Reviewed and revised 30 July 2014
- Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
- Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving
- all available alternative treatment options should be considered before administering chemical or physical restraint, as it infringes an individual’s autonomy and dignity
- actual or high risk of harm to self, others or property where verbal de-escalation is inappropriate or ineffective
- medical instability
- risk of harm to staff in applying restraint
- alternative strategies available and appropriate
APPROACH TO PHYSICAL RESTRAINT
Exclude other therapeutic options first
- e.g. attempt verbal de-escalation and involvement of trusted others
Ensure safety at all times
- do not attempt physical restraint if inadequate staff available
- if unsafe allow patient to leave
- call Police if appropriate
Prepare physical restraint team
- activate the appropriate code to assemble team
- requires 6 trained staff
- Personal protective equipment: Gloves, gowns and face-masks when possible
- brief team (e.g. indication, size of patient, specific risks e.g. martial arts training, potential weapons)
- allocate roles and and state plan of action
- decide on trigger word to be used to initiate action
- give patient a final chance to comply with requests with restraint team in attendance (‘show of force’)
Initiate manual restraint
- one person for each limb
- one person controls the head (has airway skills)
- one person to administer pre-prepared medications
- restrain limbs with one arm above and one arm below the knee
- trigger word used to initiate patient take down; some advise initially into a prone position (safest for staff) but patient must not remain prone
- Arms beside body, legs extended – alternative is to have one arm up (reduces movement)
- avoid neck or torso restraint (unsafe for patient), avoid hobble restraints (i.e. tying hands and legs behind back)
- use medical grade restraints secured to the bed-frame (not side-rails)
- explain to patient what is happening at all times
During manual restraint
- administer chemical restraint when safe to do so
- supine position
- Elevate head of bed to 30 degrees (decrease aspiration risk)
- No pillows (decrease suffocation risk)
- perform cyclical limb release if possible
- ensure appropriate fluid maintenance, toileting and pressure cares
Monitoring (according to depth of sedation) may include:
- Pulse and respiratory rate
- An initial temperature should be recorded
- Pulse oximetry
- Blood pressure
- Close monitoring of conscious state and airway adequacy
- neurovascular observations distal to restraints
- reason for restraint
- alternative therapies attempted
- assessment of potential injuries and any complications of restraint
- monitoring plan
- thresholds for further interventions
- ongoing sedation options and sedation chart
Removal of restraints
- as soon as possible
- once patient is calm and/or sedated
- remove restraints from one limb at a time, start ith a leg then contra-lateral arm
- place in recovery position if sedated
- close observation will be necessary until the patient recovers from sedation (able to safely eat, drink and toilet)
- debrief patient when calm (explain what happen, ask patient to volunteer what they could have done differently, agree on future strategy)
- psychiatric assessment
References and Links
- Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012 Jan;109(3):27-32. PMC3272587.
- Cannon ME, Sprivulis P, McCarthy J. Restraint practices in Australasian emergency departments. Aust N Z J Psychiatry. 2001 Aug;35(4):464-7. PMID: 11531726.
- Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.
- Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.
- Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. PMC3298214.
- Melamed E, Oron Y, Ben-Avraham R, Blumenfeld A, Lin G. The combative multitrauma patient: a protocol for prehospital management. Eur J Emerg Med. 2007 Oct;14(5):265-8. PMID: 17823561.
FOAM and web resources
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.