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In recent years, 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 and psychological disturbances, head trauma, psychiatric illness, or other medical conditions may be aggressive, physically injurious, or violent.2,3 The aggression may be exhibited toward themselves or toward the healthcare personnel who are caring for them.4 Given the volatile nature of some presenting conditions, physical restraints might be necessary to ensure the safety of the patient and the healthcare personnel. One prospective study found that 0.07% of ED patients were restrained during the 1-year study period.5 Consistent with clinical practice, most patients in this study were restrained for agitation, disruptive behavior, or violent behavior.
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Physical restraints are the direct application of physical force to a patient without patient 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 they cannot remove and that restricts freedom of movement or normal access to one's body.”6 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 the application of physical restraints.6 Once applied, physical restraints must be used for the shortest time possible and with the least restriction possible.6,7 If used properly and in the appropriate patient, physical restraints are humane and effective in the management and treatment of the patient while ensuring the safety of the patient and the healthcare personnel.
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This chapter will present the rationale and technique for using both locked-door seclusion and physical restraints in the ED. This chapter focuses on the aggressive, dangerous, and/or violent patient. It does not review the techniques for physically restraining the young child during brief diagnostic or therapeutic procedures.
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Informed consent is required before Emergency Physicians can lawfully treat competent adult patients, all of whom have the right to refuse medical treatment. Refer to Chapter 1 for a complete discussion of the informed consent process. United States courts have consistently upheld the idea that a competent adult would consent to treatment to maintain health or life and also that a patient could be restrained to protect others or self as long as the reasons for interventions are clearly documented.8 Even in an emergency setting, the competent adult retains their right to refuse treatment. Coercive measures, including restraints and threat of restraints, cannot be used solely because a patient refuses treatment. It is never ...