Know risks of restraint with violent patients

After an intoxicated and combative man broke loose from restraints, he struck two ED nurses and threw a computer at another nurse at a New York hospital in December 2007. Could this happen at your ED?

"This incident should be used as a means to sharpen our own practices by learning and gaining knowledge from their unfortunate experience," says Mary J. Ross, RN, BSN, CEN, charge nurse in the Emergency Medicine Trauma Center at Methodist Hospital in Indianapolis.

At Methodist, ED nurses are required to assess and document the status of all patients in restraints every 15 minutes, says Ross. "We have four locked rooms, along with two more equipped with cameras for close monitoring," she says. Suicidal patients and individuals who are being involuntarily detained for a medical evaluation are placed in these rooms, with security sitting outside and monitoring continuously, she says.

"Whenever possible, we use chemical restraints, although oftentimes both are needed," says Ross.

When an intoxicated patient is put into restraints at Northwest Community Hospital in Arlington Heights, IL, ED nurses give ziprasidone or haloperidol intramuscularly, says Carol A. Ziolo, RN, LCPC, clinical educator. "The least restrictive alternatives should be used, and medications definitely should be given when a patient is put in restraints," she says.

At Northwest, restrained patients are continually observed in person or on a monitor with audio features — a practice that could have prevented the New York incident, says Ziolo. "The person observing the patient would have seen that the patient was getting out of the restraints, and an intervention could have occurred before he was able to hurt anyone," she says.

Weigh risks and danger

There are risks to the patient from physical restraints, including positional asphyxia and cardiac arrest, says Ziolo. "Restraints are only used when the patient's behavior is more dangerous than the use of restraints," she says. "Intoxicated patients can be extremely unpredictable."

For this reason, medications are used if possible before resorting to physical restraints, says Ziolo. "We also give medications after the patient is put in restraints, to de-escalate unsafe behaviors so restraints can hopefully be removed as soon as possible," she says.

Susan Allard, RN, CMC, now an ED case manager at University of California — Los Angeles Medical Center, was caring for a patient in her previous ED when he suddenly began thrashing, yelling, and striking anyone who came near him.

"He had all the signs of substance abuse and was a good-sized man who we were having difficulty keeping on the stretcher," she says.

ED nurses isolated the man in a private room, dimmed the lights, and had everyone speak only in slow soft tones while security stayed close by, says Allard. "He focused in on one nurse in particular and appeared to be listening to her," she says. "We all stopped talking and backed off while she just kept on assuring him that he was safe, where he was, and who we were."

The nurse was able to give him a mild sedative, and when the medication took effect, the man was markedly calmer and cooperative, so restraints weren't needed, says Allard. "This nurse stayed with him through his assessment and work-up and was able to talk him down each time that his agitation increased," she says. "It was ultimately determined that he was having a psychotic episode and adverse reactions to new medications that he was taking. The entire staff was delighted at not having to use restraints."