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If you are considering restraining a patient, you always should have a key priority in mind: that individual’s right to quality care, stresses Fidela S.J. Blank, RN, MN, MBA, research coordinator for the emergency department (ED) at Baystate Medical Center in Springfield, MA. "When dealing with out-of-control patients, you should do everything possible to preserve their dignity as human beings," she emphasizes.
Here are ways to promote safer use of restraints:
• Give staff extensive education. Members of the ED staff at Blank’s facility receive ongoing education on the criteria for the use of seclusion and restraints. "This contributed tremendously to improving care of secluded and restrained patients," she says. The ED’s seclusion and restraint policies and procedures are included in the annual skills update, adds Blank, and direct-care staff also take a nonviolence crisis intervention class.
• Use a rehearsed team approach. Blank says that the following occurs when a patient needs to be restrained: There are always at least four team members involved, each team member is assigned an extremity to restrain, and a single team leader makes all the decisions and speaks to the patient. "Nobody else on the team is allowed to talk to the patient," she says. "This way, the patient is not overwhelmed by a lot of people talking at the same time." The team leader calmly talks to the patient and explains why the restraint is necessary, Blank says. "When the caregivers are calm and confident in their role, there is a de-escalating effect on the patient."
• Consider placing agitated patients in a quiet area. Place an agitated patient in a quiet room before he or she gets out of control, with a staff member observing closely, Blank advises. "We are lucky to have the luxury of three psychiatric rooms in the ED," she says. This is not considered seclusion by the definition of the Joint Commission on Accreditation of Healthcare Organizations because the patient voluntarily agrees to be placed in a separate room, Blank explains. "Most of the time, this is all the patient needs," she says. "Often, this alone prevents the need for further intervention."
Exposure to noise and people will worsen the agitation of some patients, says Kathleen Emde, RN, MN, CCRN, CEN, trauma service coordinator at Overlake Hospital Medical Center in Bellevue, WA. However, Emde cautions that others become more agitated in isolation. For this reason, assessing the specific patient’s needs is key, she says. "If the patient will be most comfortable in isolation, then use that strategy," she says. "If they will benefit from being in the ED and are not being disruptive to other patients and families, then perhaps a different setting with an assigned caregiver will be more beneficial."
• Use appropriate alternatives when possible. The alternatives to restraint will vary, depending on your assessment of the patient’s behavior, Emde says. (For more information on this topic, see "Try these alternatives to using restraints," ED Nursing, December 2000, p. 23.) While some patients may benefit from close observation, interaction, and distraction techniques, patients who are an immediate threat to themselves or others will require immobilization with restraints, she adds. Here are two alternatives to consider:
— Assigning a sitter to observe the patient closely, with intervention if there is increased agitation. "Anxious or agitated patients may not require restraints, if there is a person available to observe and interact with them," says Emde. For example, an elderly patient with Alzheimer’s disease, who might be impulsive and disoriented, may be restrained to ensure that the patient does not wander or fall while in the ED, says Emde. She suggests that assigning a staff member to interact with the patient using conversation and distraction techniques is a better option.
Although Emde acknowledges that some patients are too agitated or confused to be able to interact meaningfully, she says this can work wonders at times. "I ask them about their lives, such as, Where did you grow up?’ This leads to a discussion of youth," she says. "This is helpful in the case of elders who may have short-term memory loss, but relatively intact long-term memory." Discuss hobbies to catch their attention, Emde suggests. "If they are or were avid fishermen, you can talk about that," she says. "People seem to like to talk about their children or grandchildren, such as what they are studying in school."
— Using distractions. Have materials available to distract patients, such as videos, music, and toys, Emde says. "We have toy boxes intended for our pediatric patients, but they contain toys that are intriguing to people of all ages," she says. These include plastic Slinkies, tubes with gel inside, and colorful balls with rubber spikes. "We just give the patient a few, and see what they like," says Emde. Most EDs have an assortment of child-friendly movies, but add some classic films that appeal to an older generation, Emde suggests. "Of course, you’ll want to avoid violent or upsetting content, but there are plenty to choose from," she says. n
For more information about restraint and seclusion, contact:
• Fidela S.J. Blank, RN, MN, MBA, Research Coordinator, Emergency Department, Baystate Medical Center, 759 Chestnut St., Springfield, MA 01199. Telephone: (413) 794-8680. Fax: (413) 794-5118. E-mail: firstname.lastname@example.org.
• Kathleen Emde, RN, MN, CCRN, CEN, Trauma Service Coordinator, Overlake Hospital Medical Center, 1035 116th Ave. N.E., Bellevue, WA 98004. Telephone: (425) 688-5683. Fax: (425) 688-5101. E-mail: Kathleen.Emde@overlakehospital.org.