August 21st, 2010

The risks of restraint and seclusion

Last month, New England Psychologist looked at the use of restraint and seclusion. In this installment, the column examines some of the risks of these methods to both patients and mental health care workers.

Restraint and seclusion have their own risks because restraint can involve physical struggling, pressure on the chest or other interruptions in breathing. JCAHO reviewed 20 restraint-related deaths and found that in 40 percent, the cause of death was asphyxiation, while strangulation, cardiac arrest or fire caused the remainder.

Reported deaths (Hartford Courant) in cases where restraint or seclusion was a factor were caused by asphyxia, cardiac complications, drug overdoses or interactions, blunt trauma, strangulation or choking, fire/smoke inhalation and aspiration (breathing vomit into the lungs).

Incidents reported by the National Alliance for the Mentally Ill and Protection and Advocacy Agencies included one patient dying from cardio-respiratory failure caused by extreme agitation after being restrained by eight staff members and bound in leather restraints and another man killed after a staff member placed him in a basket hold. (A basket hold consists of crisscrossing a person’s arms over his or her chest and holding them from behind. This hold compresses the chest and also prevents the staff member from observing the person’s face and breathing).

Children are subjected to restraint and seclusion at higher rates than adults and also are at greater risk of injury. Several states that took part in a study sponsored by the Center for Mental Health Services indicated they had higher restraint rates for children, including one state where children in state-run inpatient facilities were restrained four times more frequently than adults. Children are smaller and weaker than adults, so staff who are used to overpowering adults may apply too much pressure or force when restraining children.

The National Alliance for the Mentally Ill cited cases illustrating the dangers of restraint that resulted in the deaths of teens and even a nine-year-old boy.

Patients are at particular risk if they have a combination of conditions such as both mental retardation and mental illness or mental illness and substance abuse because they may not be in specialized programs to address their unique needs.

In one state hospital, patients were kept in either restraint or seclusion 24 hours per day day. These practices were the subject of a class action suit, which resulted in implementation of a monitoring procedure.

Clinicians have noted that potentially fatal cardiac arrhythmia can result from the combination of certain drugs and the adrenaline produced by an individual’s agitation and physical struggle while being restrained.

Such was the case in Texas where a 48-year-old man was placed in a straitjacket and tied to a chair. Although 15-minute checks were required, they were not performed and he was found dead the next day. The cause of death was listed as an overdose of imipramine, an antidepressant. The medical examiner stated that the restraints contributed to his death by affecting his ability to metabolize the medicine.

Numerous cases are cited by the National Alliance for the Mentally Ill where restraints and seclusion have resulted in physical and emotional injuries to the patient.

A Massachusetts task force investigating this issue reported that research indicates at least half of all women treated in psychiatric settings have a history of physical or sexual abuse. The task force found that the use of restraints on people who have been abused often results in those people re-experiencing the trauma and causes setbacks in treatment. The task force’s report recommended that staff should identify patients who have been abused and use only certain forms of restraint and seclusion on these patients when necessary. They should avoid forms such as mechanical restraints that place a person in a spread-eagle position.

Health care workers can also be injured during the process. Studies show that the occupation of mental health care worker is dangerous, at times, more so than construction workers. The largest percentage of patient assaults on staff members occur during restraint or seclusion incidents. Another study documented that most staff injuries are sustained when staff are trying to control patient violence.

When possible, it’s best to have a camera videotape these situations. The longer the period, the more the need to be sensitive to the needs of hydration, meals, use of urinal and bedpans, personal dysfunction, sanitation, pulse, temperature, medication and other needs. The use of restraint and seclusion is not benign and is very controversial.

By Edward Stern J.D.

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