Medical restraint

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Medical restraints are physical restraints used during certain medical procedures to restrain patients with (supposedly) the minimum of discomfort and pain and to prevent them from injuring themselves or others.

Contents

Rationale

There are many kinds of mild, safety-oriented medical restraints which are widely used. For example, the use of bed rails is routine in many hospitals and other care facilities, as the restraint prevents patients from rolling out of bed accidentally. Newborns frequently wear mittens to prevent accidental scratching. Some wheelchair users use a belt or a tray to keep them from falling out of their wheelchairs. In fact, not using these kinds of restraints when needed can lead to legal liability for preventable injuries. [1] [2]

Medical restraints are generally used to prevent people with severe physical or mental disorders from harming themselves or others. A major goal of most medical restraints is to prevent injuries due to falls. Other medical restraints are intended to prevent a harmful behavior, such as hitting people.

Ethically and legally, once a person is restrained, the safety and well-being of the restrained person falls upon the restrainer, appropriate to the type and severity of the restraining method. For example, a person who is placed in a secured room should be checked at regular intervals for indications of distress. At the other extreme, a person who is rendered semi-conscious by pharmacological (or chemical) sedation should be constantly monitored by a well-trained individual who is dedicated to protecting the restrained person's physical and medical safety. Failure to properly monitor a restrained individual may result in criminal and civil prosecution, depending on jurisdiction.

Although medical restraints, used properly, can help prevent injury, they can also be dangerous. The United States Food and Drug Administration (FDA) estimated in 1992 that improper use of restraints results in at least 100 deaths each year, most by strangulation. FDA also noted reports of injuries — including broken bones and burns — caused by the improper use of restraints. [3] Medical restraints in psychiatric hospitals in Japan are sometimes kept on patients for weeks and months, [4] and they are thought to have caused several deaths due to deep vein thrombosis and pulmonary embolism. [5] [6] More information about Japanese use of restraints is described in the page on physical restraints.

Because of the potential for abuse, the use of medical restraints is regulated in many jurisdictions. At one time in California, psychiatric restraint was viewed as a treatment. However, with the passing of SB-130, which became law in 2004, the use of psychiatric restraint(s) is no longer viewed as a treatment, but can be used as a behavioral intervention when an individual is in imminent danger of serious harm to self or others. [7] [ unreliable medical source ]

Criticism

In the U.S. in the late 2010s and into the 2020s (so far), restraint of psychiatric patients and/or people with mental disorders (for all purpose other than very temporarily if another person would be in danger) has come under heavy fire from many professionals (such as those in the Therapist Neurodiversity Collective) and human rights groups (such as Alliance Against Seclusion and Restraint, Inc. a Maryland nonprofit), often when pertaining to restraint being used in mental health institutions and against autistic people such as children in U.S. public schools. [8] [9] [10] [11] [12] [13]

Types

Medical restraint
PinelRestaint.jpg
An example of a person in Pinel restraints

There are many types of medical restraint:

Manual techniques

A number of private national and regional companies teach physical (non-mechanical) restraint techniques for companies and agencies that care for or have custody of people who might become aggressive. The strategies vary widely, with many based on police or martial art pain compliance techniques, with others using only pain-free techniques. Most also emphasize verbal de-escalation and defusing skills before using any physical skills. A non-inclusive list:

Adverse effects

Throughout the last decade or so, there has been an increasing amount of evidence and literature supporting the idea of a restraint free environment due to their contradictory and dangerous effects. [16] This is due to the adverse outcomes associated with restraint use, which include: falls and injuries, incontinence, circulation impairment, agitation, social isolation, and even death. [17] [8] [9] [10] [11] [12] [13]

In a 2017 The Guardian article:

"If you are a woman who has been sexually or physically abused, and mental health problems in women often have close links to violence and abuse, then a safer environment has to be just that: safe and not a re-traumatising experience. (...) Face-down restraint hurts, it is dangerous, and there are some big questions around why it is used more on women than men." [18]

As of 2021 research is still on-going as to how much restraint an cause and/or exacerbate PTSD for the person being restrained. [19] [20] [21] In a systematic review in 2020:

"Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions". [20]

Research is also ongoing into the adverse mental health effects on the health workers doing the restraint. [22]

Applicable laws

United States

Current United States law requires that most involuntary medical restraints may only be used when ordered by a physician. Such a physician's order, which is subject to renewal upon expiration if necessary, is valid only for a maximum of 24 hours. [23]

Japan

Japanese law states that psychiatric hospitals may use restraints on patients only if there is a danger that the patients will harm themselves or others. The law also states that a designated psychiatrist must approve the use of restraints and examine the patient at least every 12 hours to determine whether the situation has changed and the patient should be removed from restraints. [24] However, in practice, Japanese psychiatric hospitals use restraints fairly often and for long periods. Despite being required to certify every 12 hours whether a patient still needs restraints, Japanese psychiatric hospitals keep patients in restraints for a much longer time than hospitals in other countries. According to a survey conducted on 689 patients in 11 psychiatric hospitals in Japan, the average time spent in physical restraints is 96 days. [4] Meanwhile, the average time in most other developed countries is at most several hours to tens of hours.

The number of people who are physically restrained in Japanese psychiatric hospitals continues to increase. In 2014 more than 10,000 people were restrained-the highest ever recorded, and more than double the number a decade earlier. [25] It is thought that some of that increase includes older patients with dementia. As a result, the Japanese Ministry of health has revised its guidelines for elderly people in nursing homes to have more restrictions against body restraints. The changes took effect on 1 April 2018. [26]

United Kingdom

The Millfields Charter is an electronic charter which promotes an end to the teaching to frontline healthcare staff of all prone (face down) restraint holds. [27] In June 2013 the UK government announced that it was considering a ban on the use of face-down restraint in English mental health hospitals. [28]

Face down restraints are used more often on women and girls than on men. 51 out of 58 mental health trusts use restraints unnecessarily when other techniques would work.[ citation needed ] Organisations opposed to restraints include Mind and Rethink Mental Illness. YoungMinds and Agenda claim restraints are "frightening and humiliating" and "re-traumatises" patients especially women and girls who have previously been survivors of physical or sexual abuse. The charities sent an open letter to health secretary, Jeremy Hunt showing evidence from 'Agenda, the alliance for women and girls at risk', revealing that patients are routinely restrained in some mental health units while others use non-physical ways to calm patients or stop self-harm. According to the letter over half of women with psychiatric problems have suffered abuse, restraint can cause physical harm, frighten and humiliate the victim. Restraint, specially face down restraint can re-traumatise patients who previously suffered violence and abuse. "Mental health units are meant to be caring, therapeutic environments, for people feeling at their most vulnerable, not places where physical force is routine."

Government guidelines state that face down restraint should not be used at all and other types of physical restraint are only for last resort. Research by Agenda found one fifth of women and girl patients in mental health units had been physically restrained. Some trusts averaged over twelve face down restraints per female patient. Over 6% of women, close to 2,000 were restrained face-down in total more than 4,000 times. The figures vary widely between regions.

Some trusts hardly use restraints, others use them routinely. A female patient was in several hospitals and units at times for a decade with mental health issues, she said in some units she was restrained two or three times daily.[ citation needed ] Katharine Sacks-Jones director of Agenda, maintains trusts use restraint when alternatives would work. Sacks-Jones maintains women her group speak to repeatedly describe face down restraint as a traumatic experience. On occasions male nurses have used it when a woman did not want her medication. "If you are a woman who has been sexually or physically abused, and mental health problems in women often have close links to violence and abuse, then a safer environment has to be just that: safe and not a re-traumatising experience. (...) Face-down restraint hurts, it is dangerous, and there are some big questions around why it is used more on women than men." [18] The use of restraints in UK psychiatric facilities is increasing. [29] "

Prevention

Given the lack of evidence for the effectiveness and the potential harms associated with the use of physical restraints in many settings, efforts to safely decrease their use may be justified. [30] For older people who are hospitalized, approaches to reduce or eliminate physical restraints such as the use of bedrails, belts in chairs, and fixed tables may include pressure sensor bed or chair alarms, however there is no strong evidence that these types of prevention approaches are effective at decreasing reliance on physical restraints. [30]

See also

Related Research Articles

<span class="mw-page-title-main">Psychiatric hospital</span> Hospital specializing in the treatment of serious mental disorders

Psychiatric hospitals, also known as mental health hospitals or behavioral health hospitals, are hospitals or wards specializing in the treatment of severe mental disorders, including schizophrenia, bipolar disorder, eating disorders, dissociative identity disorder, major depressive disorder, and others.

<span class="mw-page-title-main">Physical restraint</span> Obstruction of physical movement

Physical restraint refers to means of purposely limiting or obstructing the freedom of a person's bodily movement.

<span class="mw-page-title-main">Seclusion</span>

Seclusion is the act of secluding, the state of being secluded, or a place that facilitates it. A person, couple, or larger group may go to a secluded place for privacy or peace and quiet. The seclusion of an individual is called solitude.

<span class="mw-page-title-main">Health care system in Japan</span> Overview of the health care system in Japan

The health care system in Japan provides different types of services, including screening examinations, prenatal care and infectious disease control, with the patient accepting responsibility for 30% of these costs while the government pays the remaining 70%. Payment for personal medical services is offered by a universal health care insurance system that provides relative equality of access, with fees set by a government committee. All residents of Japan are required by the law to have health insurance coverage. People without insurance from employers can participate in a national health insurance program, administered by local governments. Patients are free to select physicians or facilities of their choice and cannot be denied coverage. Hospitals, by law, must be run as non-profits and be managed by physicians.

Suicide watch is an intensive monitoring process used to ensure that any person cannot attempt suicide. Usually the term is used in reference to inmates or patients in a prison, hospital, psychiatric hospital or military base. People are placed on suicide watch when it is believed that they exhibit warning signs indicating that they may be at risk of committing bodily harm or purposefully killing themselves.

Involuntary treatment refers to medical treatment undertaken without the consent of the person being treated. Involuntary treatment is permitted by law in some countries when overseen by the judiciary through court orders; other countries defer directly to the medical opinions of doctors.

<span class="mw-page-title-main">Deinstitutionalisation</span> Replacement of psychiatric hospitals

Deinstitutionalisation is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all.

<span class="mw-page-title-main">Padded cell</span> Room in a psychiatric hospital

A padded cell or seclusion room is a cell used in a psychiatric hospital or special education setting in both private schools and public schools with cushions lining the walls and often a cushioned floor as well. The padding is an attempt to prevent patients from hurting themselves by hitting their head on the hard surface of the walls. In most cases, an individual's placement in a padded cell is involuntary.

St Andrew's Healthcare is a large independent charity based at St Andrew's Hospital in Northampton, which provides psychiatric services. It also has sites in Essex, Birmingham and Nottinghamshire. It runs specialist services for adolescents, men, women and older people with mental illness, learning disability, brain injury, autism and dementia and hosts the National Brain Injury Centre. It is a psychiatric hospital and service provider that caters for individuals requiring inpatient care and rehabilitation, and step-down housing.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, and perceptions.

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<span class="mw-page-title-main">Limb restraint</span> Physical restraints

Limb restraints can be physical restraints that inhibit an individual's movement in their arms or legs. The most common limb restraint is physical, whereby restraints are fixed to the individual in order to prevent movement of the limbs. They are most commonly used within the field of medicine. However, opposed to physical restraints, chemical restraints are forms of psychoactive medication that intentionally inhibit an individual's behaviour or movement.

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<span class="mw-page-title-main">Lunatic asylum</span> Place for housing the insane, an aspect of history

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Patient abuse or patient neglect is any action or failure to act which causes unreasonable suffering, misery or harm to the patient. Elder abuse is classified as patient abuse of those older than 60 and forms a large proportion of patient abuse.

<span class="mw-page-title-main">Restraint chair</span> Physical restraint device

A restraint chair is a type of physical restraint that is used to force an individual to remain seated in one place to prevent injury and harm to themselves or others. They are commonly used in prisons for violent inmates and hospitals for out of control patients. However, they have also been used to restrain prisoners at Guantanamo Bay detention camp during force-feeding.

The Keeping All Students Safe Act or KASSA is designed to protect children from the abuse of restraint and seclusion in school. The first Congressional bill was introduced in the United States House of Representatives on December 9, 2007, and named the Preventing Harmful Restraint and Seclusion in Schools Act. The primary sponsors of the two bills are Senator Tom Harkin (D-IA), Chair of the Senate Health, Education, Labor, and Pensions Committee, Congressman George Miller (D-CA), Ranking Member of the House Education and Workforce Committee, and Congressman Gregg Harper (R-MS).

Kelly Robert Savage was an Assistant Language Teacher in Japan whose death sparked an international outcry and a national debate in Japan about their psychiatric system and its use of long-term physical restraints. Savage was a dual citizen of New Zealand and the United States, and worked in Shibushi, Kagoshima in Japan from August 2015 until his death in May 2017.

Acute behavioral disturbance (ABD) is an umbrella term referring to various conditions of medical emergency where a person behaves in a manner that may put themselves or others at risk. It is not a formal diagnosis. Another controversial term, excited delirium, is sometimes used interchangeably with ABD.

<span class="mw-page-title-main">Death of Olaseni Lewis</span> Policing incident in the United Kingdom

Olaseni Lewis, a 23-year-old British man, died on 3 September 2010 at Bethlem Royal Hospital in London, United Kingdom, after police subjected him to prolonged physical restraint. Lewis had voluntarily sought care following the onset of acute mental health issues and died from cerebral hypoxia soon after, following actions that involved eleven officers of London's Metropolitan Police. After seven years of campaigning by Lewis' family and two inquiries by the Independent Police Complaints Commission (IPCC), a second coroners' inquiry was raised.

References

  1. ↑ "Use of Restraints". 15 Nov 2016.
  2. ↑ "Physical Restraints: Patient Who Had Fallen Should Have Been Restrained, Court Rules". Legal Eagle Eye Newsletter for the Nursing Profession. December 1997. Archived from the original on 2013-10-15.
  3. ↑ Cruzan, Susan (1992-06-16). "Patient Restraint Devices Can Be Dangerous". News Release. Food and Drug Administration. Archived from the original on 2008-01-29. Retrieved 2009-08-15.
  4. 1 2 長谷川利夫. (2016). 精神科医療における隔離・ 身体拘束実態調査 ～その急増の背景要因を探り縮減への道筋を考える～. 病院・地域精神医学, 59(1), 18–21.
  5. ↑ "Family blames prolonged use of restraints at Kanagawa hospital for English teacher's death". 18 July 2017.
  6. ↑ "認知症でしばられる!? ～急増・病院での身体拘束～".
  7. ↑ Morrison, Leslie (2004-09-16). "Restraint & Seclusion: Review and Update". Archived from the original (PPT) on 2015-12-04.
  8. 1 2 Richards, Jodi S. Cohen,Jennifer Smith (19 November 2020). "National Ban on School Use of Seclusion and Restraint of Students Introduced in Congress". ProPublica. Retrieved 2022-01-05.{{cite web}}: CS1 maint: multiple names: authors list (link)
  9. 1 2 Cohen, Jennifer Smith Richards,Jodi S. (17 November 2020). "New Data Shows the Use of Seclusion and Restraint Increased in Illinois Schools During the 2017–18 School Year". ProPublica. Retrieved 2022-01-05.{{cite web}}: CS1 maint: multiple names: authors list (link)
  10. 1 2 Richards, Jodi S. Cohen,Jennifer Smith (23 April 2020). "How Often Do Schools Use Seclusion and Restraint? The Federal Government Isn't Properly Tracking the Data, According to a New Report". ProPublica. Retrieved 2022-01-05.{{cite web}}: CS1 maint: multiple names: authors list (link)
  11. 1 2 Cohen, Jodi S.; Richards, Jennifer Smith; Chavis, Lakeidra (2019-11-19). "Children are being locked away, alone and terrified, in schools across Illinois. Often, it's against the law". ProPublica. Retrieved 2022-01-05.
  12. 1 2 Abamu, Jenny (2019-06-15). "How Some Schools Restrain Or Seclude Students: A Look At A Controversial Practice". NPR. Retrieved 2022-01-05.
  13. 1 2 "Restraint and Seclusion". Therapist Neurodiversity Collective. Retrieved 2022-01-05.
  14. ↑ "A Parent's Guide to Respectful Feeding Therapy: Part 2". Therapist Neurodiversity Collective. 2021-11-20. Retrieved 2022-01-05.
  15. ↑ "Professional Crisis Management Association".
  16. ↑ Evans D, Wood J, Lambert L (Feb 2003). "Patient injury and physical restraint devices: a systematic review". Journal of Advanced Nursing. 41 (3): 274–82. doi:10.1046/j.1365-2648.2003.02501.x. PMID   12581115.
  17. ↑ Luo H, Lin M, Castle N (Feb 2011). "Physical restraint use and falls in nursing homes: a comparison between residents with and without dementia". American Journal of Alzheimer's Disease & Other Dementias. 26 (1): 44–50. doi:10.1177/1533317510387585. PMID   21282277. S2CID   27371684.
  18. 1 2 End humiliating restraint of mentally ill people, say charities
  19. ↑ Franks, Zenan M.; Alcock, Jonathan A.; Lam, Tommy; Haines, Kimberley J.; Arora, Nitin; Ramanan, Mahesh (2021-04-01). "Physical Restraints and Post-Traumatic Stress Disorder in Survivors of Critical Illness. A Systematic Review and Meta-analysis". Annals of the American Thoracic Society. 18 (4): 689–697. doi:10.1513/AnnalsATS.202006-738OC. ISSN   2329-6933. PMID   33075240. S2CID   224811147.
  20. 1 2 Chieze, Marie; Hurst, Samia; Kaiser, Stefan; Sentissi, Othman (2019-07-16). "Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review". Frontiers in Psychiatry. 10: 491. doi: 10.3389/fpsyt.2019.00491 . ISSN   1664-0640. PMC   6673758 . PMID   31404294.
  21. ↑ Fugger, G.; Gleiss, A.; Baldinger, P.; Strnad, A.; Kasper, S.; Frey, R. (March 2016). "Psychiatric patients' perception of physical restraint". Acta Psychiatrica Scandinavica. 133 (3): 221–231. doi:10.1111/acps.12501. ISSN   1600-0447. PMID   26472265. S2CID   30176888.
  22. ↑ "The Psychological Effects of Restraints on Mental Health Workers".
  23. ↑ Wigder, Herbert; Matthews, Mary S. (2006-03-07). "Restraints". emedicine.com. Archived from the original on 2006-12-05.
  24. ↑ "Number of patients physically restrained at psychiatric hospitals soars". 9 May 2016.
  25. ↑ "身体拘束と隔離がまた増えた". February 2017.
  26. ↑ <!—Staff writer(s) (4 December 2017). "介護施設、身体拘束の要件厳格化" [Tough changes in requirements for physical restraints in nursing homes] (in Japanese). Thompson-Reuters: Reuters Japan.
  27. ↑ "Archived copy". Archived from the original on 2006-12-05. Retrieved 2006-12-05.{{cite web}}: CS1 maint: archived copy as title (link)
  28. ↑ "'Excessive' use of face-down restraint in mental health hospitals". bbc.co.uk. 18 June 2013. Retrieved 19 June 2013.
  29. ↑ Mental health trusts restrain patients 'every 10 minutes' BBC
  30. 1 2 Abraham, Jens; Hirt, Julian; Richter, Christin; Köpke, Sascha; Meyer, Gabriele; Möhler, Ralph (2022-08-25). "Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings". The Cochrane Database of Systematic Reviews. 2022 (8): CD012476. doi:10.1002/14651858.CD012476.pub2. ISSN   1469-493X. PMC   9404383 . PMID   36004796.
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