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Seclusion and Restraint


This chapter defines seclusion and restraint; outlines the indications and contraindications for these procedures; and provides step-by-step guidelines for the implementation, documentation, and discontinuation of seclusion and restraint for patients. Medication for the agitated patient, which often accompanies seclusion and restraint, is discussed in the management sections of the Agitated Patient, Violent Patient, and Psychotic Patient chapters.

General Principles

The regulations and procedures concerning the seclusion and physical restraint of patients vary from state to state and among different institutions within the same state. It is important for physicians to know the laws and policies governing seclusion and restraint in the states and the institutions in which they are working. Seclusion and restraint restrict a patient’s movement, environment, and rights. These procedures, no matter how necessary, are often frightening for patients and are generally experienced in a negative way and as punishment. Given the increasing effort to provide restraint-free environments, locked seclusion and restraint should be used as a last resort and only to maintain patient and staff safety and/or to facilitate therapeutic intervention.

Literature Review

Fisher (see Suggested Readings) reached the following conclusions concerning the risks and benefits of these interventions:

  • Seclusion and restraint are efficacious in preventing injury and reducing agitation.

  • Some form of seclusion or physical restraints is necessary to maximize patient and staff safety in treatment settings for severely symptomatic individuals.

  • Restraint and seclusion may have deleterious physical and psychological effects on patients and staff.

  • Local nonclinical factors, such as cultural biases, staff role perceptions, and the attitude of hospital administration, have a substantial influence on rates of restraint and seclusion. Overall, Flammer et al. found that illness severity and violent behavior in the past 24 hours were the strongest predictors of restraint use, whereas voluntary admission status was the strongest protective factor.

  • In recent years, many hospitals have initiated restraint-reducing programs, with reported success, particularly with behavioral and cognitive-behavioral programs in children; however, systematic data are still lacking to identify the common elements of successful programs.

  • D’Orio et al. ascertained that a hospital program founded on principles of early identification and management of problematic behaviors was associated with a 39% reduction in the use of seclusion and restraint and an increase in compliance with hospital standards. Specifically, the program used two-way radios, which alerted staff when emergency codes were called, and continuous video monitoring by staff to enhance early identification, communication, and responsiveness. Although these measures may not be available where all residents train, residents should inquire about the particular safety measures in place at each facility. Often, units will have alert buttons that notify additional staff of a behavioral emergency immediately when pressed.

  • Jonikas et al. have shown that incidents of seclusion and restraint can be reduced by helping patients identify personal stress (or agitation), triggers, and individual calming measures during the initial evaluation. This worked in conjunction with staff education, focusing on factors that precipitate agitation and nonviolent means for its management.

  • Hellerstein et al. found that decreasing the initial time spent in restraint/seclusion before a new order for restraint/seclusion was placed, educating staff about patients at risk of restraint/seclusion, and implementing a coping questionnaire to assess patent preferences for dealing with agitation helped to decrease the use of restraint and seclusion.

Definitions

  • 1.

    Seclusion

    • a.

      Open seclusion: The therapeutic isolation of a patient. Methods of open seclusion include quiet time alone in a patient’s room, in an unlocked time-out room, or in a partitioned area. Open seclusion represents the least restrictive form of seclusion. Most regulations referring to seclusion relate specifically to locked seclusion only.

    • b.

      Locked seclusion: The therapeutic isolation of a patient in a locked room designed specifically for the purpose of confining an agitated individual.

  • 2.

    Physical Restraint: A confining apparatus commonly composed of leather or canvas. When properly applied, restraints maximally restrict physical movement without threatening the integrity of the limb or body part being restrained. Restraint configurations include the following:

    • a.

      Bilateral wristlets and anklets; also known as four-point restraint.

    • b.

      Camisole controlling the upper half of the body with or without bilateral anklets.

    • c.

      Chest strap with either of the above.

    • d.

      Whole body restraints, such as safety suits, which contain the patient’s entire body with the exception of the head.

    • e.

      Posey vests—used on medical floors, these vests are applied to the torso and tied to the bed, to prevent patients from climbing out of bed

Please note that each of these restraints may not be available at all hospitals; residents should become familiar with the restraints used at their particular facilities.

Indications and Contraindications

Indications

  • Prevention of imminent harm to the patient or to others when other means are ineffective

  • Prevention of substantial damage to the physical environment

  • Indications for seclusion without physical restraint:

    • Decreasing stimulation for an agitated, potentially violent patient

    • Fulfilling a patient’s request in appropriate circumstances, such as self-awareness of poor impulse control or low frustration tolerance

Contraindications

  • For the convenience or comfort of staff

  • To punish a patient

  • Absolute contraindications specific to seclusion:

    • The acutely suicidal patient (without constant observation)

    • The patient with unstable medical status

    • The delirious or otherwise neurologically impaired patient whose clinical status may decline when stimulation is reduced

    • The restrained patient who cannot be adequately monitored for aspiration or circulatory impairment

  • Relative contraindications specific to seclusion:

    • The self-mutilating patient (without constant observation)

    • The patient with a seizure disorder

    • The hyperactive patient at risk for exhaustion

    • The developmentally disabled patient (discussed next)

Special Considerations

Developmental disabilities

Patients with documented developmental disabilities are at higher risk for injury during restraint and seclusion procedures and during the actual period of the restraint and/or seclusion. Such patients may have underlying physical anomalies, particularly craniofacial and cardiac, that can further endanger their safety during restraint and seclusion procedures. Developmentally disabled persons may not be able to understand why such interventions have been imposed and may not be able to communicate their discomfort while in restraints or while being secluded.

Children

Mechanical restraint and locked seclusion are not generally used for young or small children. A technique called therapeutic holding is often used to help control agitated and dangerous children. This typically entails hugging a child from behind, whereby his or her arms are held securely to each side. This technique requires training, and the physician on call should be familiar with the procedures used at his or her facility.

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