Is your restraint use too high? Try patient advocates

(Editor’s note: This is the second of a two-part series on psychiatric patients in the ED. This month, we explain how psychiatric advocates can decrease use of restraints, and a related story on p. 127 gives effective ways to avoid placing patients in restraint. Last month, we covered ways to improve care, ensure safety, and maintain throughput.)

As numbers of psychiatric patients continue to increase in many EDs, with more than 2 million treated in EDs in 2002, you might expect use of restraints to rise commensurately. But this is not the case at Springfield, MA-based Baystate Medical Center's ED.

"Not only are they safer, kinder, and gentler,’ but the numbers of restraints are down," due to the ED’s unique psychiatric advocacy program, says Ann Maynard, RN, BSN, emergency services manager.

"By having an advocate present, the patient does not feel as though they were forgotten," she says. "They are able to communicate their needs, fears, and concerns, so they do not escalate." (For more information on the advocate’s role in the ED, see Role of the ED Psychiatric Advocate, below.)

Role of the ED Psychiatric Advocate
  • Continuous in-person observation of the patient.
  • Simple reassessment and documentation of mental status every 15 minutes.
  • Neurovascular check of the restrained patient’s extremities every hour.
  • If it is deemed safe for the patient and staff, remove one extremity at a time from restraint, and do range of motion exercise. This step is taken every two hours.
  • Assess the need for nutrition and toileting every two hours while awake and every four hours while asleep.
  • Take vital signs every four hours.
  • Report assessment findings to the primary nurse.

Source: Baystate Medical Center, Springfield, MA.

Since the program was implemented, monthly restraint use has decreased from about 20 patients to fewer than 10 for most months; and while patients used to spend about an hour in restraints, they are now typically removed in fewer than 20 minutes, reports Maynard.

At Arlington Heights, IL-based Northwest Community Hospital, specially trained individuals assess psychiatric patients and help physicians develop a plan of care, says Carol A. Ziolo, RN, MA, LCPC, one of the ED’s mental health liaison specialists. "The liaison is truly an advocate for the mental health patient in the ED," she says.

To successfully reduce use of restraint with psychiatric advocates, do the following:

  • Include input from ED nurses.

Baystate Medical Center’s psychiatric advocacy program was developed by ED nurses who were frustrated with their lack of ability to meet the needs of psychiatric patients.

"It truly was a grass-roots effort," says Maynard. "We as nurses realized that we were not doing justice to patients in crisis."

The goal was to make restraint use safer and reduce use and duration of restraints, says Maynard. Psychiatric patients often escalate because they are kept waiting while ED nurses care for patients with emergent medical conditions, she adds. "The advocate prevents that from happening, since psychiatric patients now have a staff person with them all the time and their needs are met," she says.

Less restrictive methods of restraints, such as seclusion or chemical methodsw, are now the first choice unless safety issues demand immediate physical intervention, says Maynard. "When a decision is made that a patient needs physical restraints, the psychiatric advocate is the leader in applying restraints," she adds.

  • Have a single person communicate with the patient.

There is always risk of injury when agitated patients need to be restrained, but the advocate decreases the risk by making the situation more controlled, says Maynard.

"We all have a role to play, and we all know exactly what our role is," she explains. "Instead of everyone talking at the patient all at once, the advocate talks with the patient and gives direction to the other staff members."

  • Use liaisons to de-escalate agitated patients.

"We get involved with mental health patients as soon as possible, to reduce the number of staff who interact with patients," says Ziolo. "We medicate patients as soon as it is apparent that verbal de-escalation will not be successful and the patient becomes a danger to him or herself or others."

The liaisons quickly develop a treatment plan to remove the patient from the stimulation of the ED as soon as possible, explains Ziolo. To de-escalate an agitated patient, she recommends the following:

— Always use caution when caring for a mental health patient even if he or she appears calm and cooperative. "Staff need to talk in a low, calming voice," says Ziolo.

— Allow the patient to assist in decisions about their care when possible, such as asking the patient to undress and put on gowns. "If the patient refuses, give the option of the patient doing it voluntarily or having the assistance of security," says Ziolo. "The patient can assist with the decision, but the outcome will be the same."

— Always explain any procedures to the patient. "Many times, the patient is experiencing internal turmoil, and this can offer a sense of security," says Ziolo.

— Never demand that a patient do something. "This loss of control can escalate a patient very quickly," says Ziolo.

— Never remove restraints without evaluating the patient’s understanding as to why the restraints were needed and what behaviors are expected for the restraints to be removed. "Always have a staff person or security accompany you when restraints are being removed," Ziolo adds.

  • Use liaisons to make staff and patients safer.

Liaisons and all ED nurses are given crisis prevention training to help them recognize when a patient is escalating and how to defuse the situation, notes Ziolo. In addition, policies were developed for having security officers visible, placing patients in gowns, requiring sitters to observe patients in restraint, and removing all belongings from the patient for safety. "These policies have helped the liaison team and ED nurses work more cohesively as a team, to coordinate the best treatment plan for each individual person and his or her family," she says.


For more information about reducing risk of restraint, contact:

  • Ann M. Maynard, RN, BSN, Emergency Services, Baystate Medical Center, 759 Chestnut St., Springfield, MA 01199. Telephone: (413) 794-1715. E-mail:
  • Carol A. Ziolo, RN, MA, LCPC, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4145. Fax: (847) 618-3996. E-mail: