Adverse events related to physical restraint use in intensive care units: A review of the literature.

Physical restraints are widely used and accepted as protective measures during treatment in intensive care unit (ICU). This review of the literature summarizes the adverse events and outcomes associated with physical restraint use, and the risk factors associated with their use during treatment in the ICU. The PubMed, Scopus, and Google Scholar databases were screened using predefined search terms to identify studies pertaining to adverse events and/or outcomes associated with physical restraint use, and the factors associated with their use in adult patients admitted to the ICU. A total of 24 articles (including 6126 patients) that were published between 2006 and 2022 were identified. The described adverse events associated with physical restraint use included skin injuries, subsequent delirium, neurofunctional impairment, and a higher rate of post-traumatic stress disorder. Subsequent delirium was the most frequent adverse event to be reported. No alternative measures to physical restraints were discussed, and only one study reported a standardized protocol for their use. Although physical restraint use has been reported to be associated with adverse events (including neurofunctional impairment) in the literature, the available evidence is limited. Although causality cannot be confirmed, a definite association appears to exist. Our findings suggest that it is essential to improve awareness regarding their adverse impact and optimize approaches for their detection, management, and prevention using protocols or checklists.

Impact of the restraint decision tree for physical restraint use in South Korean neurointensive care units.

BACKGROUND: Nurses in neurointensive care units (NCUs) commonly use physical restraint (PR) to prevent adverse events like unplanned removal of devices (URDs) or falls. However, PR use should be based on evidenced decisions as it has drawbacks. Unfortunately, there is a lack of research-based PR protocol to support decision-making for nurses, especially for neurocritical patients. AIMS: This study developed a restraint decision tree for neurocritical patients (RDT-N) to assist nurses in making PR decisions. We assessed its effectiveness in reducing PR use and adverse events. STUDY DESIGN: This study employed a baseline and post-intervention test design at a NCU with 19 beds and 45 nurses in a tertiary hospital in a metropolitan city in South Korea. Two-hundred and thirty-seven adult patients were admitted during the study period. During the intervention, nurses were trained on the RDT-N. PR use and adverse events between the baseline and post-intervention periods were compared. RESULTS: Post-intervention, total number of restrained patients decreased (20.7%-16.3%; χ2 = 7.68, p = .006), and the average number of PR applied per restrained patient decreased (2.42-1.71; t = 5.74, p < .001). The most frequently used PR type changed from extremity cuff to mitten (χ2 = 397.62, p < .001). No falls occurred during the study periods. On the other hand, URDs at baseline were 18.67 cases per 1000 patient days in the high-risk group and 5.78 cases per 1000 patient days in the moderate-risk group; however, no URD cases were reported post-intervention. CONCLUSIONS: The RDT-N effectively reduced PR use and adverse events. Its application can enhance patient-centred care based on individual condition and potential risks in NCUs. RELEVANCE TO CLINICAL PRACTICE: Nurses can use the RDT-N to assess the need for PR in caring for neurocritical patients, reducing PR use and adverse events.

Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department.

OBJECTIVES: Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS: Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION: Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.

Physical restraint and associated agitation.

BACKGROUND: Physical restraint of patients in intensive care units (ICUs) has an estimated prevalence of 50%. Many medical centres do not have specific protocols for physical restraint, and the decision of whether to physically restrain a patient is up to the nursing staff. Disadvantages of physical restraint include injuries, exacerbation of agitation and an increased risk of developing post-traumatic stress disorder (PTSD). AIM: To report prevalence and outcomes in terms of morbidity and mortality of physical restraint in general ICU patients in an 800-bed secondary medical centre. STUDY DESIGN: This retrospective study included 647 patients admitted to a general ICU in an 800-bed secondary medical centre in Kfar Saba, Israel, between January and December 2020. Data included demographics, medical history, length of stay, need for mechanical ventilation, number of ventilation days, 28-day mortality, reason for admission, agitation rate assessed by Richmond Agitation and Sedation Scale (RASS) score, need for physical restraint and need for anti-psychotics. RESULTS: Among the patients, 40% (256 of 647) required physical restraint. Older adult patients had a greater likelihood of being physically restrained along with those admitted because of sepsis or acute respiratory failure. Among the study sample, 11% (71 of 647) required anti-psychotics. Patients who were restrained had longer duration of ventilation (5.9 ± 8.2 vs. 0.36 ± 1.4 days; p < .001) and higher 28-day mortality (0.26 ± 0.45 vs. 0.07 ± 0.25, Z = 6.86, p < .001). There was no difference in medical history, except for chronic drug abuse, which was more frequent in the restraint group (18 [6.9%] vs. 11 [2.8%], respectively; p = .019), as well as the use of anti-psychotic medications (24 [9.3%] vs. 19 [4.8%], respectively; p = .034) and anti-depressants (55 [21.2%] vs. 59 [14.8%], respectively; p = .042). The restraint group had higher disease severity scores, as reflected in requirements for vasopressor support (174 [67.2%] vs. 69 [17.3%], respectively; p < .001) and need for dialysis (39 [15.1%] vs. 19 [4.8%], respectively; p < .001); higher frequency of in-hospital anti-psychotic treatment (60 [23.2%] vs. 11 [2.8%], respectively; p < .001); a greater tendency for agitation events and more severe agitation scores (episodes of RASS above zero [1.7 ± 4.0 vs. 0.04 ± 0.27, respectively; p < .001] and maximum RASS score [0.19 ± 1.6 vs. 0.01 ± 0.54, respectively; p < .001]). Overall, advanced age, number of ventilation days and need for dialysis were associated with increased 28-day mortality. In the restraint group, advanced age, chronic use of diuretics and the use of dialysis during ICU admission were associated with increased mortality risk. CONCLUSIONS: Restrained patients tended to have higher morbidity and mortality during ICU and hospital stays, as well as a greater tendency for agitation events and more severe agitation scores, with an increased need for in-hospital anti-psychotic treatment. These findings regarding patient characteristics might be used to formulate treatment plans to reduce the rate of physical restraint in the ICU. RELEVANCE TO CLINICAL PRACTICE: Because restrained ICU patients tend to have higher morbidity and mortality, treatment plans should be formulated to reduce the rate of physical restraint in the ICU. CLINICAL TRIAL REGISTRATION: NCT04771793.

Vascular complications in extremities of physically restrained intensive care unit patients: A prospective, observational study.

BACKGROUND: Physical restraint is used to prevent agitation, to continue treatments and to ensure safety in intensive care patients. Physical restraint has negative effects on physical and psychological health, and physical restraint should not be used unless necessary. AIMS: The purpose of this study was to evaluate the development of vascular complications in extremities of physically restrained patients hospitalized in the intensive care unit (ICU) and the associated factors. STUDY DESIGN: A prospective, observational study. The study was conducted between September 1, 2022, and March 31, 2023 in eight ICUs of a hospital located in the inner regions of Türkiye. The development of vascular complications (discolouration, distemperature, variations in capillary refill time, fluctuations in peripheral pulse, skin ulceration and oedema in the area of physical restraint) rate in patients hospitalized in the ICUs who were physically restrained. Independent sample t test, Mann-Whitney U test and Pearson-χ2 test were used to analyse the data. RESULTS: During the study, 2409 patients were admitted to ICUs. Physical restraint was applied to 209 of these patients. Of the 209 patients, 112 patients who met the inclusion criteria were included in the study. The physical restraint site of the patients was evaluated an average of 230.12 times and physical restraint was terminated in 9.8% of the patients (n = 112) because of vascular complications that developed in the physical restraint site. The rate of vascular complications at the site of physical restraint was higher in patients with endotracheal tubes (p < .05), lower GCS scores (p < .05) and higher INR values (p < .05). Patients with skin ulceration at the restraint site received more massages and cream applications (%95CL = 1. 1.692-34.734, OR = 7.667, p = .032). It was determined that more massage was applied to patients with changes in skin temperature at the restraint site (%95Cl = 1.062-11.599, OR = 3.510, p = .032). CONCLUSIONS: Vascular complications may develop at the restraint site in patients hospitalized in the ICU. This may be more common in ICU patients with endotracheal tube, lower GCS score and higher INR values. RELEVANCE TO CLINICAL PRACTICE: Nurses should closely monitor ICUs patients with endotracheal tube, lower GCS score and higher INR values, and implement care interventions to prevent the development of vascular complications.

Physical restraint intervention in the intensive care unit: An observational pilot study.

PURPOSE: Physical restraint (PR) is applied for patients' safety and to prevent the removal of inserted devices. No matter how well applied, PR causes undesired effects and discomfort to patients. Because PR-Guidelines are not yet implemented in Turkey, an observational study was performed to get baseline data on the type and number of PR-activities and on patients' complications in intensive care unit (ICU) patients. METHODS: An observational pilot study was conducted in anesthesia and reanimation adult ICUs in a midsized general hospital in Turkey. Included were 31 patients and two data collection tools: a basic form (patient demographics, medical information, and complications) and a PR observation guide on nurses' PR-activities. Descriptive statistics (frequencies, percentages, and mean and standard deviation) were used for data evaluation. FINDINGS: Most patients (61.3%) were male, and 74.2% were aged 60-79 years. Almost a third was unconscious (Glasgow Coma Scale <9) and at risk for falling. Of the total 33 activities of the Nursing Interventions Classification (NIC), 13 were never applied in 33% of patients. The most applied activity was "provide sufficient staff to assist with the safe application of physical restraining devices or manual restraints" (96.8%). Least applied were "explain inpatient and significant others the behaviors necessary for the termination of the intervention," "Provide the dependent patient with a means of summoning help" (6.5%), and "Teach family the risks and benefits of restraint reduction" (3.2%). Overall, 58.1% of patients had PR complications. CONCLUSIONS: For the first time, PR NIC activities were evaluated in a Turkish ICU. Findings show low performance of NIC activities and a high complication rate. IMPLICATIONS FOR NURSING PRACTICE: The findings provide the basis to implement a PR-Guideline in Turkish ICUs to enhance patients' safety and comfort.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study.

BACKGROUND: Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. AIMS: To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. METHOD: PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. RESULTS: Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. CONCLUSIONS: Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Intention to use physical restraint in paediatric intensive care units and correlated variables: A multicentre and cross-sectional study.

OBJECTIVES: To determine the intention to use physical restraint (PR) and the relationship with sociodemographic and professional variables of the Paediatric Intensive Care Unit (PICU) nurses. RESEARCH METHODOLOGY/DESIGN AND SETTING: A multicentre and correlational study was carried out from October 2021 to December 2023 in five paediatric intensive care units from five maternal and child hospitals in Spain. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire was provided. Moreover, sociodemographic and employment variables were registered. RESULTS: A total of 230 paediatric nurses participated in the study. A total of 87.7 % were females with an average age of 35.5 ± 9.7 years and working experience of 10.5 ± 8.4 years. The mean scores obtained were 21.1 ± 3.8 for attitude, 13.1 ± 5.0 for subjective norms, 14.4 ± 4.3 for perceived behavioural control and 28.0 ± 6.0 for intention. The nurses apply more physical restraint to anxious patients, with scarce analgesics and sedation, those affected with pharmacological withdrawal symptoms and those with a high risk of accidental removal of vital support devices or fall from bed. The sex (p = 0.007) and type of employment contract (p = 0.01) are the variables that are significantly correlated with the intention to use of PR. CONCLUSION: The paediatric nurses analysed had a moderate attitude, social pressure and perceived behavioural control towards the use of PR. IMPLICATIONS FOR CLINICAL PRACTICE: It is important to know the factors that influence the intention to use physical restraint in order to standardise safe practice for critically ill paediatric and to ensure that patients' rights are respected by obtaining informed consent and assessing the prescription, continuation and removal of physical restraint.

Non-pharmacological interventions to reduce physical restraints in critical care units.

Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey.

PURPOSE: To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings. METHODS: We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention. RESULTS: A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores. CONCLUSIONS: The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

Technical-tactical behavior analysis of general duty police officers during non-compliant suspect apprehensions: A novel approach to establish minimum force requirements.

BACKGROUND: While effective apprehensions of non-compliant suspects are central to public safety, the minimal force needed to transition a suspect from standing to the ground, vital for apprehension success, has not been established. OBJECTIVE: To examine the technical-tactical behaviors of general duty police officers during simulated apprehensions and quantify the minimum force required to destabilize non-compliant suspects. METHODS: Task simulations conducted with 91 officers were analyzed to identify common grappling movements, strikes, control tactics, and changes in body posture. A separate assessment of 55 male officers aimed to determine the minimum force required for destabilization in five body regions (wrist, forearm, shoulder, mid-chest, and mid-back). Data are presented as mean±standard deviation. RESULTS: On average, apprehensions took 7.3±3.2 seconds. While all officers used grappling movements (100%) and the majority employed control tactics (75%), strikes were seldom used (4%). Apprehensions typically began with a two-handed pull (97%; Contact Phase), 55% then attempted an arm bar takedown, followed by a two-handed cross-body pull (68%; Transition/Control Phase), and a two-handed push to the ground (19%; Ground Phase). All officers began in the upright posture, with most shifting to squat (75%), kneel (58%), or bent (45%) postures to complete the apprehension. The minimum force required to disrupt balance differed across body regions (wrist: 54±12 kg; forearm: 49±12 kg; shoulder: 42±10 kg; mid-chest: 44±11 kg; mid-back: 30±7 kg, all P < 0.05), except between the shoulder and chest (P = 0.19). CONCLUSION: These findings provide insights that can enhance the design and accuracy of future apprehension evaluations and inform the optimization of law enforcement physical employment standards.

Physical Restraint Experience of Patients with Mental Disorders in Mainland China: A Qualitative Study.

Introduction: The use of physical restraint (PR) is considered a controversial practice and research in Western countries has demonstrated negative physical and psychological consequences for patients, as well as staff, family members/carers, organisations and society as a whole. However, there are few research reports on restraint experiences of patients with mental disorders in non-Western countries, especially in mainland China. Aim: This study aims to explore the subjective experiences and perceptions of patients with psychiatric disorders who have experienced PR in mainland China. Methods: Semi-structured interviews were conducted with 8 inpatients with mental disorders in convalescence at a specialized mental health hospital in Shanghai. Interviews were recorded on audiotape and transcribed verbatim. Transcripts were analyzed using thematic analysis. Results: Five themes emerged: "perception and understanding of PR", "response to PR", "negative physical and psychological experiences", "unmet care needs during PR" and "changes after PR", which together characterize patients' perceptions, experiences, feelings, and needs in PR. Conclusion: The use of PR involves ethical issues and brings negative experiences to patients with mental disorders that cannot be ignored and should be used as a last resort. Different patients have different attitudes and reactions to PR. During PR, patients' physical and psychological needs are not adequately met. Medical staff should give more attention to patients in PR, meet their physical and psychological needs, and actively seek PR alternatives and reduction options based on evidence-based resources on restraint reduction available in the West and the national context and culture of China.

Nursing Ethical Decision Making on Adult Physical Restraint: A Scoping Review.

OBJECTIVE: to map the existing knowledge on nursing ethical decision making in the physical restraint of hospitalised adults. (1) Background: physical restraint is a technique that conditions the free movement of the body, with risks and benefits. The prevalence of physical restraint in healthcare suffers a wide variation, considering the environment or pathology, and it raises ethical issues that hinders decision making. This article intends to analyse and discuss this problem, starting from a literature review that will provoke a grounded discussion on the ethical and legal aspects. Inclusion criteria are: studies on physical restraint (C) and ethical nursing decision making (C) in hospitalized adults (P); (2) methods: a three-step search strategy was used according to the JBI. The databases consulted were CINAHL Plus with Full Text (EBSCOhost), MEDLINE Full Text (EBSCOhost), Nursing and Allied Health Collection: Comprehensive and Cochrane Database of Systematic Reviews (by Cochrane Library, RCAAP and Google Scholar. All articles were analysed by two independent reviewers; (3) results: according to the inclusion criteria, 18 articles were included. The categories that influence ethical decision in nursing are: consequence of the decision, the context, the nature of the decision in terms of its complexity, the principles of the ethical decision in nursing, ethical issues and universal values; (4) conclusions: the findings of this review provide evidence that there is extensive knowledge regarding nursing ethical decision making in adult physical restriction, also, it is considered an ethical issue with many associated assumptions. In this article we aim to confront all these issues from a legal perspective.

Students' perception of protective stabilization of pediatric dental patients: a qualitative study.

Protective stabilization (PS) has been utilized to safely perform examinations, make diagnoses and/or provide limited treatment of short duration to uncooperative children. The literature supports PS as an alternative technique when behavior management strategies are not sufficient to enable oral care. The use of PS in pediatric dentistry can be traumatic for patients, parents and the medical team and has sometimes been described as being non-compliant with standards of care. Semi-structured qualitative interviews on dental students' perception of PS were conducted in the pediatric department of dentistry at the University Hospital of Toulouse, France. A thematic analysis of the transcript of interviews was provided using the NViVo software. This analysis identified four main themes. The students described their first experience with physical restraint in pediatric dentistry and wondered about the definition of PS. The students' perception of PS showed that this procedure has a psychological impact and is disturbing. There is a lack of information on PS in dental curricula and didactic and clinical education which requires attention. Finally, the students took into consideration the role of PS in future practice. Dental students' perception of PS provides justification for the development and improvement of theoretical and clinical education in behavior guidance techniques for pediatric dental patients, in accordance with national and international guidelines.

Factors affecting nursing practice of patient physical restraint among nurses.

BACKGROUND: This study was aimed to identify perception, knowledge, attitude and nursing practice toward use of physical restraints among clinical nurses. METHODS: The research participants were 180 nurses from general hospitals located in Korea. Data were collected using self-report questionnaires regarding perception, attitude, knowledge, and nursing practice on application of physical restraints and analyzed using t-test, ANOVA, Pearson correlation coefficients, and multiple regression. RESULTS: There were significant negative relationships attitudes towards the use of physical restraints with knowledge (r = -.32, p < .001). Knowledge showed a positive correlation with nursing practice (r = .28, p < .001). Factors affecting nursing practice of clinical nurses were identified as knowledge (ß = .23), education experiences on physical restraints (Yes) (ß = .18), and work unit (ICU) (ß = .43). The explanation power of this regression model was 22% and it was statistically significant (F = 7.45, p < .001). CONCLUSION: This study suggests that knowledge, education experiences on physical restraints, and work unit were the strongest predictor on nursing practice toward use of patient physical restraints. Therefore, developing and applying evidence-based educational intervention programs by work unit to reduce the inappropriate use of physical restraints in hospitals are required.

[Measuring the intensity of restraint during care in children: Validation of the Pric scale]. / Mesurer l'intensité de la contention lors des soins chez les enfants : validation de l'échelle Pric.

Restraint is used relatively often during pediatric care. However, no scale has yet been validated to assess its intensity. The study presented here did this for the Procedural Restraint Intensity in Children tool in metrological terms (with some limitations). In the absence of a reference scale in this area, the reliability of this tool was studied under experimental conditions. It is nevertheless the first scale with metrological validation, measuring the intensity of physical constraint. Other work is underway to validate it in real clinical situations.

[How do parents perceive their child's restraint during emergency care?] / Comment les parents perçoivent-ils la contention de leur enfant lors d'un soin aux urgences ?

Restraint during care in pediatrics is a professional practice that is beginning to be studied. However, few studies explore this phenomenon from the point of view of the parents of children who are firmly restrained during care. Guided by the caregiver's perspective, care remains a priority for them. Some perceive the violence of the situation, while others focus on the benevolence of the professionals. In all cases, this practice implies the need for professionals to support the parents and children concerned, in order to safeguard the best interests of the young patient.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department.

INTRODUCTION: Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS: A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS: Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS: A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Exploring the impact of a multilevel intervention focused on reducing the practices of seclusion and restraint in acute mental health units in an Australian mental health service.

Reducing and eliminating seclusion and restraint in inpatient settings has been a key area of focus in mental health policy and research for many years. To address this issue, numerous programmes aimed at minimising the use of these practices have been developed over the past two decades, with varying degrees of success. This article reports on research focused on the implementation of a localised, multilevel complex intervention that targeted both organisational and individual factors related to the use of seclusion and restraint. The researchers followed the impact of the intervention by interviewing medical, nursing and allied health staff who worked within the service (N = 12) and analysing the rates of seclusion and restraint over an 18-month period. Post-adoption, participants identified that there were clear changes in practice culture. Seclusion clearly became a practice of last resort and other options became prominent in staff's practice. Participants identified that there was a sense of shared purpose across the multidisciplinary team. The clinical environment was viewed as being more therapeutic for service users and less frightening for staff. There was a significant difference in the total number of seclusion events between pre- (Mean = 6.22, SD = 5.82) and post-implementation (Mean = 2.55, SD = 2.44, p = 0.002, d = 0.94), demonstrating a significantly lower number of seclusions was observed after the intervention. Similarly, a significant difference in restraint events between pre- (Mean = 5.50, SD = 3.77) and post-implementations (Mean = 3.38, SD = 3.21, p = 0.037, d = 0.62) was observed.

Characteristics of pediatric behavioral health emergencies in the prehospital setting.

OBJECTIVE: Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS: We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS: Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS: Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.