Doing away with Restraints?

Nurse Ratched, RN · Mar 13, 2004

Not to be flip, but the use of restraints is such a complete pain in the butt paper-work wise, no one goes out of their way to do so. It requires a whole helluva lot of staff time to initiate, a one-on-one sitter who has been trained in NVCI, a private room, and q4h order renewal and q8 hour visual assessment by the doc (try getting THAT at 3 am :chuckle.) We are also required to file a form after the person is released from restraints "debriefing" the episode - essentially asking if there was any way to have prevented the restraint.

The last QI report I saw from our unit was 5 separate restraint episodes in the past one year period; most of them on the adolescent unit, and most for under 4 hours.

Seclusions are a bit more common; still a lot of paperwork, but the patient is able to roam in his room.

We reserve restraints for the patients who are the most violent and cannot be controlled by other means. Typically they are acting out their violence on themselves.

CliveUK · Mar 13, 2004

Here in the UK, mechanical restraints aren't used at all. We use a three/four-man team to restrain a person and more often than not, medicate them under restraint. Once they are calmer, we let go. Sometimes (rarely), medication isn't used at all.

In the management of violence and aggression, restraint is seen as the last resort, if all other attempts to defuse and de-escalate the situation have failed. We are soon to have new guidance from central government on the management of violence and aggression, which will place more emphasis on psychological management than restraint &c. We have also recently had a report published into the death of a young man while under restraint, which recommended new regulations on the use of restraint, on training in restraint techniques and so on.

lucianne · Mar 13, 2004

We don't use mechanical restraints on our child and adolescent unit. Seclusion or physical management by a 2-3 person team is usually enough to allow someone to regain control of themselves. We don't touch anyone unless they are hurting themselves or threatening to hurt other people. We may physically escort them to a seclusion room if they aren't willing to go, but once there we don't touch them if they aren't physically violent. We don't lock anyone in seclusion alone, there's always someone in the room with them and both are checked on frequently. If the patient falls asleep after being medicated, their one to one staff may sit at the door of the room as long as they can still see the patient.

While we don't use the restraints, we have had several kids come up from the ED in 4-point or 5-point restraint but usually when they get to us, they're calm enough that the restraints can be removed. I only know of one case when they couldn't be removed for a couple of hours and I wasn't working.

Of course, the best policy is to prevent escalation before it occurs, but sometimes that isn't possible. I generally believe in medication at the very first sign of agitation in a patient who has a history of becoming out of control.

If you are in a restraint situation, just make sure you know what the protocal is and follow it to the letter.

luci

TitaniaSidhe · Mar 14, 2004

I agree with Nurse Ratched as far as the huge amount of paperwork involved with using leather restraints. Unfortunately at our facillity we do not have seclusion as an option. Restraints are used as a last resort. I would much rather keep a difficult patient medicated & restrained chemically as it is less traumatic to all involved. Sometimes using leather restraints becomes necessary but almost always there is some forewarning behavior wise from the patient. If intervention is taken in a timely manner many times restraint can be avoided all together, this is why it is best to always be very aware of all patients. Unfortunately where I work is an admissions unit & on occasion we have recieved a brand spanking new admission who is so completely psychotic/out of control/violent that I have seen patients kept in restraint for 24hrs. & beyond. I fault these occurances on the docs who are too conservative to do rapid tranquilization but rather give little drips & drabs of haldol or ativan every 4 hours. *sigh* In any event if restraint should become necessary follow policy to the letter for your facillity. Document, document, document- everything. As far as the actual mechanics of placing someone in restraint your facillity prob offers some course on management of disturbed behavior. I would however suggest you speak & listen very well to some of the employees who have worked in acute psych for a long time- nurses & nursing assistants. Their advise can be invaluable in saving your butt in a dangerous situation...

PRNMEDS · Mar 19, 2004

I work on an Adolescent Unit (11 - 17 y/o) in NY. On average we do about 7 - 10 restraints a week (sometimes more ). The majority are with leather restraints (4 points), with a smaller amount being a canvass Calming Blanket.

The 4 point restraints may only last one (1) hour the Calming Blanket 15 minutes. So there is a clear rule or guideline on this. At first I had many of the same fears or worries that you spoke of. However, after seeing these kids hurt themselves, peers, or staff I have come to appreciate that RESTRAINTS are nescessary. Follow your hospitals Rules & Regs, document well. Our guidelines call for restraints when a pt. is endangering themselves, or others. It is used as a "last resort" and is almost always used in conjunction with IM meds (CPZ, Haldol, Ativan). Frequently it is enough to get the patient through a short period when they just cannot control themselves. My advice is to remember you are not placing the patient in restraints as a punishment but rather to insure their and others safety. As for deaths associated with restraints - 99% if not more are related to staff not watching them while in restraints - so make sure you assign a specific staff to do that with each restraint. Also monitor to make sure staff does not get carried away and get to rough (after being assaulted by a pt. this can easily happen). Good luck.

PRNMEDS · Mar 19, 2004

I work on an Adolescent Unit (11 - 17 y/o) in NY. On average we do about 7 - 10 restraints a week (sometimes more ). The majority are with leather restraints (4 points), with a smaller amount being a canvass Calming Blanket.

The 4 point restraints may only last one (1) hour the Calming Blanket 15 minutes. So there is a clear rule or guideline on this. At first I had many of the same fears or worries that you spoke of. However, after seeing these kids hurt themselves, peers, or staff I have come to appreciate that RESTRAINTS are nescessary. Follow your hospitals Rules & Regs, document well. Our guidelines call for restraints when a pt. is endangering themselves, or others. It is used as a "last resort" and is almost always used in conjunction with IM meds (CPZ, Haldol, Ativan). Frequently it is enough to get the patient through a short period when they just cannot control themselves. My advice is to remember you are not placing the patient in restraints as a punishment but rather to insure their and others safety. As for deaths associated with restraints - 99% if not more are related to staff not watching them while in restraints - so make sure you assign a specific staff to do that with each restraint. Also monitor to make sure staff does not get carried away and get to rough (after being assaulted by a pt. this can easily happen). Good luck.