Seclusion and physical restraint

General:
- Implemented when a patient creates a risk of harm to self or others and no less
restrictive alternative is available and/or temporarily in order to administer medications
- Requires a written order confined to specific, time-limited periods. Any extension of an
original order must be reviewed and reauthorized
- When a clinician restrains a patient they become responsible for the well-
being of the patient. The patient’s condition must be regularly reviewed and
documented
- Physical restraints should be removed as soon as possible, usually once
adequate chemical sedation is achieved

Examples of patient and scenarios requiring the implementation of physical restraints:

- Patients with an organic disorder for whom restraints facilitate evaluation.
- Patients with functional psychosis for whom verbal techniques are less
effective and restraints facilitate administration of medications.
- Patients with personality disorders for whom verbal techniques are not
useful.

Indications for emergency seclusion and restraint include:

- Prevent clear, imminent harm to the patient or others
- Prevent significant disruption to treatment program or physical surroundings including
damage to the surrounding environment
- Assist in treatment as part of an effective ongoing behavior therapy program
- Decrease sensory overstimulation (seclusion only)
- Patient’s voluntary, reasonable request
- Patients who obviously do not understand what is occurring, for psychiatric
or other reasons, or are unable to communicate and are perceived by
medical staff to be potentially violent should be restrained.
- Actively violent patients and uncooperative, agitated patients, particularly
those who exhibit signs of impending violence, require immediate restraint.
o Signs of impending violence include:
 Provocative behavior
 Angry demeanor
 Loud, aggressive speech
 Tense posturing (eg, gripping arm rails tightly, clenching
fists)
 Frequently changing body position, pacing
 Aggressive acts (eg, pounding walls, throwing objects,
hitting oneself
 Psychiatric texts emphasize the attitude of the patient's
hands as an indicator of tension.
 Seclusion and physical restraint

Contraindications (*unless close supervision and direct observation are provided)

- Extremely unstable medical and psychiatric conditions* including hemodynamic
instability
- Delirious or demented patients who are unable to tolerate decreased stimulation*
- Overtly suicidal patients*
- Patients with severe drug reactions or overdoses or who require close monitoring of
drug dosages*
- For punishment or convenience of staff
- A patient with the capacity to make reasonable decisions and who poses
no threat to himself, the medical staff, or others cannot be confined or
restrained without their permission. Doing so can lead to a legal charge
of false imprisonment or battery

Restraint team
- Whenever possible, the treating clinician should not participate directly in
applying restraints in order to preserve the clinician-patient relationship
and not be viewed as adversarial.
- Preferably five people (minimum of four) should be used to restrain the patient,
including a team leader.
- The leader is the only person giving orders.
- All team members should remove personal effects, which the patient
could use against them.
- If the patient to be restrained is female, at least one member of the
restraint team should be female.

Considerations
- Restraints should be implemented systematically, ideally using an
approved institutional protocol. Consider the application of restraints like
a procedure, analogous to running an advanced cardiac life support code
- Even if the patient suddenly appears less dangerous, physical restraints
MUST be placed once the decision to use them has been made. Do NOT
negotiate with the patient.
- A staff member should always be visible and reassuring the patient who is being
restrained. Reassurance helps alleviate the patient’s fear of helplessness, impotence
and loss of control
- Leather is the optimal material for restraints because it is strong,
prevents escape, and is less constricting than typical soft restraints.
- Gauze should not be used. Soft restraints are helpful in restricting
extremity use in a semi-cooperative patient, but are less effective in the
truly violent patient who continues to struggle.
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- If chest restraints are used, it is vital that adequate chest expansion for
ventilation is ensured.
- Applying a soft Philadelphia collar to the patient's neck will help to
prevent head-banging and biting.
- Restraints should be placed so that intravenous fluids can be given, if necessary
- Restraining patients on their side helps to prevent aspiration, although
supine positioning with the head elevated is more comfortable for the
patient and allows a more thorough medical examination while providing
some protection against aspiration.
- Avoid the prone restraint position and using aggressive chemical
sedation in patients who continue to struggle against physical restraints.
Sudden, unexpected deaths have been reported in such patients.
- Restraints applied by prehospital personnel that place patients in the
prone or hobble position (ie, arms and legs restrained behind the
patient) have resulted in deaths possibly due to asphyxia.
- Restrained patients who are intoxicated with cocaine, amphetamines, or
other stimulants appear to be at particularly high risk for adverse
outcomes.
o Increased sympathetic tone and altered pain sensation may allow
exertion beyond normal physiologic limits in these patients and
may cause vasoconstriction that impedes the clearance of
metabolic waste products.
- Always thoroughly document the reason for the restraints, the course of treatment,
and the patient’s response to treatment while in restraints

Applying restraints
- Begins with the examiner leaving the room once verbal techniques have
been unsuccessful and summoning assistance/forming the restraint team.
- Before entering the room, the leader outlines the restraint protocol and
warns of anticipated danger (eg, the presence of objects that may be
used as weapons)
- The team enters the room in force and displays a professional, rather
than threatening, attitude.
- The leader speaks to the patient in a calm and organized manner,
explaining why restraints are needed and what the course of events will
be (eg, "You will receive a medical and psychiatric examination as well as
treatment").
- The patient is instructed to cooperate and lie down to have restraints
applied. Some patients will be relieved at the protection to self and
others afforded by restraints when they feel themselves losing control.
 Seclusion and physical restraint

- Patients should be restrained with legs spread-eagled and one arm restrained to one
side and the other restrained over the patient’s head
- The patient’s head is raised slightly to decrease the patient’s feelings of vulnerability
and to reduce the possibility of aspiration
- If it becomes necessary to use force to control the patient, one team
member restrains a preassigned extremity by controlling the major joint
(knee or elbow). This can be accomplished by locking the major joint in
extension.
- The team leader controls the head.
- Restraints are applied securely to each extremity and tied to the solid
frame of the bed (not side rails, as later repositioning of side rails also
repositions the patient's extremity).
- Once the patient is immobilized, announcing "the crisis is over" will have
a calming effect on the restraint team and the patient.
- After the patient is in restraints, the clinician begins treatment, using verbal
intervention
- Even in restraints, most patients still take antipsychotic medication in concentrated
form
- The restraint team should review their performance and discuss ways to
improve effectiveness. Education and rehearsal by staff is imperative to
maintain skills.

Monitoring and care of physically restrained patients

- A complete set of vitals, neurologic exam and thorough mental status exam should
be obtained
- A rapid blood glucose determination and pulse oximetry should be
obtained in all combative patients.
- The patient should be monitored frequently and have his or her position
changed regularly
- Ensure that basic needs (eg, hydration, toilet) are met for any patient
who is physically restrained or chemically sedated
- Documentation should include the specific indication for restraints and a
colleague's agreement that restraints were necessary.
- Physical restraints should be removed as soon as possible.

Removal of restraints
- After the patient is under control, one restraint at a time should be removed at 5-
minute intervals until the patient only has two restraints on.
- Both of the remaining restraints should be removed at the same time, because it is
inadvisable to keep a patient in only one restraint
 Seclusion and physical restraint

Legal considerations 
- Regardless of the legal system in which a clinician practices, adherence
to the following guidelines will help to minimize potential liability:
o The patient should be assessed by the clinician to determine if the
patient appears to have the capacity to make reasonable decisions
about their health care, workup, and therapy. Courts have
consistently given great latitude to clinicians in retrospect as long
as they were acting in good faith.
o Having a clinician coworker record that they agree with the
assessment and treatment described by the clinician primarily
responsible for the patient represents powerful supporting
documentation. Although obtaining court approval in advance of
actions is ideal, it is often impossible due to time constraints and
the limited availability of legal authorities.
o If a clinician decides to suspend the liberty of a patient and make
decisions for them, the reasons should be clearly documented in
the medical chart and any required forms completed.
o When a clinician restrains a patient physically or sedates them
chemically they become responsible for the well-being of the
patient. Attention to adequate comfort, hydration, respiration,
bathroom needs, and protection are required. Such a patient must
be closely monitored.
o Should physical restraints be placed, they should be removed as
soon as possible.
o A patient with the capacity to make reasonable decisions and who
poses no threat to himself, the medical staff, or others cannot be
confined or restrained without their permission. Doing so can lead
to a legal charge of false imprisonment or battery. In the US, false
imprisonment and battery are generally not covered in
malpractice insurance policies.

Restraint protocol
KCVA
1) Nursing and/or police will assist in placing the patient in restraints and call the physician
when they are in restraints.
2) You must evaluate within 1 hr of being put in restraints.
3) Check patient’s pulses and ensure the placement of the restraints won’t cause them harm
4) Complete the “KC-MH Physician restraint/seclusion” progress note
 Seclusion and physical restraint

5) Place an order for restraints

6) YOU WILL HAVE TO PHYSICALLY EVALUATE THE PATIENT EVERY EIGHT HOURS AND
COMPLETE A PHYSICIAN NOTE. If you are doing overnight call, you will have to physically
come in and evaluate the patient within every 8 hours throughout the night.
7) YOU WILL NEED RENEW THE ORDER EVERY FOUR HOURS.
8) The patient will also need to be on CO (order is needed) while in restraints

KUMC
**If the patient is on medicine service in restraints, the same protocol does NOT apply. You
do not have to evaluate the patient. **
1) Nursing and/or police will assist in placing the patient in restraints. They will call you once in
restraints. You must evaluate the patient within one hour of being placed in restraints.
2) Check patient’s pulses and ensure the placement of the restraints won’t cause them harm
3) Complete the “violent restraint/seclusion” note.
4) Place an order for restraints
5) YOU WILL HAVE TO PHYSICALLY EVALUATE THE PATIENT EVERY THREE HOURS AND WRITE
A NOTE! (specific seclusion restraint note) THIS IS VERY IMPORTANT! If you are doing
overnight call, you will have to physically come in and evaluate the patient every three
hours throughout the night.
6) The patient will also need to be on CO (order is needed) while in restraints