Restraints - page 2

by jojo

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Looking for information on use of restraints for acute patients in psychiatric nursing in USA. What sort of restraints are available What are the rules? What are the feelings of American nurses reguarding the use of... Read More


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    Originally posted by jojo:
    Looking for information on use of restraints for acute patients in psychiatric nursing in USA.
    What sort of restraints are available
    What are the rules?
    What are the feelings of American nurses reguarding the use of restraints?
    What is the ethical position?
    What is the legal position?
    Any information and references, especially web references. Thanks.
    I'm a registered practical nurse in Canada and I must say I was a bit surprised at the replies you've received (from the original questions). I've worked in a large provincial psych hospital for sixteen years in geriatrics, chronic care, rehab and admissions. Over the years I have seen a fair bit of change in management of disturbed behavior but none so positive as has been described here. Certainly there is much less use of passive and active restraint in our facility but restraints are still utilized frequently. Our policies have become tighter, with higher degree of monitoring by physicians.

    Currently we use "special observation rooms" when a client becomes dangerous to himself or others. If the person is at risk of self harm, seclusion is not permitted. They are either monitored at least every fifteen minutes OR if they are more critically suicidal, they are monitored on a constant one on one protocol. Clients with self harm/suicidal ideation are NEVER secluded (locked in a seclusion room). Agressive/threatening/hostile/abusive clients are secluded, monitored every fifteen minutes and when escorted to the washroom or shower they are on constant observation by two or more staff. Most times when a constant observation client is out of seclusion the physicians will order that they must wear three point OR wrist to waist restraints. These are applied before bringing the person out of seclusion and then ALWAYS removed before seclusion resumes. Wrist to waist to chair orders are less and less frequently used, ankle to ankle restraints are also used less frequently in recent years. The type of restraints we use are cloth and velcro wrist to waist restraints (which I personally don't care for since most clients can easily remove them) and the older version of plastic keylock cuffs with leather belt. These have an archaic appearance but when used are far superior IMHO. When a client is completely out of control and use of medications is limited or ineffective, or if the person is at serious risk of suicide even with constant observation, we have a specially designed bed that is used in combination with the leather and plastic cuffs, to prevent imminent harm of the client or others. I work in an acute admission ward so we use this means of restraint a few times a year. In any of the described cases, the expectation is to use the restraint for the least length of time as possible and encourage the client to regain control of his/her actions. Other restraints used previously were the "Posey Company" restraints. These generally were used in chronic care and geriatrics to restrain clients in bed or in a chair. They were generally used with clients suffereing from dementia where the client was unaware that they could not ambulate and would be at risk in the night of getting out of bed. The "vest" type of bed/chair restraint have been banned due to strangulation accidents that occurred in our facility and others around the world. We still use belt restraints for this type of client. It is secured to the bed/chair with a magnet and around the patient's middle with a magnet. When applied properly these restraints are quite effective in preventing falls. These again are used less and less but are effective in certain situations such as dementia clients who are post surgery and don't realize they are not to be walking.

    I can't comment on your question about detox and seizures, as I have not worked in this kind of situation. Our clients have to be physically cleared in a general setting before they can be admitted, so if they were in detox we would return them to a general hospital.

    ------------------
    Barb
    Registered Practical Nurse
    Psychiatry
    Ontario CANADA
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    WOW
    I can not believe the use of restraints. What happenned to risk management? If a client is a risk for violence why not call in extra staff to assist? We have two ten bed closed units at my hospital, no jackets and no wrist restraints. We have the most abusive and violent clients come in. When an admission comes in, a risk assessment is done before their arrival. Staff from other areas are called in to assist and when the client enters the ward admissions area they are greeted by 5 or more staff members. When they are yelling/screaming we give them the opportunity to talk, modelling to them the behaviour/interaction we are wanting. When these skil;ls don't work we let the client know firmly the expectations of their behaviour. When this does not work we expklain to the client that they are going to get medication to help their agitation. If they refuse they are then given an opportunity to chose how they want the medication, either injection or orally. The next step is that staff restrain him/her, placed in seclusion and medicated IM. Throughout the process we re-emphasize it was his/her decision to have the injection, what medication is given and what the expeceted outcome will be. We also explain to them the legal implications of what is happenning so that the client can understand this is treatment and not punishment. When the client is asleep, the seclusion door is oipened and trhe client upon awakening finds him/herself in a corridor where he/she can come to the nurses station window to speak to staff. Haldol is being less used, and a combination of zuclopenthixol and midazalam are being used, less side effects and quite sedating (short-term).

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    [This message has been edited by psych-rn (edited March 28, 2001).]
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    I worked for an unlocked psych crisis unit; a bizarre setup. If the client was a risk to self/ others we had to put them on an involuntary hold--but could not lock them in a room!! On a typical night the police would bring in a suicidal client (in cuffs) who wanted to go back out and finish the job. The cuffs would come off and the client would run. They would go to the "restraint room"; I'd jump on the phone with the doc and the police would assist in the restraint. We used a combination of chemical/ mechanical restraints. Clients would get one on one observation, nursing checks q15 mins, and the doc had to be called after 2 hours for another order. After 4 hours, the doc had to come in. Usually after an hour, the meds would kick in and the patient could be released. There were nights when I had tandem restraints, and several people detoxing!! I'd run from one room to another with my equipment and juice and snacks and a notepad to keep track of myself LOL! Luckily I had good docs and great social workers-- the police were a big help too.

    The state department of mental health created guidelines for the use of restraints (we always used leather, except for children-- then it was the "burrito bag", but very rare). Our first duty was to keep the client and ourselves safe from harm until they could transfer to the hospital. The order for involuntary hold could be completed by the police, court, probate officer or doctor. Careful documentation to validate the need was essential. There were times we had to let the person run and then call the police to bring them back and write the order.

    [This message has been edited by TopazStone (edited April 16, 2001).]
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    Originally posted by elainelisa:
    Hi..I want to find out if you should put a patient who is actively going thru alcohol withdrawal and having DT's into restraints, if they are also at risk for having a siezure. I cared for a patient who had a siezure after dialysis, who also needed to be restrained because he was disoriented and climbing out of bed while going thru ETOH withdrawal. Meds were not working with him because of his poor liver and kidney function... restraint use was literally our last option and we could barely keep control of him with those on! What have you heard or found out? Please reply. thanks
    Where possible different types and strengths of medication should be used to reduce agitation, however in the event the patient is still so agitated that he is a risk to himself, then as a nurse I would be satisfied restraint was needed. Most places do or should have protocols on their safe use and the guidelines and all care taken. Other options should also be considered where possible eg confine to a small area with limited furnishings (a mattress on the floor ideally), reduced stimuli/light and sometimes the presence of a close family member can help. No one likes restraining patients but we want the patient to be safe when going through this painful process.

    Michelle
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    I WORK FOR A STATE MENTAL HOSPITAL. AS OF JAN '01, WHEN A PATIENT IS PLACED IN SECLUSION OR RESTRAINT (WHICH IS ONLY AN OPTION IF THEY ARE AN IMMEDIATE THREAT TO SELF OR OTHERS),THE RN MUST SIT 1:1 WITH THEM IN RESTRAINT ROOM OR OUTSIDE SECLUSION ROOM DOOR (VIEWING THEM THROUGH WINDOW). THE RN MUST DOCUMENT PT'S BEHAVIOR EVERY 15 MINS. IN THE PROGRESS NOTES AND ON A SPECIAL FORM. THE DOCTOR MUST ACCESS PATIENT WITHIN ONE HOUR OF PATIENT GOING IN. ORDERS ARE GENERALLY UP TO 4 HOURS. MY FACILITY IS TRYING TO GET TO ZERO RESTRAINT AND SECLUSION HOURS.
    IT HAS BEEN MY EXPERIENCE THAT SITTING OUTSIDE SECLUSION ROOM DOOR LOOKING AT A HIGHLY AGITATED PATIENT TENDS TO INCREASE THEIR AGITATION.
    PRIOR TO THIS NEW POLICY, THE PATIENTS WERE MONITORD BY A PSYCHIATRIC ATTENDENT SITTING AT A VISUAL AND AUDIO MONITIR 1:1 THROUGHOUT THE SECLUSION/RESTRAINT. THE RN WOULD ACCESS PATIENT IN PERSON EVERY HOUR AND DOCUMENT. THE PATIENTS VITALS EVERY 2 HOURS WERE MONITORED. ALSO ROM OF RESTRAINED PATIENTS WAS DONE EVERY 2 HOURS.
    MANY TIMES I HAVE BEEN THE ONLY RN FOR THREE UNITS (EACH UNIT HAVING APPROX. 20 TO 25 PATIENTS). THE ONLY TIME ASSISTANCE IS ASKED FOR FROM THE SUPERVISORS OR NURSES IN OTHER AREAS OF THE FACILITY IS TO BE IN EMERGENCY SITUATIONS (ANOTHER PATIENT GOING OFF OR NEEDING IMMEDIATE ATTENTION). OTHER THAN THAT, MY WORK ALONG WITH ALL THE OTHER PATIENTS, IS BASICALLY "ON HOLD".
    DO OTHER FACILITIES HAVE THE STIPULATION THAT IT MUST BE THE RN THAT SITS 1:1 WITH RESTRAINT/SECLUSION PATIENTS?
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    Quote from jojo
    Hi Las

    Thankyou so much for your reply. This information is very useful.

    What I am really looking for are descriptions of what is actually permitted by the current rules what these rules are and who is responsible for formulating these.

    The restraint practices in the UK are a little different and the reason for my enquiry.

    Since 1959 all forms of artificial restraint devices are banned. Restraint may be used legally to prevent injury to the patient, other patients and property but this takes the form of physical contact, holding the patients wrists usually. In extreme cases several nurses may assist in physical restraint. Clearly this is a short term measure though.

    Isolation rooms are still used in some hospitals but these may only be used for a maximum of 1 hour after which a doctor must attend.

    In the past 10 years this physical restraint has been gradually phased out, except to protect other people from harm and then only sufficient to remove that harm. 'Cot sides', rails applied to the side of beds and chairs which have special tables which can be secured to make standing up difficult are now outlawed.

    The result has been that actual violence is comparitively rare in most psychiatric hospitals. My own experience from working in forensic (legal), long stay, mentally acute and elderly is that I have rarely if ever been attacked with the exception of elderly confused and in this case any such attacks usually ammount to grabbing, throwing something, or an agressive gesture and are easily resisted, usually by diverting the patients attention.

    I should say that there are a few hospitals where old habits amoung staff do surface but over the last 20 or so years these old hospitals have been closed down.

    Now this is very important. I discovered the existence of restraint practices in US psychiatric hospitals while reading some articles on the internet. I have discussed this with some colleagues and the consensus is this:

    Care of the mentally ill is a social matter. While progessive approaches are to be applauded such progress is a matter for the local society and it is not our place to criticise or place judgement upon another society's practices. Clearly, in the UK society has a more developed attitude to mental illness than in other countries but this is down to UK society and any lack of progress in this regard is not an criticism of psychiartic nurses elsewhere, though it may be a criticism of leadership.

    Secondly, we are all jointly interested in the approach curently used in the US. We appreciate that many issues are currently a mater for local debate. I have managed to access some American Nursing Magazines and down-loaded articles on reforming the current practices in relation to restraint. However we are very interested in learning what the current regulations and practices are and the equipment used.

    I hope you can help. If you want any further information from our side of the pond, please don't hesitate to ask.

    Jojo
    Wow, I am so impressed by the Uk philosophy of care. Unfortunately mechanical external controlls such as restraints and seclusion and sometimes chemicals are still unnecessarily being frequently used to treat the mentally ill in psychiatric hospital in this Country even though many of our laws will dictate otherwise.

    Have you read about the Pa. success story; Leading The Way Towards a Seclusion and Restraint-Free Environment?

    You are right, positive leadership is required if we are to change the insensitive culture of care that has existed far too long in this country when it comes to treating the mentally ill with the dignity and respect they deserve.

    Yes, I would love to hear more information from your side of the pond.

    Warm regards,

    Tom
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    I can not believe the use of restraints. What happenned to risk management? If a client is a risk for violence why not call in extra staff to assist?
    There is NO extra staff & that many times is a large part of the problem. I have worked acute, locked, psych admissions for the past 14 yrs. Most certainly our us of mechanical ( leather ) restraints has decreased however they are still utilized. Matter of fact I utilized them just last night on an acutely psychotic, assaultive Paranoid, Schiz. Yes all alternatives such as medications, offering quiet area, activity, 1:1 interventions, etc. are to be tried prior to utilization however my frustration comes in when I am attempting to medicate a potentially out of control patient & the covering doc is waaaaay too conservative with ordering prn meds that will effectivly chemically restrain the patient & thus hopefully avoid the use of the mechanical restraint. *sigh* That coupled with the EXTREEM sthortage of staff on the units makes for a dangerous environment. I worked the unit last night with myself, 1 LPN & 3 NA's. I had a census of 26 male/female patients- 1 of which was in restraints with 1:1 observation, 1 of which was on 1:1 observation for unpredictable behavior & 7 of the 26 patient were committed by the court to be hospitalized. *sigh* I dislike having to use mechanical restraints however when your facillity leaves you no other alternative due to the choices offered...you just do yur best in the circumstance & document, document, document.
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    I don't think there is a national organization that sets laws for restraints but rather is done on state by state basis.

    In NY it is OMH (Office of Mental Health) in conjunction with JACHO.

    The facility where I work currently use leather restraints. Restraints are strongly discouraged and used only as a last resort if a patient is posing and IMMEDIATE threat to themselves or others. A doctor must order the restraint and they can last no longer then an hour.
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    Hello Jojo,
    I was trained in the UK and therefore know the philosophy behind the use of physical holding and medication when other methods of de-escalation have failed. I too have an ethical reluctance to look at mechanical restraints. However our Area Health Service and the NSW state are looking again at the use of mechanical restraints as being an acceptable action in an acutely disturbed client.
    The reason, Health & Safety at Work legislation, the law here states that if an employer does'nt do everything in their power to reduce the risk of injury to staff, they will be liable to heavy fines. This legislation supercedes all other Acts, including the Mental Health Act and also puts the safety of workers above the rights of individual clients.
    In light of this, mechanical restraint, which once imposed, prevents injury to workers and is being looked at as acceptable. Chemical restraint, is considered a lesser option, because of the risk to workers who are required to monitor the clients obs while sedated.
    As yet, this has not become common practice, but our ex-medical director for mental health is now heading for the centre of mental health, and he is in favour of the use of mechanical restraints for the reasons I have outlined... ho-hum
    regards StuPer
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    Quote from PRNMEDS
    I don't think there is a national organization that sets laws for restraints but rather is done on state by state basis.

    In NY it is OMH (Office of Mental Health) in conjunction with JACHO.

    The facility where I work currently use leather restraints. Restraints are strongly discouraged and used only as a last resort if a patient is posing and IMMEDIATE threat to themselves or others. A doctor must order the restraint and they can last no longer then an hour.
    Actually there are Federal requirements now for facilities receiving Medicare/Medicaid funds. Here is a link to get you started. It pertains mostly to children but you can follow links to the regulations for adults.
    http://www.bazelon.org/issues/restra...n/children.htm

    I have worked in psychiatric inpatient units since 1976 in six different states and a couple of dozen different facilities. The variations in philosophy and rules among facilities is very interesting. Some states (and some institutions in other states) consider mechanical reatraints more humane than chemical (drugs) restraints. Others ban using drugs for control purposes. I worked on one hospital general psychiatric unit where security guards actually used mace on patients on the psych unit. (Twice in a one year period.) Other states absolutely forbid anything like that.
    I remember having people in restraints for days at a time and thinking it was okay. Now I seldom see restraints lasting more than an hour or two. I used to think it was ok to leave someone who was asleep in restraints overnight to reduce risk to night shift staff when there aren't as many people around.
    I have read discussions on the issue of whether or not to use restraints dating back as far as the 1830's.
    I would love to find a way to have a restraint free environment but I don't think it is feasible in the types of units I've worked on.
    Two things that make it difficult:
    1) Continued reduction is staffing. You need adequate staffing for a couple of reasons. Obviously, more staff can pay closer attention to what's going on and prevent situations from escalating to the point of violence. Less obviously, many psychotic patients become frightened if they think staff can't protect them, and they will act out as a way of forcing you to demonstrate that you can take care of a situation.
    2) In some parts of the country the increasing use of methamphetamine has increased the incidence of violence on psychiatric units. It is the most disinhibiting drug I've ever seen. People high on "Ice" are often extremely aggressive and do not respond to most de-escalation strategies.

    I have found that many nurses take the philosophy of non-violent interventions way too far. I have seen many nurses get hurt because they personally or the unit they work on believe in no restraints and no intervention that might cause discomfort to a patient. I believe now that I have a right to protect myself and a responsibility to ensure that I can return to work the next day. From some of the responses to this thread, it appears that some institutions are starting to come around to this, even if it's only due to fear of liability.

    I would be interested in more responses as to what you personally believe is ethical and appropriate regarding use of restraints and self-protection methods.


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