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INTRODUCTION

Psychiatric emergency services have become a major point of entry into the mental health system and a principal treatment site for many patients with chronic and severe mental illness.1 Emergency Department (ED) patients with altered mental status, emotional disturbances, head trauma, psychiatric illness, psychological disturbances, or other medical conditions may be aggressive, physically injurious, or violent.2,3 The aggression may be exhibited toward themselves or toward the health care personnel who are caring for them.4 Emergency Physicians must be prepared to cope effectively with agitated or violent patients to reduce the risk of serious injury to the patient and health care personnel. Physical restraints might be necessary to ensure the safety of the patient and the health care personnel given the volatile nature of some presenting conditions. A prospective study found that 0.07% of ED patients were restrained during the 1-year study period.5 Up to 8.5% of psychiatric patients seen in the ED may require the use of physical restraints.6 Most patients were restrained for agitation, disruptive behavior, or violent behavior.5,6

Physical restraints are the direct application of physical force to a patient without the patient’s consent to restrict their freedom of movement. The use of restraints for managing behavioral emergencies is allowed only when all other less restrictive measures have failed and severely aggressive or destructive behaviors place the patient or others in imminent danger. The Centers for Medicare and Medicaid Services (CMS) defines physical restraint as “any manual method, physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot remove and that restricts freedom of movement or normal access to one’s body.”7 The use of restraints in the ED may help to prevent patients from physically harming themselves or others. Imminent safety concerns are the only justification for application of physical restraints.7 Physical restraints must be used for the shortest time possible and with the least restriction possible.7,8 Physical restraints are humane and effective in the management and treatment of the patient while ensuring the safety of the patient and the health care personnel if used properly and in the appropriate patient.

This chapter will present the rationale and technique for using locked-door seclusion and physical restraints in the ED. This chapter focuses on the aggressive, dangerous, and/or violent patient. It briefly reviews some of the techniques for physically restraining the young child during brief diagnostic or therapeutic procedures.

LEGAL CONSIDERATIONS

Informed consent is required before Emergency Physicians can lawfully treat competent adult patients, all of whom have the right to refuse medical treatment (Chapter 1). U.S. courts have consistently upheld the idea that a competent adult would consent to treatment to maintain health or life and that a patient could be restrained to protect others or self if the reasons for ...

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