EDs Are Seeking to Minimize Restraint Use

At Hennepin County Medical Center’s ED, quality improvement and quality assurance have been a long-term focus. “There was an interest, particularly in the wake of the local and national events of the summer of 2020, to reexamine our restraint practices and look for opportunities to minimize coercive care in our ED,” reports Aaron E. Robinson, MD, MPH, a faculty physician in the Department of Emergency Medicine at Hennepin County Medical Center and assistant medical director at Hennepin Emergency Medical Services (EMS).

The ED has made changes to optimize the care of patients with intoxication, substance use disorders, and agitation. “This work was part of our ongoing commitment to those patient populations,” says Robinson. “Some examples of this work include more robust options for opioid use disorder, like Suboxone.” This includes Suboxone initiation in the prehospital setting with Hennepin EMS before the patient arrives at the hospital. Another example is the emphasis on medications that can be given via pill or liquid instead of intramuscular injection for agitated patients. By interacting more with patients and shifting the focus from intramuscular injection to the patient taking a medication as they would at home, ED providers help de-escalate patients and avoid an injection. “This has worked for many patients,” reports Robinson.

Although physical restraint is necessary in some clinical scenarios to protect both the patient and caregivers, the authors strongly believe that the use of restraints should be heavily evaluated and minimized. “The use of restraints, especially with people of color, is associated with negative outcomes, humiliation, and moral injury. We must consider these aspects when caring for our patients, especially in our marginalized populations,” urges Robinson. Researchers analyzed 464,031 ED encounters involving 162,244 patients at Hennepin County Medical Center over a five-year time period beginning in 2017.¹ Of these ED encounters, 7.5% had restraint application, involving 18,166 patients.

Drug/alcohol intoxication was the most important factor resulting in an ED patient being restrained. “Intoxicated patients are some of the highest-risk patients that we encounter, for both medical complexity and patient/provider safety,” says Robinson. Intervening with escalating patients earlier, including offering oral medications, is key. Sometimes, though, restraints and sedation still are needed. Having hospital security in the ED 24/7 has lessened the need for sedation and restraint and has increased provider/patient safety. “We try to set an environment of healing and safety in the ED for all patients, and security has been essential in this,” says Robinson.

The study also found that American Indian race was linked to higher odds of restraint application. Four of the study authors are members of local American Indian tribes and have a special interest in American Indian health. “Even when controlled for the obvious confounders like substance intoxication and psychiatric disorders, American Indians still had a higher chance of being restrained than their white counterparts,” observes Robinson.

The study did not replicate multiple prior studies, which found other racial disparities in restraint use. Black race and Hispanic ethnicity were linked to lower odds of restraint application. “Our racial data does not reflect the rest of the country’s EDs,” says Robinson. “In our ED, Blacks are restrained less often than whites. This is reflective of our efforts to reduce restraint use in all patient populations.”

Understaffing is something that plagues almost every hospital in the United States. “Restraints should not be used as a substitute for inadequate hospital staffing/resources,” warns Robinson. To help minimize the use of restraints, the ED has increased use of video monitoring systems, which are portable monitoring systems that can keep an eye on certain patients without needing to restrain them. The ED also has prioritized “1:1s,” which are healthcare staff who sit with certain patients to help redirect and keep them calm to minimize restraint use. “Restraints should be reserved for violent patients who are at a risk of harming themselves or a member of the healthcare team,” says Robinson. Taken as a whole, the study findings suggest the need for all EDs to take a thoughtful look at their restraint policies, procedures, and data. “It is imperative to help both minimize their use and decrease moral injury,” concludes Robinson. “This will lead to better patient care.”

Physical restraint of ED patients potentially can harm patients and has been linked to increased patient injury, increased lengths of stay, decreased outpatient follow-up, and long-lasting emotional effects.^2-6

“Many hospitals believe that the use of restraints may be protective against lawsuits,” says Michael Wilson, MD, PhD, FAAEM, FACEP, associate professor in the Division of Research and Evidence-Based Medicine at UAMS Department of Emergency Medicine. However, inappropriate use of restraints also has been the focus of lawsuits. “It is likely the case that overuse of restraints may be the more legally risky option,” says Stacey Makhanova, PhD, an assistant professor of psychology at University of Arkansas.

Stephen Colucciello, MD, FACEP, offers these three key principles for ED providers to reduce risks of ED restraints:

• ensure rapid, safe, and effective control of agitation;

• protect the patient and the team;

• optimize collaboration between the ED provider, nursing, and ED security.

“While it is very easy to recognize ED violence when someone’s hands are around your neck, we would like to predict possible violence long before it ever occurs, hopefully preventing attacks,” says Colucciello, a clinical professor of emergency medicine at Wake Forest University School of Medicine.

Although verbal de-escalation is ideal, it is not adequate for all situations. ED providers should look for signs of impending violence, such as pacing, yelling threats, clenching fists, and any dramatic increase in motor activity, Colucciello advises.

“Many, if not most, patients who require emergency application of restraints will require sedation to prevent hyperthermia, rhabdomyolysis, acidosis, or injury,” adds Colucciello. The application of physical restraints is a high-risk procedure for all parties involved. “The responsible ED provider should be present during application of restraints to oversee decision-making, be prepared to order sedative medication, and remain in proximity until the patient is restrained and a sedation plan (if needed) has been determined,” says Colucciello.

According to the most recent American College of Emergency Physicians policy on severe agitation, a combination of droperidol and midazolam is preferred, given the improved time to sedation and side effect profile.⁷ For the most dangerous encounters, Colucciello says to consider intramuscular ketamine for sedation, but recognize the potential need for unplanned airway intervention, and that patients given high-dose ketamine should have cardiac, pulse oximetry, and end-tidal CO2 monitoring.

If the patient’s clinical status and sedation needs change or escalate during their ED course, bedside reassessment by the ED provider and/or additional sedative strategies may be required, adds Colucciello.

ED providers should perform all necessary documentation (including a face-to-face evaluation, appropriate restraint orders, and indications for both physical restraints and any sedative medications), recommends Colucciello. Colucciello offers this example of good documentation: “Patient did not respond to verbal de-escalation. Signs of impending violence made physical restraint the safest option.”

“Applying restraints a minute too early can be a therapeutic blunder. Using them a second too late can be a tragedy,” warns Colucciello.

REFERENCES

1. Robinson AE, Driver BE, Cole JB, et al. Factors associated with physical restraint in an urban emergency department. Ann Emerg Med 2024;83:91-99.
2. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med 2003;24:119-124.
3. Weiss AP, Chang G, Rauch SL, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012;60:162-171.
4. Currier GW, Walsh P, Lawrence D. Physical restraints in the emergency department and attendance at subsequent outpatient psychiatric treatment. J Psychiatr Pract 2011;17:387-393.
5. Wong AH, Ray JM, Rosenberg A, et al. Experiences of individuals who were physically restrained in the emergency department. JAMA Netw Open 2020;3:e1919381.
6. Wong AH, Taylor RA, Ray JM, Bernstein SL. Physical restraint use in adult patients presenting to a general emergency department. Ann Emerg Med 2019;73:183-192.
7. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Severe Agitation; Thiessen MEW, Godwin SA, Hatten BW, et al. Clinical policy: Critical issues in the evaluation and management of adult out-of-hospital or emergency department patients presenting with severe agitation. Ann Emerg Med 2024;83:e1-e30.