**4. Initiation of patient restraints**

When environmental/architectural, procedural, and practice-based interventions have been inadequate in staving off agitation and the individual in question has become combative and a threat to staff and self, it is then time to escalate care to the utilization of restraints. Much like the previous section, restraints can be divided into multiple categories: chemical, physical, environmental, and seclusion [22]. Although both chemical and physical restraint are far more commonly discussed in the literature, the utilization of seclusion and the environment as restraint are also important to discuss. Environmental restraint is predominantly the utilization of the items such as fences, walls, doors, and barriers to prevent movement freely throughout a building, department, or area. Seclusion is a further escalation of environmental restraint to where the person is isolated or restrained into an environment that also prevents free movement.

A frequently cited guideline, the NICE Guidelines, from the NHS of England is an extensive advisory publication to assist with staff training and implementation of both chemical and mechanical restraints in ABDs in the setting of mental health problems [23]. This guideline may also be relevant to those who do not have diagnosed mental health pathology [23]. The guidelines are targeted "for adults older than 18, children younger than 12, and ages 13-17 with a mental health problem who are currently within mental health, health, and community settings".

It is important to utilize pre-initiation measurements to mitigate or reduce occurrence of agitation. The implementation of chemical restraint (rapid tranquillization), physical restraints, and seclusion should only be considered after de-escalation strategies are attempted and are unsuccessful [31]. There is no strong evidence concerning the efficacy of these three interventions in ABDs, but the following description of restraint application and monitoring is formulated in the setting of best available data [31]. De-escalation techniques should also be continually employed during this process as they are used in conjunction with other interventions. Continual use of deescalation techniques throughout the process of restraint will help facilitate restraint placement and minimize agitation [23, 31].

Chemical restraints can be administered intramuscularly (IM) or intravenously (IV) when oral medication is unavailable or not a feasible option when the patient's agitation needs to be treated rapidly. In accordance with the algorithms noted in the NICE Guidelines, some of the most commonly used therapies for ABD is IM Lorazepam alone or the combination of IM haloperidol and promethazine [23]. However, the available options and combinations are numerous and ever growing. Broadly, the available chemical restraints can be categorized into first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and other [7].

The first-generation antipsychotics (typical) block dopamine receptors in the central nervous system. This class of medication can be further divided into high and

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

low potency agents [7]. The high potency agents include: fluphenazine, haloperidol, loxapine, perphenazine, pimozide, thiothixene and trifluoperazine [7]. The low potency agents consist of chlorpromazine and thioridazine. These medications are effective but carry the risk of extrapyramidal syndromes (EPS) more commonly noted in the high-potency agents [7].

The second-generation antipsychotics (atypical) partially block dopamine and serotonin receptors. These medications, in comparison to first generation agents, have decreased rates of EPS, hyperprolactinemia, and movement disorders [7]. Despite this improved side effective profile, these medications are not without limitations. Prolonged use of these medication are associated with hyperglycemia and dyslipidemia as well as increased risk of cardiovascular disease [7]. The common agents within this group of medications are risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole.

The benzodiazepines are another class of medications that possess rapid anxiolytic and sedative properties. They also possess potential side effects of respiratory depression, hyper-salvia, and ataxia [7]. The most commonly used benzodiazepines are lorazepam, diazepam and midazolam.

Several other medications have been found to be effective in inducing sedation. Promethazine, an antihistamine, has been shown to be effective when utilized in combination with haloperidol. The combination of haloperidol-promethazine is the recommended first line medications of for rapid tranquilization in ABDs if no contraindications are present [23]. The purported mechanism of action for this drug mixture is to speed both the sedative and antimuscarinic effects of promethazine [7].

Although these various medication categories are commonly used in the ED for chemical restraint, providers must account for the patient's past medical history, possible intoxication, and interaction with other medications as well as total dose of daily medications. For example, Haloperidol-Promethazine or other QT prolonging medications should not be given to patients with prolonged QT intervals on ECG [7]. Medications should also be ordered as single doses as opposed to PRN to avoid inadvertent administrations and to ensure that appropriate response to medications is obtained.

If chemical restraint measures fail, care may be escalated to the use of physical restraints. Physical restraints are the next and often final option employed by available staff. Physical restraint can refer to two main categories: manual restraints in which the patient's body is held by other people or the utilization of devices and appliances. Both types of physical restraints are meant to assist the patient by preventing bodily harm to themselves or others.

The initiation of physical restraints can be conducted in a variety of manners. Traditionally, the camisole or straight jacket was used as a primary physical restraint [7]. Another option is to fasten the patient to a chair often referred to as ambulatory restraint [7]. However, 4- and 5-point restraints are most frequently used in the modern ED and will be the focus of this chapter's discussion of physical restraint. The four "points" of this restraint methods refer to the immobilization of both hands and both feet. 5-point restraint includes the previously mentioned four points with the addition of the chest. The mobility limiting agents are often leather and cloth straps with soft padding where they meet the skin to minimize the occurrence of skin breakdown or trauma. A principle of "only as necessary" should be employed with regards to restraint use and the patient's limitation should be as low as possible until the need for restraint is no longer needed. A host of factors should be considered in the sequence of applying restraints and continuous monitoring is imperative.

As with all procedures in the ED, proper management of the airway, breathing, and circulation is paramount during the application of physical restraints. The team leader should remain at the head of the bed while providing support and stabilization to the head and neck when appropriate [31]. This team member should direct the group in order that airway and breathing compromise can be evaluated and/or prevented during the process of restraint application. Vital signs should be continually monitored during this process to assess for acute decompensation or need for further medical intervention during the application of restraints.

The team leader is required to provide support and stabilization to the head as restraint application can have high morbidity and mortality including the potential for positional asphyxia [32]. Reduction in breathing is noted to occur less often when the patient was in supine positioning compared to prone [32]. The team leader should make sure to convey to the team that the patient should remain in the supine position during application of physical restraints [32]. Special consideration should be given to patients with pre-existing medical conditions (namely cardiac and respiratory disease) or also have been prescribed high-dose antipsychotics [32].

If restraints are being applied, one should employ an "all-or-none" philosophy to the restraint devices. Regarding either 4- or 5-point restraints, the team should apply all restraints to the patient. The freedom of one or multiple limbs can present a situation in which the patient can harm themselves, harm the staff, or damage the environment in which they are receiving care. To limit kicking and thrashing while in restraints, staff can employ a cross anchoring pattern with respect to the lower extremities. Staff can fasten the right leg to the left corner of the bed and the left leg to the right corner of the bed. Note that the patient should be maintained in the supine position during this fastening for minimization of risks discussed above. The devices for restraint should be attached to areas of the bed that move freely with bed repositioning (namely elevation of the head of the bed) [33].

During the process of restraint application, it is imperative to remember that the team is still providing care to an individual. Healthcare providers should make reasonable attempts to maintain patient privacy and mitigate humiliating factors. These factors should be considered when the intervention is occurring, and maintenance of dignity and privacy should be accommodated when possible. The level of applied force should be appropriate and proportional to the situation unfolding before health care professionals. Force should only be applied for the minimum amount of time that it is required. Although the situations are often fluid and rapidly evolving, care should be taken to minimize painful techniques. Although pain has no therapeutic role, it may be used when immediate danger or harm to health care professionals and staff is present. It is never the goal to enact a painful stimulus to a patient, however under certain circumstances it may be necessary for the defense and preservation of ED individual safety.

Following the conclusion of restraints, it is important for the team to be lead in a post-incident debrief and review of the ABD. The debrief provides an opportunity to review the factors leading up to the event, the performance of the team during the event, and areas for improvement. This debrief provides a forum to identify and evaluate potential risks, to address physical harms to staff, and evaluate the emotional impact to staff and bystanders. This debrief allows bystanders to discuss and process the events that occurred. It also gives active members an opportunity to discuss with non-active staff. Debrief engenders an area of safety, relaxation, and a return to previous activities and tasks [7, 31].
