I guess the answer is to look at each incident as a seperate entity, and debrief each time.
    Having a crisis intervention team with a clear leader helps too. I have worked in places where de-esclation technigues were the first line of defense.
    Last edit by sanakruz on Nov 26, '02
  7. by   maureeno
    we never restrain face down.
    when our unit opened 20 years ago I requested and tried out the experience of being restrained, was very scary when staff left the room and locked the door and I will never forget the vulnerable feeling I had. I always recommend it to new staff, hardly any are takers.
  8. by   sjoe
    These and other (like "chair") restraints are used in both psych and corrections.

    My thoughts? They ought to be used more AND with much less paperwork involved. That combination would prevent a lot of staff injuries, as well as not wasting so much staff time.

    IMHO.
  9. by   slinkeecat
    I work in a forensic pysch hosp. We use mechanical restraints... 4 point leathers as a last resort when all other interventions have failed when trying to de-esculate a patient. We use CPI We are required to get a doc order (we have a doc inhouse 24/7) and then we have to document 15 min intervals, we usually medicate (chemical restraint) , we can keep them in restraints up to 3 hrs at a time and then we have to do a trial release. If they are not cooperative and will not contract for safety then we can can get a doc order to continue. The doc has to examine them with one hr of the time the pt is placed in restraints.

    I feel that CPI (Crisis prevention intervention) works. We have a crisis team and we all work well together. Sometimes a little seclusion and leather restraints is exactly the attitude adjustment that the pt needs......

    I am a big fan of chemical intervention. Haldol and Ativan can work magic.....it depends on the pt ....
  10. by   slinkeecat
    I do want to mention that there is a danger of medical issues that we seem to forget... when you place a pt in leathers you have to check for circulation and we have seen a rise in the incident of DVT in the metally ill from venous stasis ....even from one hr of being tied down.... I always try to keep that in mind I would rather let them walk around than to drug them up to the point of inactivity and then find them dead of a pulmonary emboli it has happened in the past and it is something I think about....you have to be very careful when you have to restrain a person ....... just a thought Every intervention has it's risks!@
  11. by   CliveUK
    Thank you for your answers - very illuminating. As I said, over here, we never use mechanical restraints. De-escalation is the first line of defence, followed by restraint (by nursing staff trained in restraint techniques) and meds (if necessary). Seclusion (or as it is now called, "supervised confinement") is a last resort. Sometimes, the restraint team can be holding people down for a long time, though we try to avoid this as there have been documented cases of patients asphyxiating through restraint (the face down position can compromise breathing, especially if the patient is very aroused). What this inevitably leads to is the use of high doses of medication, with all their concomitant dangers. I guess nothing's perfect.
  12. by   sjoe
    slinkee--you are right that every intervention has its risks. as does the lack of intervention in many of these cases, particularly for the staff.
  13. by   Frankcah
    Im a uk nurse, and I must say that mechanical restraint really bothers me. There are methods to restrain people that require less than 4 people (and I presume u mean C & R) which I am very much opposed to. Other methods such as the Studio 3 approach uses methods such as walk around techniques which has many benefits over traditional restraint. It is more dignified. U do not hold people down. U use the patients energy in a more positive way...
    When people are in a hightened state of arousal, adrenaline is coursing through them and so the best way to is to metabolise (and therefore shorten the duration of the period of anxiety) this through exercise and movement, not holding someone down and sticking a needle in their arse!!!
    It is something that has really bothered me in the past, especially when staff feel that decking someone and holding them down is a power thing. Surely this is wrong!
    I'd appreciate feedback...
  14. by   sjoe
    Frank--interesting THEORIES you have. So what happens when you are working a forensics psych ward with 25 male patients, several of whom are relatively easily triggered, one assaults another and they begin fist-fighting, throwing chairs, etc. And the staff consists of you (an RN) and ONE aide to help out. Several of the patients are now "getting high" on adrenaline, shouting, beginnning to get into each others' spaces, etc.

    Duh!

    If you can, you grab the major troublemaker and put him in restraints, then the next one, etc. until things calm down. If you need more help temporarily to do this, be aware that this "help" might take 15 or more minutes to arrive.

    Whether restraining or decking "bothers you" is beside the point. It might bother you a lot more to have your two front teeth punched out (as happened to one of my co-workers) in a similar situation. Fortunately, this was just before shift change, so while I was wrestling with the chief assailant (I had to physically pull him off her as he was trying to twist her head off, literally), one of the new staff happened to come in and notice us. Together we wrestled him into restraints in a seclusion room.

    So while your theories may sound "nice" and "humane," we are talking about the real world here, not a nursing school exercise. Liberal sentimentalism (as one of your own--Terry Eagleton terms it in his excellent and amusing "The Gatekeeper") is hardly a useful model when the rubber meets the road.

    (Or perhaps the psych patients in the UK are better-mannered than some of ours.)

    By the way, that facility's theory was (and perhaps still is, I don't know since I quit after that shift when they inappropriately blamed the injured nurse for this attack) that it "bothered them" to have these patients on high doses of psychotropics, so they were using minimal doses, or none at all. (Of course, these decison-makers were not around to put out the fires their policy caused. Surprise!)
    Last edit by sjoe on Nov 30, '02

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