New Research Helps ER Staff Identify Patients for Restraint

New research sheds light on the characteristics of patients who are placed in physical restraint while receiving emergency room care.

Most patients restrained in emergency departments fall into two categories—a relatively young and predominantly male group presenting with alcohol or drug use, and an older group with medical complaints, recent research shows.

"Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED," the researchers wrote this month in Annals of Emergency Medicine.

Knowing which agitated patients in the ED could require restraint is valuable information because of a steadily growing number of behavioral emergencies and grave risks associated with restraint.

Behavioral emergencies in EDs have skyrocketed in recent years, with national estimates of a 50% increase in ED visits for behavioral disorders between 2006 and 2011 compared with an 8.6% increase in the total number visits. Agitation is often associated with behavioral ED visits, with 1.7 million events occurring annually.

Although the use of patient restraint is common in the ED setting, negative health outcomes and potential liability can be severe.

"Adverse events have been cited in the restraint process, including blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest. In addition, a survey of ED patients found that 66% reported experiencing severe psychological distress and lasting consequences in regard to care-seeking behavior after physical restraint," the Annals of Emergency Medicine researchers wrote.

Restraint patients
 

The researchers conducted the first large-scale study to characterize the kinds of patients who are restrained in the ED setting. Their study features 3,739 patients who were restrained in the emergency rooms of five hospitals.

For the vast majority of patients in the study, the researchers found there were two groupings of restrained patients with significantly different characteristics:

• The larger grouping accounted for two-thirds of restrained patients, with a median age of 39. The smaller grouping of restrained patients had a median age of 64.
   
• About 70% of the larger grouping were men, compared to about 60% male sex in the small grouping.
   
• About 30% of patients in the larger grouping were black, compared to 20% in the smaller grouping.
   
• About 60% of patients in the larger grouping had Medicaid coverage, and about 49% in the smaller grouping had Medicare coverage.
   
• Homelessness was much higher in the larger grouping at 8.9%, compared to 0.9% in the smaller grouping.
   
• Chief complaints varied widely between the two patient categories, with about 50% of the larger grouping complaining of drug or alcohol use and about 80% of the smaller grouping presenting with medical complaints.

The researchers say ED staff should take a cautious approach when deciding whether to restrain both kinds of patients.

An earlier study showed ED staff had strong sentiments of frustration and resentment toward patients with alcohol or drug use, psychiatric illness, homelessness, and frequent ED visits—all qualities associated with the larger grouping of patients in the Annals of Emergency Medicine research.

"These negative sentiments highlight a potential pitfall for implicit bias and stigmatization by ED health workers of an already marginalized population because of their underlying health conditions," the researchers wrote.

The researchers say there is significant risk associated with restraining older adults.

"Two previous retrospective studies of elderly ED patients with behavioral emergencies reported significant rates of cognitive impairment and multiple comorbidities that may be affected by sedation and restraint use," the researchers wrote.

Best practices
 

The Joint Commission has 10 primary standards for restraint and seclusion of patients:

• Restraint and seclusion should be used only when clinically justified or when patient behavior poses a physical danger to the patient or others.
   
• Patient restraint or seclusion should be implemented safely based on hospital policy as well as laws and regulations.
   
• Restraint or seclusion should be based on an individual order for specific patients, not standing orders. If the attending physician did not make the restraint or seclusion order, he or she should be consulted as soon as possible.
   
• Medical staff should monitor restrained or secluded patients.
   
• Hospitals should have written guidelines for restraint and seclusion.
   
• Patients who are restrained or secluded should be evaluated repeatedly.
   
• Patients who are both restrained and secluded should be monitored continually.
   
• Use of restraint or seclusion should be documented.
   
• Staff should be trained in the safe use of restraint and seclusion.
   
• Deaths linked to restraint or seclusion should be reported to the Centers for Medicare & Medicaid Services.