Physical Restraints on Acute Child and Adolescent Unit

[tconlgirl]

So, I recently applied for a position on an acute child and adolescent behavorial health unit. While I was there with the nurse manager, we were discussing the in's and out's of the job and he told me that when isolating a patient they CANNOT use 5 point restraints. They must only use techs or other trained professionals to physically restrain, and then basically move out of the room as quickly as possible. I know they use 5 points at the adult acute center in town, and I assumed that they could use them here as well. The also very rarely use IM ativan or other "chemical restraints" like less than 25 /year. The nurse manager said that this was a JCAHO thing. Is this a typical thing for child/adolescent units? I understand why they shy away from the ativan, but for the safety of the staff why no five point restraints? Is it like this at your facility? I am in Nebraska if it makes any difference.

Thanks in Advance

Sally

[lucianne]

When I worked acute child and adolescent, we did not use 5-points either. Therapeutic holds were all done by nurses and techs. We also did not leave a patient alone in seclusion. A couple of years ago, I ran into one of the staff and she told me they had reduced holds and seclusions dramatically with behavioral interventions and timely PRNs. When we did use chemical restraints, it was usually benedryl or thorazine (they aren't using thorazine on the unit much any more either). Ativan was way too disinhibiting.

[tconlgirl]

Well thats good to know. I support the use of least restrictive means necessary. It also illustrates that there are considerable differences between adult and child psych units. Another thing about our unit is that we have great docs that support "medication vacations" and then start over in assessing symptoms. Apparently some kids come in on dozens of meds and only need one or maybe two, or are completely mis-diagnosed, bipolar is a big one.

Thanks for Sharing

Sally

[stephva1008]

We don't use 5 point restraints either. We do use 4 point restraints and only on very rare occasions and never for longer than 2 hours start to finish. We rarely use seclusion and restraint (maybe once every 2 months). Training staff to recognize the stages of the crisis cycle helps. We do use therapeutic holds for IM injections. Some kids go from 0-60 in seconds and you can't always spot the signs of escalation. We use Thorazine which works 8 times out of 10. The teenagers who have substance abuse issues usually get Ativan IM on top of the initial thorazine.

Loads of kids have died in restraints and we are actually considered a "restraint-free" facility due to the few actual restraints we do have. But we're trained in it because there's always that possibility.

[Orca, ADN, ASN, RN]

Another thing about our unit is that we have great docs that support "medication vacations" and then start over in assessing symptoms.

I have worked with a number of doctors who did this. It is often a good idea. Sometimes patients get on such a hodgepodge of different medications (and sometimes from different doctors who don't know everything the patient is taking) that the end result is a mess.

When I was working on a hospital adult mental health/CD unit we had a family practice doctor in the community who liked to play psychiatrist. Instead of referring his patients to a specialist he would try to treat their conditions himself - with less-than-ideal results. At one time we were getting two or three of his patients a week. His approach was to give the most popular medication for whatever symptom the patient reported (anxiety, depression, etc.), and if that didn't work he would add something else without DCing any of their prior meds. By the time we got these people they would be on five or six different meds, some of which were working against each other. Our psychiatrists' approach was usually to stop everything and start from ground zero in treating the problem. Often the problems came more from the meds than anything else. Several were sent home on nothing at all.

[tconlgirl]

I think there should be regulations on physicians who are NOT psychiatrists prescribing psych-meds. I know some people would argue that this is mainly an ethical issue, as they are within their defined scope of practice or that its "easier" ( and less costly) to manage their care at a PCP than to involve a psychiatrist. However, would YOU want a GP doing your heart procedures or being the sole Dr at your C-Sect? Or haphazardly prescribing brain altering medications? I think not. Just some examples of how the medical community sometimes gets it wrong.

[Orca, ADN, ASN, RN]

My impression is that some doctors believe that they can practice psychiatry because there is no organ system involved. Psychiatry is as much art as it is science. Post-op care for patients with the same procedure usually won't vary much from patient to patient, but in psychiatry you can have two patients with identical diagnoses and symptoms that require entirely different approaches to treatment. Throwing the most popular medication at the most evident symptom is not always the best approach. For instance, a depressed patient may actually be bipolar, but if the patient seeks treatment while in the depressive phase (which most of them do), you are treating a symptom but not the underlying cause if you give them Zoloft or Paxil. Those medications may prove to be useful, but a trained specialist should be prescribing them.

[Jules A, MSN]

We don't use restraints but the PRNs flow like a river! I'm not sure I'm in favor of medication vacations because even the tweaking of meds can result in disasters in the acutely ill children I care for. My kids are residential so the only meds they are on have been prescribed by one of our psychiatrists. It would make for an intersting thread.

[aloevera]

No 5 points used at my facility either........but I try to use PRN's at the first sign of escalation.........we use Zyprexa and Benadryl most frequently....

Seroquel sometimes but haven't used Ativan in quite some time.

I agree, I see kids coming in with bags of medications.....makes you wonder...are the helping? or causing?? But I don't think I agree with taking them off of everything so dramatically.....that could cause problems, too...I don't know what the answer is.....Our Docs usually try other meds, cuz evidently what they are on is not working or they wouldn't have come in !!

It is a catch 22.........

[marilynmom, LPN, NP]

I work in adolescent psych and we don't use restraints either, only CAPE holds.

[cocoon2butterfly]

...he told me that when isolating a patient they CANNOT use 5 point restraints. They must only use techs or other trained professionals to physically restrain, and then basically move out of the room as quickly as possible...

By isolation, did he mean seclusion??? Because I wonder if he meant that you couldn't use 5-point restraints during isolation because it would count as a double restraint, which I know you can't do at my facility...this sounds like it might fit what you're asking...