**3. Pre-initiation considerations regarding patient restraints**

When considering the initiation of patient restraints, the goal is always to control the situation without the initiation of restraints. Many variables and factors can be involved in the situations that precede and evolve into ABDs. These variables can include environmental/architectural factors, hospital policy factors, and practicebased interventions. Most broadly, these variables reside within two major buckets of consideration: proactive vs. reactive measures [11]. This section will parse common listed proactive and reactive measures that can provide potential areas of conflict mitigation to limit or eliminate the need for restraints.

Proactive approaches are important interventions that can potentially stop ABDs before they occur. The literature lists many examples, but they are often discussed in the context of weak to moderate evidence [2, 11, 22]. Although there are many efforts to stop ABDs, no single proactive measure has been able to definitively address ABDs [2, 11]. Without one agreed effective measure, it is then important to review multiple common interventions that are frequently discussed in the literature.

One proactive measure is providing maximum patient visibility in scenarios that include potentially agitated patients [11]. Increased patient visibility by providers can be achieved from a host of interventions. Closed circuit TV (CCTV) and reinforced glassed areas are two common architectural interventions that aid in maximizing visibility. The utilization of increased visibility allows providers to more rapidly identify situations where patients could become agitated (pacing, aggressive verbalizations, responding to inappropriate stimuli, etc.). This could help providers intervene earlier and assess patient needs before the situation evolves to a situation where restraints could be needed. This visibility can also be augmented through the utilization of alarm systems which provide an environmental tool for the management and assessment of patients by providing indications for those who are potentially ambulating or disregarding reorientation methods by staff.

Designated evaluation spaces are another proactive approach towards mitigation and minimization of ABDs. These rooms have been referred to as safe rooms, seclusion areas, and low stimulus environments [2, 11]. They provide modifiable and controllable environments that remove agents that increase agitation, help foster a therapeutic alliance, and increase rapport with patients. In accordance with multiple sources that also include the National Institutes for Care and Excellence (NICE) criteria, there are recommendations regarding the layout of the room that will help with health assessment interviews [2, 11, 23]. The rooms should be as close as possible to the receiving area of the ED [2, 11, 23]. Spacing should also accommodate up to six people and be fitted with technology and windows that help with the ability to observe individuals [2, 11, 23]. This area should also contain furnishing that are soft, be well-ventilated, and contain no items that could be potential utilized as a potential weapon [2, 11, 23]. With some of these variables established, the rooms provide an area that can both mitigate and anticipate of situations involving agitation.

From the purview of practice-based interventions, the utilization of targeted triage screening scales that have been utilized in Psychiatric care have yet to be widely adopted in the ED setting. These triage tools have been identified as a potential area of practice-based intervention [17]. For example, screening questionnaires for proper triaging of individuals experiencing psychosis have been validate in the inpatient settings, but a standardized screening tool regarding psychosis has not been validated in an ED setting [17]. These tools may better identify organic causes of agitation. If one can identify a primary psychiatric cause of agitation as opposed to substance intoxication, better patient triage can prevent escalation to restraint application and provide a clearer view of the incidence and prevalence of ABD presentations in the ED.

Policy interventions targeted towards patient perceptions and timely dissemination of information have also been noted to help mitigate patient agitation occurrences while also improving reported patient experiences [9]. For example, one area of negative patient experience is the perception of "judgmental attitudes" by either staff, EMS, or police present during evaluation [9]. Policy interventions that inform groups of their impact on patient experience are areas that could eliminate behaviors that negatively shape patient agitation. Long wait times also provide situations in which individuals become more agitated. This agitation is alleviated when patients

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were provided with timely support and information on wait times [2, 11]. Patients also express "vulnerability" and "overstimulation" when ABDs are recorded, so providing areas of privacy and personal space have also been associated with significant improvements to patient reported outcomes and agitation occurrence [9, 14]. Patients express that the use of seclusion and restraint were also mitigated when an advocate who could explain interventions and evaluations was present. These are a sample of policy interventions that can be proactively enacted to mitigate scenarios in which feelings of agitation or aggression could flourish [9].

An additional proactive measure is the implementation of training programs for staff. These training programs can help better train providers in verbal de-escalation techniques and evaluation methods. These training programs have been evaluated to increase provider confidence in addressing ABDs [2, 11]. The number, quality, and names of training programs are too varied and extensive to innumerate within this chapter, so general principles of these programs will be discussed instead. The core competencies of workplace policy knowledge, behavioral theories and aggression etiologies, identification of high risk scenarios, assertiveness, and communication techniques are central to these training programs [11]. Although these programs were associated with increased in ABD interaction confidence, it is important not to conflate confidence with efficaciousness when dealing with ABDs [11]. These training programs do provide another avenue of implementation of tools to help health care professionals with identification of agitation in a quick and efficient way and provide another layer of conflict resolution that can possibly reduce occurrence of ABDs.

Secondly, consider more reactive approaches. These approaches include mobilization of designated teams with the expressed intent of mitigating or addressing the concerns of the agitated patient [11, 19, 24–26]. These resources contain many institution specific naming conventions and personnel classifications that would be outside of the ability of this chapter to fully enumerate, but there are generalizable concepts that occur across these teams. These teams consist of multi-disciplinary teams from a host of backgrounds – administration, security, and nursing to name a few. These teams have designated roles that range from interaction with the patient, interaction with bystanders, interaction with the environment, and interaction with medications and tools. With a clear division of labor and rehearsed practice in these roles, these teams help to specifically address unique clinical scenarios and best mitigate ABDs short of needing to escalate the level of care [2, 11].

The mobilization of security or law enforcement personnel is another resource providers can mobilize during ABDs. It is important to foster relationships with these personnel as they can be invaluable in providing support to mitigate aggressive behavior. However, it is important to note that the presence of law enforcement or security can potentially be a "double-edged sword." For acutely agitated patients, the presence of these support individuals can provide a negative stimulus and may strain the therapeutic alliance if they have had negative interactions with these personnel in the past [20, 27]. Evaluate each patient's situation with regards to each patient's personal history and presenting complaints.

A trained crisis worker or psychiatric emergency services (PES) is an additional area of support and reactive mitigating approaches [17]. These providers have training in acute management and mitigation techniques that are targeted to address agitation secondary to psychiatric disturbances. A variety of techniques, agitation scoring systems, and clinical triaging tools are present and discussed in the psychiatric literature which allows providers to assess developing and established situations [4, 18, 19, 21, 28–30]. These providers can provide additional support and techniques to properly engage with

the patient, better assess the source of their agitation, and provide recommendations on further therapy or medication. However, it is important to note that these clinical tools and evaluation techniques are not always validated or easily applicable to the ED setting when compared to inpatient hospital settings. Additionally, not all EDs have access to these providers, and these providers are rarely available twenty-four hours a day. However when present, the utilization of counselors trained in emergency psychiatric services and evaluation reduces the use of restraint and seclusion in cases of psychosis while bolstering a therapeutic alliance [17].
