**1. Introduction**

Restraint use during patient care is a serious and important safety topic because restraints are often utilized in high stress, rapidly evolving, and unique situations where patients may pose harm to themselves and others. There are a panoply of reasons for the initiation and maintenance of physical and chemical restraints that can range from the protection of patients from self-extubation in the ICU [1] to the prevention of bodily harm and property damage during acute behavioral disturbances (ABDs) in the emergency department (ED) [2–6]. Current restraint literature contains a wide range of studies with varying levels of evidence. Due to this wide range of studies, the proper time to use restraints, the most effective types of restraints, and the proper management of agitated patients is an area of continual research. However, a troubling trend is present upon review of restraint literature – patient aggression in the healthcare sector is increasing [2, 7–13].

An increase in patient aggression is correlated with increased staff turnover and increased "burnout" in EDs [2, 8]. When evaluating United States ED visits, agitation incidence was reported at 2.6% of all visits [14]. A provider must have a plan to address and manage the agitated patient. Therefore, issues regarding restraint utilization are a commonplace challenge in the ED given the wide range and continual change in patient populations [5, 15, 16]. However, why are agitated and violent

presentations so prevalent and trending upward? This manuscript will discuss two major factors pertinent to this restraint utilization question.

First, patients commonly access the ED pragmatically to receive *rapid* medical attention as opposed to *emergent* medical care [13]. The twenty-four hour availability of medical attention in the ED has led to increasing ED visits. There is often a disconnect between the expectations of patients-families when compared to health care professional expectations [13]. This cognitive disconnect can develop an environment ripe for "misunderstanding and conflict" [13]. Within a setting of high patient volumes, cramped working areas, mental fatigue, and insufficient administrative support, the addition of areas ripe for misunderstanding place further stress on an already stressed system. Considering this combination of potential patient-provider disconnect and a milieu of onerous situational variables, an already depleted health care workforce continues to suffer from decreased staffing numbers and dangerous lack of resource availability [11, 13]. It is imperative that health care providers have plans and resources in place in order to address situations that could involve violence, assault, and aggression.

Secondly, the increasing prevalence of psychiatric patients with acute behavioral needs provides an increasing level of complexity to the ED workflow. The World Health Organization (WHO) lists psychiatric disorders as "a major impact on health, society, human rights, and economy" while attributing 14% of global disease burden to psychiatric disorders [13]. Psychiatric patients also possess a higher frequency of ED utilization when compared to non-psychiatric patients [9, 13]. Additionally, one of the main reasons for a patient with psychiatric needs to pursue medical attention is violent behavior and incidence of violent behavior is higher in this increased in this population [13]. Therefore, the ED is often a setting where management of acute psychiatric needs are acutely addressed at times of crisis [17]. These acutely agitated patients require additional considerations and resources from staff to address de-escalation, chemical sedation, prevention of elopement, and violence [13]. In a high speed environment with rapid care, health care professionals express difficulty assessing and addressing the needs of this patient population [13]. This challenging communication difficulty provides yet another area for potential development of violent behavior. Naturally, the discussion of restraint use is more frequent in this dangerous setting.

The cumulative effect of incongruence between staff and patient expectations, the utilization of the ED as a primary source of acute behavioral health crisis evaluation, and increasing ABDs makes the ED rife for conflict and agitation. This scenario begets a need for a streamlined processes to provide safety measures for both patients and staff. Restraints are an important but high-risk tool in the management of the agitated patient. Providers must consider the use of this intervention alongside potential complications much like any procedure or medicine. Therefore, both the patient and health care professional perspectives must be considered when contemplating the risks of restraint initiation.

From the perspective of the patients, it is important to consider the risks and factors that lead up to the consideration of restraint initiation. Patient perception and experience in the ED when restraints have been utilized have been studied, and the utilization of restraints has been shown to cause lasting emotional damage to the patient despite a focus on the patient's best interests [9, 14]. This damage can impact the course of their medical care. The therapeutic alliance is often based on the establishment of rapport, a task that is often daunting given the dynamic nature of ED interactions and the challenges of first-time patient introductions. In addition,

#### *Emergency Department Restraint Safety DOI: http://dx.doi.org/10.5772/intechopen.107478*

commonly reported adverse events associated with restraint use are prolonged physical injuries and cardiac events [14].

Verbal de-escalation is an effective mitigating technique, but the ED environment is a challenging setting that may hamper its effectiveness. It is difficult to gain insight to a patient's wants, desires, and goals in the setting of agitation which only further impairs the utilization of verbal de-escalation techniques [14]. With the potential mitigation of verbal de-escalation techniques, difficulty at establishing a de novo therapeutic alliance, and potential adverse reactions to restraints, patients have expressed feeling of coercion and entrapment when restraints are employed [14, 17–20]. While several barriers to de-escalation exist in the ED, frequent failed attempts at de-escalation and increased ED ABDs leads to challenging encounters and the likelihood of restraint placement.

From the perspective of the health care professionals, patient and staff safety is the ultimate goal. This goal can be difficult to obtain. The occurrence of ABDs not only impacts patient's health and management but impacts the health and safety of the staff providing care. A UK study reported that greater than 30% of health care providers reported assault while working with patients in the ED [2]. This number is likely to be grossly underestimated given the total high prevalence of underreporting [2]. The ED has been reported to be one of a medical settings with the "highest risk" of harm [11]. Rates of aggression and assault have been noted to be skewed towards nurses and health-care assistants when compared to all ED personnel [3, 11–13, 21].
