APA Resource Document Outlines Principles on Use of Seclusion, Restraint
The 21-page document outlines practical considerations for using seclusion and restraint and is intended to help guide their use based on patient experience/preference and clinical considerations.
Seclusion or restraint (S/R) should be used only as interventions of last resort in the management of severe agitation in patients, and both carry risks to patients and staff that must be considered in deciding whether to use them at all in a clinical situation.
Principles to Guide Development of Seclusion, Restraint Protocols
The APA Resource Document on Seclusion and Restraint, written by the Patient Safety Work Group of the Council on Quality Care, outlines nine key principles that should guide the development of protocols for seclusion and restraint (S/R). They are as follows:
The overarching goal in the management of agitation is to help patients regain control over their behaviors so that they can participate safely in their evaluation and treatment.
Clinicians should aim to maintain the patient’s dignity and opportunities to express a choice or preference to the extent possible, including use of the least restrictive method of intervention to facilitate clinical patient assessment and medically indicated treatment, and to ensure the safety of the patient and others.
Verbal de-escalation techniques are the first-line treatment for patients who are agitated and can be effective for a majority of patients in a behavioral health crisis within five minutes.
Environmental interventions should be provided to decrease stimulation, promote calming, and decrease access to means to harm self or others.
Patients should be initially assessed (ideally upon admission to a facility) to obtain information, including collateral, that could help minimize the use of S/R, including whether there is a Psychiatric Advance Directive in place.
The decision to utilize medication to treat agitation is a critical health care decision. Pharmacologic intervention may be required for the safety of the patient, clinician, and/or others when verbal de-escalation techniques alone are ineffective.
Facilities should establish clear protocols to assist clinicians with decision-making about the use of “quiet room,” locked seclusion, physical hold, or physical restraint.
S/R should never be used as a form of punishment, deliberate/intentional coercion, or intimidation; for staff convenience; or as retaliation. Such use is also prohibited by law in many jurisdictions.
Facilities should maintain clear policies, procedures, and training protocols regarding the management of patients with agitation, including guidance on the use of seclusion vs. restraint.
That’s the conclusion of a resource document on seclusion and restraint written by the Patient Safety Work Group (PSWG) of the APA Council on Quality Care.
“Both S/R episodes should be as short as possible, dignified, and as safe as possible for all involved,” according to the document. “Patient preference should always be considered when feasible.”
The 21-page document outlines seven practical considerations for using S/R and includes references and resources for further reading, a model for a verbal de-escalation, and a “decision tree” that may be used as an algorithm for assessing the need for S/R.
These are the seven considerations for use of S/R:
Decision-support algorithms help guide the use of S/R. Agitation is defined as a hyperaroused state (ranging in severity from anxious and cooperative to violent and combative) in which the individual exhibits excessive, repeated, and purposeless motor or verbal behaviors. These may include pacing, fidgeting, clenching fists or teeth, prolonged staring, picking at clothing or skin, responding to internal stimuli such as hallucinations, and threatening or carrying out violent acts. It is important, and in some jurisdictions mandated, to develop protocols and decision-support algorithms for staff to safely manage agitated patients in acute care facilities such as emergency departments and inpatient psychiatric hospitals. (See box above for nine key principles to guide the development of protocols.)
Understanding the clinician’s role in S/R can lead to more appropriate use of these interventions. Psychiatrists need to know their roles and responsibilities in S/R. APA has produced an interactive presentation on this topic at the SMI Adviser website.
Understanding the risks can reduce harm when using S/R. It is important to understand the differential risks of physical restraints compared with seclusion. While some studies have not found a significant variation in adverse effects between the two procedures, others have described notably heightened risks with physical restraint, such as deep vein thrombosis and aspiration pneumonia. Compared with non-physically restrained patients, more total days of physical restraint have been associated with an increased risk for pulmonary embolism.
Advocating for availability of environmental interventions, including seclusion rooms, can minimize the need for restraint. Because restraints are associated with the highest level of morbidity and mortality, every effort should be made to avoid their use. Plans for new psychiatric facilities or renovations should include calming, sensory, and seclusion rooms to minimize the need for restraint. The choice of seclusion vs. restraint should be based on any federal or state requirements and the clinical presentation and/or patient preference.
The patient’s experience of S/R is important. Most psychiatrists have not likely experienced their own S/R in a psychiatric facility or other clinical setting. One way to develop empathy is to consider how they may have felt in other situations in their lives when their freedom, physical or otherwise, was limited or suppressed.
A culturally competent, trauma-informed, and patient-centered approach is necessary when making decisions about whether to use S/R. The prevalence of a history of trauma among psychiatric inpatients ranges from 50% to 80%. As such, mental health professionals should recognize the impact and signs of trauma when considering S/R, keeping in mind that these interventions can legally be used only as a last resort. In this context, trauma-informed care has emerged as an approach to allow patients to engage in their health care, develop a trusting relationship with their physician, and improve health outcomes.
Patient preferences and psychiatric advance directives are critical when considering the use of S/R. Patients who have experienced seclusion and/or restraint likely have strong opinions about their use. Most patients would choose seclusion over restraint, but there may be exceptions, depending on previous experience, including psychological traumas. In this context, psychiatric advance directives (PAD) have emerged as a tool to allow people with mental health conditions to state their preferences in advance for treatments in case a mental health crisis impacts their ability to make decisions at the time.
The work group notes in the document that there is still much to be learned about S/R and that training for medical students and residents is lacking or nonstandardized. “More rigorous research is needed, particularly in the areas of comparisons between S/R and when or how to choose between them, racial/ethnic and other biases in their use, and S/R use in special populations (for example, children and adolescents, geriatric patients, and individuals with developmental disorders). Reducing stigma and disparities in the use of S/R for all patients should be an ultimate goal.” ■