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![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](https://image.slidesharecdn.com/restraints-150930130504-lva1-app6891/75/Seclusion-and-Restraints-15-2048.jpg)
![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](https://image.slidesharecdn.com/restraints-150930130504-lva1-app6891/75/Seclusion-and-Restraints-17-2048.jpg)
Uploaded byTuti Mohd Daud
Seclusion and Restraints
The document discusses seclusion and restraints in emergency psychiatry. It describes the different types of seclusion, restraints, and how to reduce their use. Seclusion involves confining a disturbed patient alone in a locked room to contain behavior, while restraints physically limit a patient's movement. Both should only be used as a last resort for safety and minimizing time in restraints. Staff must closely monitor patients and prioritize preventative de-escalation techniques to reduce the need for seclusion and restraints.
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Seclusion and Restraints
- 1. SECLUSION AND RESTRAINTS IN EMERGENCYPSYCHIATRY 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 ENDOF 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 THEPURPOSE OF SECLUSION & RESTRAINTS? safety of everyone in the treatment environment
- 5. Intervention during the crisisphase Breakaway technique Restraints
- 6. BREAKAWAY TECHNIQUES “A setof 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
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- 10. Intervention during the crisisphase Breakaway technique Restraints PhysicalChemical Environmental
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- 12. CHEMICAL RESTRAINT Oral Intramuscularor intravenous Sublingual Antipsychotic Olanzepine (Zydis) BDZ clonazepam, lorazepam Tablet
- 13. RESTRAINT Rapid tranquilisation: “Use ofmedication 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 additiveCNS depression geriatric over-sedation CHEMICAL RESTRAINT Oral Intramuscular or intravenous Antipsychotic Benzodiazepine Haloperidol Lorazepam (in our setting - Midazolam) IM procyclidine A f t e r p a r e n t e r a l a n t i - 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 ofAggression 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 ofAggression 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 thephysician–patient relationship needle-stick injuries to staff
- 19. Intervention during the crisisphase Breakaway technique Seclusion Restraints PhysicalChemical Environmental
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- 21. SECLUSION “the supervised confinementof 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 ofpatient and others (ii)reduce stimulation NOT suitable, if patient is danger to himself INDICATION
- 24. Intervention during the crisisphase Breakaway technique Restraints PhysicalChemical 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 methodof 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 shouldbe 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: StewartD, 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 ofstaff • 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. andH. 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. andH. 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 THEAGITATED PATIENT
- 39. Medical assessment: • identifyingany 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 informationis 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 Alllevel (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." Internat Journal of Social Psychiatry.
- 43. Before discharge: discuss experiencewith 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 purposeof 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 restraintsin emergency psychiatry by Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.