Experiences of Individuals Who Were Physically Restrained in the Emergency Department

Abstract

IMPORTANCE Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. OBJECTIVE To characterize how individuals experience episodes of physical restraint during their ED visits. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast MAIN OUTCOMES AND MEASURES Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED. RESULTS Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%]non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. CONCLUSIONS AND RELEVANCEIn this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm. Findings This qualitative study of 25 patients who were physically restrained in the emergency department found the 3 following major themes: harmful experiences of restraint use and care provision, diverse and complex personal contexts affecting visits to the emergency department, and challenges in resolving their restraint experiences, leading to negative consequences on well-being. Meaning Results of this study suggest that the participants in this study desired compassion and therapeutic engagement during physical restraint, warranting further attention to patientcentered approaches and coercionreduction techniques that fit with the needs of emergency care.

Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting

“…Physical restraint use is common in the ED setting 12 despite known adverse consequences. [6][7][8] Minimizing restraint utilization via prevention and deescalation should be a treatment goal for every ED patient. Health care providers should conduct a careful medical assessment of all patients at risk for acute agitation and whenever possible begin agitation management with verbal deescalation techniques, using pharmacologic agents to help calm the patient if deescalation is ineffective.…”

“…5 One area of medical care in the ED that has not received adequate attention is the use of restraints. Restraints can have serious adverse outcomes including aspiration, physical trauma, and psychological distress, [6][7][8] and as a result, the Joint Commission and Centers for Medicare and Medicaid Services have implemented regulations around the use of restraints in U.S. hospitals (42 CFR Part 482). Vulnerable populations (patients with psychiatric illness, substance use problems) are more likely to undergo restraint, 9 and identifying the role of race and ethnicity in rates of restraint use in the ED may highlight areas for improvement and guide interventions to address health disparities.…”

Management of Agitation During the COVID-19 Pandemic

“…Patients presenting with agitation often represent socioeconomically disadvantaged populations with significant health disparities. 20 Unfortunately, individuals with homelessness, mental illness, and substance use disorders face additional potential problems with screening, quarantine, and symptom treatment during pandemics. 21 Preliminary data demonstrating associations between mortality and challenges in accessing healthcare resources have already surfaced during COVID-19.…”

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

“…10 Although restraints are thought to be an effective method to temporarily halt violent behaviors, restraints carry an elevated risk of injury to patients and staff, 15,33,53 are experienced as coercion or aggression, and can lead to psychological trauma. 34 For these reasons, the Center for The patients' privacy and dignity need to be maintained during restraint application. 55 If possible, five trained individuals need to apply the physical restraints with one person at each extremity and one person at the head of the bed, being careful to avoid bodily injury due to excessive use of force or compromise the patient's F I G U R E 2 Pharmacology algorithm: medication recommendations depend on most likely etiology of the patient's agitation 11,56 F I G U R E 3 Correct application of restraints for severely agitated patients.…”