Ask the Expert: Seclusion and Restraint

“The inpatient nurse is asking me how to deal with a threatening 16-year-old male patient diagnosed with bipolar disorder who is having a breakdown. When is seclusion or restraint an appropriate intervention?”

The short answer is only when there is immediate danger to the patient or others, and other measures are not possible. The long answer is that coercive interventions like seclusion or restraint are dangerous both psychologically and medically and are more likely to occur in an insensitive or unprepared environment. Effective seclusion and restraint reduction programs can reduce patient/staff conflict and patient stress.

Leadership

Seclusion and restraint governance should be provided by a committee of stakeholders including administration, staff, the facility psychiatric medical director, patients, and community patient advocates (1, 2). This group should evaluate the existing facility seclusion and restraint (S/R) data and the prevention elements that are described below. Initial S/R frequency rates can aim to match the national public rate of 0.40 seclusions per 1,000 inpatient hours, 2.4% of patients being secluded; and 0.45 hours of restraint per 1,000 inpatient hours, and 5% of patients being restrained (NASNHPD Research Institute 2012) (3). The committee should review the literature about factors contributing to seclusion and restraints and decide on a therapeutic environmental model of care, together with a separate crisis de-escalation program.

Staff Training

Two examples of model of care on which staff can be trained are described below.

Trauma informed care recognizes that many psychiatric patients have suffered traumas and abuse, which can be exacerbated by reminders occurring in treatment settings (4, 5). Examples of trauma-re-experiencing behaviors include staff directions given in a loud voice, finger pointing, “getting inside the patients’ physical comfort zone,” and giving verbal ultimatums. Patients may also associate staff members with previous abusers. Sanctuary care (6) is one example of a trauma-based treatment model. It stresses staff awareness of the patients’ trauma history and triggers, while encouraging empathic support at times of patient distress. It can be helpful with all staff members including those who have trauma histories themselves. It can also help patients who have experienced abuse in other treatment settings especially those involving seclusion or restraint.

Collaborative problem solving trains staff to negotiate with patients to resolve disagreements (7). This approach replaces confrontation over unit rules or directives with compromises that increase patient autonomy and strengthens patient trust in staff decision making.

Crisis de-escalation programs are used in emergent situations when the environment model is not effective or possible to implement. Two widely used programs are the Crisis Prevention Institute’s “Nonviolent Crisis Intervention” (8) and Cornell University’s College of Human Ecology’s “Therapeutic Crisis Intervention System” (9). Both of these programs are focused primarily on direct patient care staff techniques to de-escalate agitated patients, and both include appropriate ways to carry out physical restraints.

Alternatives to Seclusion

Self-directed time out is often more effective than locked seclusion, because it promotes self-efficacy. Comfort rooms are therapeutic places for patients to manage their acute stresses. They can be equipped with padded beanbag chairs, and have soft lighting and music (10). They are also places where patients and staff can discuss important issues away from the hustle and bustle of unit activity.

Patient and Family Input

Welcoming a patient to an inpatient and residential program has the following seclusion and restraint reduction elements:

Medications

It is preferable to use medications for the primary psychiatric diagnosis rather than use them as pro re nata (PRN) management tools in aggression or self-harm crises. Current practice for PRN medication has expanded in the last decade to include oral and intramuscular second generation antipsychotic medications. A discussion of emergency use of these agents is beyond the scope of this article, but may be found elsewhere in the literature (11, 12).

It is important to recognize that children in behavioral crises may see intramuscular medication as punishment such as spanking. Furthermore, in some of these situations, patients are capable of self-control, rendering pharmacological intervention unnecessary (13).

Requirements for use of Seclusion or Restraint

The Centers for Medicare and Medicaid Services (CMS) 1999 regulations permit the use of these restrictive procedures to prevent imminent self-harm or harm to others. All seclusions and restraints require ongoing monitoring (15). Because there are many ethical, therapeutic, and legal issues associated with a psychiatrist or therapist participating in the physical restraint of a patient, this decision should be carefully considered in advance (16).

Since hypoxia is a major cause of morbidity and mortality during restraint, the use of pulse oximetry to monitor a patient’s level of oxygenation during and after restraint has been proposed (17).

The 2006 CMS regulations require a 1-hour review of restraint or seclusion to be complete by a trained nurse. However, a physician must conduct a face-to-face interview with the patient within 24 hours of the event.

Debriefing: Two debriefing sessions are required after each seclusion or restraint, one between the staff and the patient, the other with involved staff members. Both of them focus on preventing recurrence of these interventions.

Review: Seclusion and restraint data are used in two ways to decrease the use of these interventions. 1) The leadership team member should review each individual episode to identify ways to prevent it from recurring with that patient (3). For example, should different medications be used? Should the family have more input? Should the safety plan be changed? Does staff need more behavioral training to work with the patient?

Data about a facilities aggregate use of seclusion and restraint with multiple patients can be used by the leadership to assess the effectiveness of training, patient input, and crisis de-escalation strategies in the program. The benefit of any changes should be reflected in decreases in seclusion and restraint rates.

In summary, the answer to the initial question: “When is seclusion or restraint an appropriate intervention?” must be informed by knowledge about the ecology of the psychiatric unit on which the procedure is being considered, and the possibilities for the patient to use alternative self soothing and crisis de-escalation options.