Physical Restraint

Reviewed and revised 30 July 2014

OVERVIEW

• 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

INDICATIONS

• actual or high risk of harm to self, others or property where verbal de-escalation is inappropriate or ineffective

CONTRA-INDICATIONS

• medical instability
• risk of harm to staff in applying restraint
• alternative strategies available and appropriate

ASSESSMENT

• See chemical restraint

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
• ECG
• Blood pressure
• Close monitoring of conscious state and airway adequacy
• neurovascular observations distal to restraints

Documentation

• 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

Disposition

• 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

Journal articles

• 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

• EMCrit — Podcast 060 – On Human Bondage and the Art of the Chemical Takedown (2013)