Investigators recently identified some trends when it comes to who is more likely to be physically restrained in the ED.1

Researchers analyzed 726,417 adult visits to three hospital EDs in the Yale-New Haven Health System that occurred from 2013-2018. A total of 7,090 patients were physically restrained. Of this group, 64.8% were male, 28.8% were Black or African American, 71% presented with either Medicare or Medicaid, and 2.3% were homeless. Visits that were higher-acuity, visits later in the day, and visits with behavioral chief concerns also were more likely to include physical restraint.

Of 195,092 adult ED visits from 2016-2018 at Massachusetts General Hospital, 1.4% involved physical restraint.2 Black patients; men; those with public or no insurance; young age; a diagnosis pertaining to substance abuse, psychotic disorder, or bipolar disorder; history of violence; and currently homeless all were traits that led to a higher likelihood of physical restraint.

Another research group analyzed 165 agitated patients during ED visits that occurred in 2016 and 2017 at a community hospital, of which 112 were physically restrained.3 “We wanted to examine what factors result in a higher risk of being placed on restraints in the ED, including factors that are present even before the patient presents to the ED, such as their age,” says Zaira Khalid, MD, the study’s principal investigator and assistant professor of psychiatry at Central Michigan University.

The agitated patients who were not restrained were included as a control group. “Our hope is that the data can help identify factors that would place an individual at a higher risk so that other interventions, such as medications, can be utilized earlier on to hopefully prevent restraints being utilized,” Khalid says.

Khalid and colleagues found patients with these factors were more likely to be restrained: Younger age, intoxication, lower BMI, a previous diagnosis of depression, taking antipsychotics as a home medication, and haloperidol or olanzapine administered in the ED. Patients with these factors were less likely to be restrained: Diazepam or ketamine administered in the ED or a current prescription for benzodiazepine. EDs can use these data “as a platform for the development of risk management protocols and training for early identification of at-risk patients,” says Neli Ragina, PhD, director of students and residents clinical research at Central Michigan University.

ED providers and hospitals face potential legal exposure if patients are physically harmed either in the process of restraint or while restrained. There also is the possibility of psychological harm, says Leslie Zun, MD, professor of emergency medicine at Chicago Medical School/Rosalind Franklin University.

Some patients complain to the hospital about physical restraints, claiming they were traumatized by the incident. This raises more questions about what happened. “We don’t know how it was handled, whether it was explained to the patient, or whether anyone used verbal de-escalation or attempted to medicate the patient,” Zun notes. “The first approach is to see if you can get by without restraining someone.”

Staff can ask what worked in the past for the patient, medicate that person, use verbal de-escalation, maintain a designated quiet space to put the patient until he or she calms down, or ask a family member or friend to help. Early intervention could prevent situations from spiraling out of control. “Some patients are brought in by police kicking and screaming or come in already severely agitated — that’s a very small number of patients, and there’s not a lot we can do,” Zun says.

Other patients arrive somewhat agitated, but are not yet exhibiting overt symptoms. Zun says if a patient presents with any type of mental health complaint, it is helpful for the triage nurse to ask if the patient is experiencing mild, moderate, or severe agitation. “We are working on a protocol where if they did report agitation, [we] medicate the patient at triage or in the treatment room, rather than waiting until they escalate and need to be restrained,” Zun explains.

A third group arrives calm, but tempers flare at some point during the visit. Sometimes, this happens because of what transpires in the ED. Other times, it is because of the patient’s psychiatric condition. “This behooves us to assess them early, find out what they need, and address their problem before restraint becomes really the only option,” Zun offers.

Most agitated patients without mental health disorders can be treated with verbal de-escalation, according to Zun. Patients may be agitated because of concrete issues, such as waiting all day without eating or wanting a specific family member to come to the ED. “Mental health patients are more difficult. They may have more difficulty controlling themselves and may need help,” Zun reports.

To improve care of agitated patients, Zun recommends practice and analysis. “You can have dry runs — ‘We have an agitated patient in Room 10,’ and see how people would address it,” Zun offers. “Just like you’d practice responding to a patient in cardiac arrest, why don’t we practice mental health emergencies as well?”

Some patients will need to be restrained despite the ED’s best efforts to avoid it. If so, says Zun, “you need to follow proper policy and procedure.”

In the rare cases where restraint is necessary, Zun recommends a staff debrief and a patient debrief. For staff, it is a chance to ask questions: Was there a better way to deal with this? Could we have done something differently to prevent restraining this patient? Did we use proper technique and avoid harming the patient or staff? For the patient, before discharge, transfer, or admission, it is a chance for staff to explain and apologize.

REFERENCES

  1. Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of race/ethnicity and other demographic characteristics with use of physical restraints in the emergency department. JAMA Netw Open 2021;4:e2035241.
  2. Schnitzer K, Merideth F, Macias-Konstantopoulos W, et al. Disparities in care: The role of race on the utilization of physical restraints in the emergency setting. Acad Emerg Med 2020;27:943-950.
  3. Khalid Z, Fana M, Payea R, et al. Disparities and variables associated with physical restraint for acute agitation in a nonpsychiatric emergency department. Prim Care Companion CNS Disord 2019;21:19m02471.