Seclusion and Restraints

Part 3 of a 3-lecture-series on managing aggression

1. SECLUSION AND
RESTRAINTS IN
EMERGENCY PSYCHIATRY
Dr Tuti Iryani Mohd Daud
Senior Lecturer & Psychiatrist,
National University of Malaysia Medical Centre.
Seclusion and restraints in emergency psychiatry by Tuti Mohd Daud is
licensed under a Creative Commons Attribution-NonCommercial 4.0
International License.

2. BY THE END OF THIS LECTURE,
YOU WILL BE ABLE TO:
Describe the types of seclusion and restraints
Explain the principles of seclusion and restraints
Discuss the indications, advantages &
disadvantages of various types of restraints
Explain ethical issues related to seclusion and restraints
Explain ways that seclusion and restraints can be
reduced

3. Trigger
Escalation
phase
Crisis
phase
Recovery
phase
Post-crisis
depression
phase
CYCLE OF ASSAULT
(Kaplan & Wheeler,1983)
Perceived as
serious threat
body and mind
prepare for a fight.
Violent
act
body and mind
relaxes
fatigue,
depression, and
guilt.
Source: Wolf,K & Knight,M. The Assault Cycle and Verbal Diffusion Handout.
Retrieved from http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf
Seclusion & restraints
Breakaway techniques

4. WHAT IS THE PURPOSE OF
SECLUSION & RESTRAINTS?
safety of everyone
in the treatment environment

5. Intervention during the
crisis phase
Breakaway
technique
Restraints

6. BREAKAWAY TECHNIQUES
“A set of physical skills to help separate or break
away from an aggressor in a safe manner. They
do not involve the use of restraint.”
(NICE, 2015)
Reference:
NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health,
health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10

7. Hair Grab
(front)

8. Headlocks
(rear)

9. Bear Hugs

10. Intervention during the
crisis phase
Breakaway
technique
Restraints
Physical Chemical Environmental

11. CHEMICAL

12. CHEMICAL RESTRAINT
Oral Intramuscular or intravenous
Sublingual
Antipsychotic
Olanzepine
(Zydis)
BDZ
clonazepam,
lorazepam
Tablet

13. RESTRAINT
Rapid tranquilisation:
“Use of medication by the parenteral route
(usually intramuscular or, exceptionally,
intravenous) if oral medication is not possible or
appropriate and urgent sedation with
medication is needed.”
(NICE, 2015)
Reference:
NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health,
health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10

14. side effects:
EPS
prolonged QT
ataxia
sedation
additive CNS depression
geriatric over-sedation
CHEMICAL RESTRAINT
Oral Intramuscular or intravenous
AntipsychoticBenzodiazepine
Haloperidol Lorazepam
(in our setting - Midazolam)
IM
procyclidine
After parenteral anti-
psychotic & BDZ
•Temperature, pulse, BP &
respiratory rate
•Every 5-10 min for 1 hr,
then half-hourly until
patient is ambulatory
•If patient is asleep: pulse
oximetry

15. From: Neurobiology of Aggression and Violence

American Journal of Psychiatry
Figure 4. Pretreatment Abnormalities in the Pathophysiology of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third
Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure
appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
09/19/2015

16. •acute (immediate) effect on behavioral symptoms
•speed of onset
•availability of I.M., liquid, or rapidly dissolving formulation
•patient’s history of response to the medication
•limited liability for side effects
•patient preference
•ease of administration
(no need for laboratory tests and simple dosing requirements)
PROPERTIES
References:
Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.

17. From: Neurobiology of Aggression and Violence

American Journal of Psychiatry
Figure 5. Posttreatment Abnormalities in the Pathophysiology of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third
Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure
appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
09/19/2015

18. OTHER ISSUES
compromise the physician–patient relationship
needle-stick injuries to staff

19. Intervention during the
crisis phase
Breakaway
technique
Seclusion
Restraints
Physical Chemical Environmental

20. ENVIRONMENTAL

21. SECLUSION
“the supervised confinement of a patient in a
room, which may be locked.
Its sole aim is to contain severely disturbed
behaviour that is likely to cause harm to others”
(Department of Health, 2015)
Reference:
Department of Health (2015). Mental Health Act 1983 Code of Practice. Surrey: The Stationery Office:
Surrey. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/435512/MHA_Code_of_Practice.PDF

23. (i) safety of patient and others
(ii)reduce stimulation
NOT suitable, if patient is danger to himself
INDICATION

24. Intervention during the
crisis phase
Breakaway
technique
Restraints
Physical Chemical Environmental
Manual
Mechanical

25. RESTRAINT
Manual restraint:
“A skilled, hands-on method of physical restraint
used by trained healthcare professionals to
prevent service users from harming themselves,
endangering others or compromising the
therapeutic environment. Its purpose is to safely
immobilise the service user.”
Reference:
NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health,
health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10
(NICE, 2015)

28. RESTRAINT
Mechanical restraint:
“A method of physical intervention involving the
use of authorised equipment, for example
handcuffs or restraining belts, applied in a skilled
manner by designated healthcare”
(NICE, 2015)
Reference:
NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health,
health and community settings.

30. Physical restraints should be used
as the last resort
(Allen et al. ,2003)
Reference:
Allen, M. H. M., et al. (2003). "Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines." Journal of Psychiatric Practice 9(1): 16-38.

31. RISKS
Patients
dehydration
rhabdomyolysis
lactic acidosis
sudden death
Staff
Injury
psychological
distress
References:
Stewart D, Bowers L, Simpson A, Ryan C & Tziggili M (2009). Manual restraint of adult psychiatric inpatients: a literature review. Journal of Psychiatric and Mental Health Nursing 16 pp
749-757.
Stubbs B, Leadbetter D, Paterson B, Yorston G, Knight C & Davis S (2009). Physical intervention: a review of the literature on its use, staff and patient views, and the impact of training.
Journal of Psychiatric and Mental Health Nursing, 16, pp 99- 105.

32. •Safety of staff
•Minimum period of time
•Seclusion or restraint is justifiable proportional to patient’s
behaviour
•Least restrictive
•Close monitoring
PRINCIPLES OF SECLUSION
& RESTRAINT

33. •breathing
•behaviour
•skin colour
•care for the patient’s head and airway
•ensure no pressure is applied to the neck,
thorax, abdomen or pelvic area
MONITOR

34. ETHICAL ISSUES
Human rights (autonomy)
Abused:
used as punishment to patients
staff’s convenience
References:
Hay D, Cromwell R. Reducing the use of full-leather restraints on an acute adult inpatient ward. Hospital and Community Psychiatry 1980; 31: 198-200.

Moosa, M. and F. Jeenah (2009). "The use of restraints in psychiatric patients." South African Journal of Psychiatry 15(3): 72-75.

35. Photo:
Minas, H. and H. Diatri (2008). "Pasung: Physical restraint and confinement of the mentally ill in the community.” International Journal of Mental
Health Systems 2(1): 8.
Pasung:
”physical restraint or confinement of
criminals, crazy and dangerously
aggressive people." (Broch, 2001 cited in Minas &
Diatri, 2008)
•Minas & Diatri (2008)
•location: Samosir Island, Sumatra
•duration 6 months
•15 cases
•Pasung was built by family
members
•duration of pasung: 2-21 years
•diagnosis: Schizophrenia, dementia,
epilepsy
•Main reason for pasung: prevent
harm to others and ill person
•Treatment was not affordable
Iron shackles are fixed to the wooden floor of a hut in which the person is confined.
This man has his ankles in wooden stocks

36. Photo:
Minas, H. and H. Diatri (2008). "Pasung: Physical restraint and confinement of the mentally ill in the community.”
International Journal of Mental Health Systems 2(1): 8.

38. HOW TO APPROACH
THE AGITATED PATIENT

39. Medical assessment:
•identifying any medical conditions (delirium: underlying etiology)
•vital signs and a medical history, perform a visual examination of the patient, a urine toxicology
screen, a cognitive examination, and a pregnancy test if the patient is a woman of childbearing
age.
•head trauma, respiration, heart rhythm, color, smell of alcohol, diameter/reactivity of pupils,
lacerations, nuchal rigidity, and fractures
•glucometry and urine for toxicology.
Psychiatric assessment
•brief assessment leading to a general category of diagnosis
References:
Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.
INITIAL ASSESSMENT

40. No additional information is available:
Patient is willing to take oral medication: lorazepam, risperidone, olanzapine,
haloperidol, quetiapine. (Allen, 2005)
(our setting: lorazepam, risperidone, olanzapine)
If I.M. medication is needed before assessment can be done: I.M. lorazepam,
with I.M. ziprasidone, olanzapine, and haloperidol.
(our setting: IM Midazolam + IM Haloperidol)
Patient continues to be violent and extremely agitated while in restraints
•parenteral medication + restraints
•Not appropriate to leave such a patient unmedicated in restraints
•The goal in this situation is to use medication to reduce time in and
complications of restraints.
References:
Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.
MANAGEMENT

41. Source:
Knox, D. K. and G. H. Holloman (2012). "Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency
Psychiatry Project BETA Seclusion and Restraint Workgroup." Western Journal of Emergency Medicine 13(1): 35-40.
Recommended algorithm for seclusion and restraint
(Knox and Holloman, 2012)

42. REDUCING SECLUSION &
RESTRAINTS
All level (policy, infrastructure, training, attitude)
•Timely and comprehensive assessments of patients.
•earlier intervention with appropriate treatment can avoid behavioral
emergencies
•Decide whether restraint is contraindicated or must be used with caution.
•Training of staff (i.e. de-escalation and crisis management
skills)
•Restraints as extraordinary event and use should be limited
•Dignity of patients should be protected, e.g. regular personal
hygiene, bathroom, exercise, nutritional and fluid breaks.
References:
Currier, G. W. M. M. (2003). "The Controversy over "Chemical Restraint" in Acute Care Psychiatry." Journal of Psychiatric Practice 9(1): 59-70.
Moosa, M. and F. Jeenah (2009). "The use of restraints in psychiatric patients." South African Journal of Psychiatry 15(3): 72-75.
SCANLAN, J. N. (2009). "Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far. A review of the literature." International
Journal of Social Psychiatry.

43. Before discharge:
discuss experience with patients
encourage to ask questions
give patients (and family) information about prescribed
medications
References:
Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.
minimize negative impact on:
the therapeutic relationship
the person’s willingness to seek use mental health service

44. SUMMARY
•The purpose of restraint is to ensure safety for the
patient, staff and others
•There are several type of restraints, each has its
advantages and disadvantages
•Seclusion and restraint should be used judiciously
•Preventative measures for seclusion and restraint i.e.
de-escalation technique

45. Seclusion and restraints in emergency psychiatry by Tuti Mohd Daud is
licensed under a Creative Commons Attribution-NonCommercial 4.0
International License.