EDs can do these 3 things to avoid use of restraints

When restraints are needed, it’s a dangerous moment in the ED that puts the nurse and patient at risk for serious injury. For many EDs, the number of dangerous moments is rising as the number of psychiatric patients increases dramatically.

"It is a very big problem for us," reports Susan Key, RN, director of emergency services at Cape Canaveral Hospital in Cocoa Beach, FL.

Cape Canaveral Hospital does not have a psychiatric unit, and it is not a receiving facility, Key says. "Patients are sometimes in the ED for greater than 24 hours, as we cannot find placement for them," she says. "It is very hard to handle this."

However, if you have a good policy in place, your use of restraints should decrease despite increased volumes of psychiatric patients, as these should be used as a last resort only, stresses Key. "We have a great restraint policy and very rarely use restraints," she says. Instead, alternatives such as dimmed lighting, relaxing music, comfort, and diversional measures are used, says Key.

You can decrease risks of restraint with these suggestions:

  • Medicate patients quickly.

If patients present in a psychotic or agitated state, they are medicated right away with an antipsychotic and/or a benzodiazepine, says Paige Ponte, LCSW, psychiatric program specialist for the crisis intervention team at University of Utah Hospital and Clinics in Salt Lake City.

Assess the patient’s degree of agitation at triage, so medication can be given immediately if needed, Ponte recommends. "This is critical to ensure safety of the patient as well as staff and other patients in the ED," she says. "This often will take the edge off enough so that physical restraint or forced medication does not have to take place."

However, the patient should be placed in a room first so that the physician can "eyeball" them, says Ponte. "If the patient is going to refuse the medication, it is essential that they are in a room, as triage is an unsafe place to deal with this behavior," she adds.

Look for behaviors that signal the need for medication to ensure safety, says Ponte. "If someone who presents with psychosis is fairly paranoid, if they appear to be responding to internal stimuli, if they are pacing, if they won’t stay in their room, if they are agitated, if they are being disruptive, then they should be offered medication," she says.

  • Do a "show of force" when necessary.

If patients are potentially violent, crisis workers and security officers enter the rooms, set firm limits with the patients, and outline the consequences if they continue to act out, says Ponte. "Patients do not want to be physically restrained and when a relatively large group of people is at the door of their room telling them in a caring, yet firm way that they need to control their behavior or the consequence will be a shot or physical restraints, they frequently will choose to control themselves and take oral medications if that is appropriate," she says.

  • Ask for help if needed.

Don’t hesitate to ask for help from security or male staff members when a patient is escalating, advises Ponte. "Agitated, psychotic patients can be volatile and unpredictable," she says.


For more information on decreasing restraint use, contact:

  • Susan Key, RN, Director of Emergency Services, Cape Canaveral Hospital, 701 W. Cocoa Beach Causeway, Cocoa Beach, FL 32931. Telephone: (321) 799-7156. E-mail: Susan.Key@health-first.org.
  • Paige Ponte, LCSW, Psychiatric Program Specialist, Crisis Intervention Team, University of Utah Hospital and Clinics, 50 N. Medical Drive, Salt Lake City, UT 84132. Telephone: (801) 581-2137. E-mail: Paige.Ponte@hsc.utah.edu.