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Seclusion and Restraints

Overview | Clinical Scenarios | Additional Tips | References
By Kathleen Kruse, MD and Susan Hatters-Friedman, MD

OVERVIEW

General Principles

  • Definitions
    • Seclusion is the involuntary confinement of a patient alone in a room—or another area from which the patient is physically prevented from leaving
    • A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
    • A chemical restraint is a medication used to control behavior or to restrict the participant’s freedom of movement and is not a standard treatment for the participant’s medical or psychiatric condition
  • The primary goal of seclusion and restraint is maintaining imminent safety of the patient, staff, and other patients in the treatment environment
    • Potential adverse events include asphyxiation, aspiration, rhabdomyolysis, thrombosis, and cardiac arrest
    • Patients in prolonged restraints are at elevated risk for adverse outcomes
      • Supine position increases the risk for aspiration events
      • Prone position increases the risk for asphyxiation
      • Restraint that involves compression of the chest increases the risk of cardiac events.
  • Seclusion and restraint are highly regulated in psychiatric practice by regulatory bodies, including the Joint Commission and the Center for Medicare and Medicaid Services
  • Seclusion and restraint may only be used to ensure the immediate physical safety of the patient or others in the patient’s environment
  • Minimum standards must protect basic constitutional rights, including the right to liberty
    • All patients have the right to be free from restraint and seclusion imposed as a means of coercion, discipline, convenience, or retaliation by staff
    • Less restrictive alternatives to seclusion and restraint, such as verbal de-escalation or medication management, should be considered before proceeding to seclusion and/or restraint
    • Restraint may only be used when less restrictive options to protect the patient and others from harm have been proven ineffective
    • Orders for seclusion and restraint cannot be written as needed (PRN) or standing
  • Patients should be closely monitored while in seclusion or restraint for acute medical conditions, as well as aspiration or asphyxiation
    • When the patient is placed in seclusion or restraint for management of violent or self-destructive behavior that jeopardizes immediate physical safety of the environment, a patient must be evaluated face-to-face within one hour by:
      • A physician or other licensed independent practitioner; or by
      • A registered nurse or physician assistant who has met specified training requirements
    • Patients in seclusion or restraint should be monitored no less frequently than once every 15 minutes
    • Seclusion or restraint must be discontinued once deemed unnecessary to maintain safety
  • An emerging body of literature indicates racial inequities in the use of physical and chemical restraints
    • Black patients, multiracial patients, and patients of undefined race are:
      • More likely to be physically restrained
      • More likely to be chemically restrained
    • The association between Black race and restraint use remains after adjusting for confounding variables (such as age, sex, ethnicity, diagnosis, urine drug screen results)

CLINICAL SCENARIOS

Scenario #1: A patient on an inpatient psychiatry unit receives distressing news. She threatens to harm herself. When a nurse attempts to discuss strategies to manage distress, she drops to the floor and begins banging her head against the floor. She then attempts to wrap a bedsheet around her neck. Is seclusion or restraint an appropriate option?

  • Restraint may be considered to maintain immediate physical safety of the patient. While alternatives were attempted, the patient did not respond to verbal de-escalation (see Additional Tips). A medication, while an option, will take time to take effect.

Scenario #2: A patient being seen in the emergency room for psychosis begins loudly accusing staff of removing thoughts from his brain. He begins pacing, and he is observed clenching his fists. He ignores a staff member who attempts to speak with him. When a nurse offers a medication, he threatens to punch her and falls into a boxing stance. More staff attempt to assist and the patient shoves the med cart, trying to knock it over. Is seclusion or restraint an appropriate option?

  • Seclusion may be considered to maintain immediate physical safety of the patient. He is not engaging in self-injurious behavior or threatening self-harm, but there is a risk to staff. While alternatives were attempted, the patient did not respond to verbal de-escalation and refused PRN medications.

Scenario #3: An elderly patient with multiple medical comorbidities, including hypertension and chronic obstructive pulmonary disease, is placed in physical restraints after repeatedly attempting to strangle herself. Other interventions short of restraint had failed. She is restrained in the supine position with all four limbs restrained. What risks are there for her as an older patient with medical comorbidities?

  • While all patients should be monitored closely while in restraints, elderly patients and/or patients with medical comorbidities warrant increased monitoring via checks and vitals assessment.
  • Examples of medical comorbidities that may increase the risk of adverse outcomes include the following:
    • Cardiac concerns (heart failure, history of myocardial infarction/stroke)
    • Pulmonary disease (COPD/emphysema)
    • Acute substance intoxication
    • Recent surgical intervention

Scenario #4: A patient is placed in physical restraints after repeatedly charging an inpatient unit staff member. He is also given an antipsychotic injection. After one hour, the patient is calm and compliant with checks. He is not fighting at restraints and has not made any additional threats. Staff are considering whether to remove restraints. How should they decide when he should come out of restraints?

  • Restraints and seclusion are used to maintain imminent physical safety of the treatment environment and must be removed when imminent risk is no longer present.

ADDITIONAL TIPS

Documentation Tips

  • Type of intervention used
  • Observations of behavior that warranted use of seclusion or restraint
  • Time that seclusion or restraint was initiated
  • Physical assessment of person and timing of the assessment
  • Indications for discontinuing intervention

General Tips

De-Escalation Techniques

  • Be empathic and non-judgmental when speaking with the patient.
  • Respect personal space.
    • If possible, stand 1.5-3 feet away from the person.
    • If you must enter personal space, explain your actions to the person.
  • Keep your tone and body language neutral.
  • Remain calm, rational, and professional.
  • Attempt to reflect the person’s feelings or emotions back to them.
    • Listen to what the patient is saying.
    • Observe the person’s body language.
    • Example: “This must be very scary for you.”
  • Avoid engaging in a power struggle, and bring the focus back to mutual problem-solving.
  • Set clear, concise, and enforceable limits.
  • Create flexibility and choices where possible and appropriate.
  • Allow for silence and reflection.
  • Provide time to make decisions.
  • Give the person time to process information.
  • Facilitate calm decision-making.

REFERENCES

  1. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry 2003 June; 48(5):330-337.
  2. Recupero PR, Price MP, Garvey KA, Daly B, and Xavier SL. Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management. JAAPL 2011 Nov; 34(4):465-476. http://jaapl.org/content/39/4/465
  3. Knox DK, Holloman GH. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA seclusion and restraint workgroup. WEJM 2012 Feb; 8(1):35-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298214/
  4. Department of Health and Human Services. Condition of participation: patient’s rights. Federal Register 2006; 482(13):71426-71428. https://www.federalregister.gov/d/06-9559
  5. Metzner JL, Tardiff KL, Lion J, Reid WH, Recupero PR, et al. Resource document on the use of restraint and seclusion in correctional mental health. JAAPL 2007 Dec; 35(4):417-425. http://jaapl.org/content/35/4/417
  6. Smith CS, Turner NA, Thielman NM, Tweedy DS, Egger J, Gagliardi JP. Association of black race with physical and chemical restraint use among patients undergoing emergency psychiatric evaluation. Psych Services 2021. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202100474
  7. Crisis Prevention Institute, Inc. Top 10 de-escalation tips. 2016. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-47-deescalation-in-health-care/-/media/EA12EA6D68EE4DD7BDE81E96DD70D2EB.ashx
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