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How To Restrain Psych Patients


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  #1  
February 28th, 2010, 07:36 PM
foxfire_ga79
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I was watching The Green Mile today and the scene where they locked the butthead detention officer in the padded room in a straight jacked got me thinking. HOW do you control someone who is a threat to themselves?

If they are violent and a threat only to those around them, the padded room is fine I'm sure. But there are patients who would harm themselves in a manic episode, clawing at their faces and gouging their eyes, hitting themselves in the head and face.
For this, there are drugs and there are leather straps. The drug of choice for a long time was Thorazine. I don't think that's too popular anymore because they found it can have permanent side effects if it's used repeatedly. I think they use Geodon now, gawd only knows what they'll figure out about that one in 10 years. I'll admit I'm not up to date on current drugs, but I think there's someone here who might know.....
Then there are the leather restraints. Those can be used either on a bed or in a basket. Ever seen the funky backboards rescuers use to bring a person up off a steep embankment with ropes, it has sides on it? The basket is kind of like that. Minimally, restraints are on wrists and ankles, in more extreme cases they can use one across the chest and one across the abdomen, or upper and lower back if they have the patient face down on the bed. The restraints are padded and shouldn't cause pain.

Which is more humane? Extreme drugs that knock a person out for a few hours that work in a matter of minutes, not looking ahead to what damage that might cause? Or leave them awake to face the terror of being strapped down, unable to defend themselves against whatever it is they think they need to fight off? (The mind can play horrible tricks on people and make them think they are in danger when they are not.)

I'm torn on this. People who are a danger to themselves MUST be protected from themselves. Drugs are potentially dangerous. Physical restraints can terrorize a person and set their therapy back by months. What's the right answer?
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  #2  
February 28th, 2010, 08:03 PM
Poncho06's Avatar Mega Super Mommy
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I had worked in the mental heal field (both in an intuitional setting as well an in community based group homes) prior to having children, so I have a bit of personal experience with this. There is a ton of training involved with working with patients who are both aggressive twords others as well as those who are self injurious. Mechanical restraints are used as a LAST resort for a majority of these people (I say majority as there are some who will escalate their behavior if there is excessive physical contact and or isolation).

Blanket restraints are a net type device what covers the body from the shoulders to just below the knee; they are fitted and are used for one person only. The person is secured to the netting with lamb’s wool covered nylon strapping and there are nylon straps that are secured to the bed. There is at least one person in the room monitoring at all times to ensure the safety of the person in the restraint. Typically a medical (nurse) professional will check the patient every 5 (depends upon the persons behavior plan) or so. This can be used with in conjunction with a chemical restraint. The use of these must go through a HUGE approval process from doctors, psychs, advocates as well as a human rights committee made up an independent panel of people.

Padded rooms (now called quiet rooms) are also considered to be a physical restraint as they are used to restrict a person’s movement. Again this is closely monitored the entire time a person in within the room. There are several different types of physical restrains (I was a trainer when I worked) where a worker would physically hold a person do stop them from injuring themselves or others. This could be s simple as holding the persons hands and verbally redirecting the person to several workers holding all of the persons extremities to the ground until the person has calmed.

Medical augmentations/chemical restraints are used as a last resort if the person has not been able to calm using the above techniques (there are people who receive a med aug without going through the above but this again had gone through a lengthy process of approval).

Do I think this practice should continue? Yes. It is an ugly truth that there are people who due to mental illness or cognitive limitations will always need these practices to keep themselves as well as others safe. From my personal observations I have found the physical/mechanical restraints to be less disruptive to the person. The medical augmentations are typically heavy duty meds that alter a person for days sometimes where at the end of a non medicated restraint, the person can quickly reenter their routine.
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  #3  
February 28th, 2010, 08:08 PM
Lash's Avatar Platinum Supermommy
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In any "good" inpatient unit, the staff will all be trained on verbal interventions, followed by the least restrictive form of restraint possible, only to be used when someone is actively becoming a threat to themselves or someone else. Not to be used just with an angry or loud patient

A side hold, or child hold can be used for patients under age 13, and is not as restrictive

A ground restraint will be used on someone, before leg or arm shackles are used. 4 point restraints are very uncommon, but I had a patient attempt suicide even in 4 points (biting tongue)

Medical intervention, what our patients call "booty juice" is used WAY more often in our state than using something like shackles or 4 points. It's less psychologically damaging, as the patient "passes out" instead of exhausting themselves or fighting staff.

I've been trained in both TCI and SAMA, and much much more prefer SAMA. I felt like it was a superior intervention AND restraint program.
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  #4  
February 28th, 2010, 08:11 PM
foxfire_ga79
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I've never seen a blanket/net restraint, that sounds far less traumatic than the wrist/ankle ones. And that will happen before medications?
Obviously the practice does have to continue for the safety of the patients and those in contact with them. It's sad, and I was curious what methods are the most humane.
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  #5  
February 28th, 2010, 08:12 PM
Lash's Avatar Platinum Supermommy
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Our chemical restraint does not have any active antipsychotic medication in the injection, only sedative medications

Quote:
Originally Posted by foxfire_ga79 View Post
I've never seen a blanket/net restraint, that sounds far less traumatic than the wrist/ankle ones. And that will happen before medications?
Obviously the practice does have to continue for the safety of the patients and those in contact with them. It's sad, and I was curious what methods are the most humane.
I think it depends on the patient. An angry, highly agitated patient vs a psychotic patient is important. A highly active aggressive teen vs a detoxing patient. Are they acting out from PTSD? Previous Trauma? Is it medication induced?

Our training and my personal opinion is that IF there is a history of trauma, rape, or PTSD with the patient, chemical restraints should be much more heavily considered over physical restraints. To touch a patient who already considers touch to be life or death, could cause some serious mental harm.
A PTSD soldier threatening homicide is not to be taken lightly. And to be dead honest, there really isnt any technique that can be used against someone that is a trained killer

On the other hand, an angry patient, threatening homicide could benefit from physical restraint, net, and distance away from the trigger in a quiet room
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  #6  
February 28th, 2010, 08:18 PM
Poncho06's Avatar Mega Super Mommy
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Quote:
Originally Posted by foxfire_ga79 View Post
I've never seen a blanket/net restraint, that sounds far less traumatic than the wrist/ankle ones. And that will happen before medications?
Obviously the practice does have to continue for the safety of the patients and those in contact with them. It's sad, and I was curious what methods are the most humane.

From the folks I worked with, yes the blanket would be put into place prior to the meds beign given for both their safety as well as the workers safety.
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  #7  
February 28th, 2010, 08:21 PM
Lash's Avatar Platinum Supermommy
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This is a small scale study, but I'd go ahead and assume this is pretty universal. We had so so many more restraints both in our youth RTC, as well as in my current state on the youth inpatient program, compared to the adult units
S/R means Seclusion Restraint
Quote:
The first hypothesis proposed at the outset of this study was that there exists a relationship between age and S/R events with younger patients experiencing more events. This hypothesis was supported, as patients who experienced S/R events were significantly younger than those who did not experience any. Additionally, age proved to be a significant predictor of the number of S/R events in a multiple regression analysis. In fact, the age of the patient was the most powerful predictor of S/R events examined in this study.

The subset of patients with multiple S/R events was substantially younger than the patients who had only one S/R event and the patients with zero S/R events. This pattern suggests that younger patients are at higher risk for repeated S/R events. It was also found that patients with an emergency status were more likely to have more than one S/R event, suggesting that those patients with such a legal status have a higher risk of S/R events.
Patient Variables Associated with the Therapeutic Use of Seclusion and Restraint in Inpatient Psychiatry

People with legal events, means those that are placed under temporary legal hold, awaiting a court date to see the judge, to determine if they should be kept under legal terms, either in that hospital or sent to the State Hospital
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  #8  
February 28th, 2010, 08:22 PM
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I just wanted to add that the states I worked in MA and NJ were very similar, it's kind of hard to cast a blanket statement as to plans for patients as each person will have thier own individual set of guidlines as to how to help them to work through a behavior.


Quote:
Originally Posted by Lash View Post
Our chemical restraint does not have any active antipsychotic medication in the injection, only sedative medications



I think it depends on the patient. An angry, highly agitated patient vs a psychotic patient is important. A highly active aggressive teen vs a detoxing patient. Are they acting out from PTSD? Previous Trauma? Is it medication induced?

Our training and my personal opinion is that IF there is a history of trauma, rape, or PTSD with the patient, chemical restraints should be much more heavily considered over physical restraints. To touch a patient who already considers touch to be life or death, could cause some serious mental harm.
A PTSD soldier threatening homicide is not to be taken lightly. And to be dead honest, there really isnt any technique that can be used against someone that is a trained killer

On the other hand, an angry patient, threatening homicide could benefit from physical restraint, net, and distance away from the trigger in a quiet room
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  #9  
February 28th, 2010, 08:23 PM
Lash's Avatar Platinum Supermommy
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Physical restraints also lead to injury and death for both the worker and the patient FAR more often than ever happens in chemical restraint

Quote:
Originally Posted by Poncho06 View Post
I just wanted to add that the states I worked in MA and NJ were very similar, it's kind of hard to cast a blanket statement as to plans for patients as each person will have thier own individual set of guidlines as to how to help them to work through a behavior.
^ Exactly this. I think that if you talk to someone working with kids, the approach will be different from someone on the CSU/ICU unit, the detox unit and so on. Some patients have issues that call for a specific type of intervention over another

And one thing that isn't always mentioned, is that it can depend on staffing each day. If we have low numbers, and a higher female work population that will be less able to physically restrain, seclusion will be much more likely than an attempt to struggle with a patient

And to give some perspective, we have approx 10 total physical restraints per year on the adult units, in a 104 bed hospital. On the children's units and ICU units, that number is higher. Those 10 total are spread across military, adult detox, adult general psych, faith based and womens units, so around 2 per unit per year.
The children's units are much higher, just with the interventions, even if they are only seclusion

Children don't have words yet to express themselves, so physical means of expression are much more likely
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  #10  
February 28th, 2010, 10:32 PM
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I work with people that have schizophrenia, autism, and other disorders that are often accompanied by behaviors that are very violent to themselves and others.

We receive yearly training on when and how to restrain someone if they are being harmful and it is extremely humane. It is a two day, 16 hour class and 90% of it is how to prevent having to restrain, and the safe way to restrain. 10% of the class is getting up and actually restraining each other.

The requirements and guidelines are ever changing, but there are limits. There has to be four people present, one of which is a manager. There is a 15 minute time limit for all hands on restraints. One person's job is to constantly check their breathing and circulation.

In our company, if we have to restrain someone, we see it as a company failure. We failed to prevent them from having to be restrained, and that's our job.. so we failed.

In our company, restraints are not taken lightly at all. They are humane, and painless, but are seen as a failure on our part.
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  #11  
March 1st, 2010, 04:35 AM
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^^^ Agree with this

I have been trained in SAMA and TCI as well, although I do not use them in my current job of course, I have just used them in the past. I agree with everything Lash said. I am not a fan of restraints unless ABSOLUTELY needed.

The other thing with restraints is you have to be extra cautious in using them if the client has been abused. It really is beyond last resort in those cases.

There is also a very in depth briefing at the agency I worked at after a restraint is done. Those who did the restraining and the person who was restrained all write a statement. These are reviewed by the supervisors and then a committee and there is a meeting each week to go over the weeks "incident reports" (which include ALL incidents agency wide not just restraints, but calls to CPS, etc) There is always debriefing with the client, and processing aorund what happened.

I think that is important to point out as well

Last edited by rachna; March 1st, 2010 at 04:40 AM.
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  #12  
March 1st, 2010, 05:58 AM
Lash's Avatar Platinum Supermommy
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Randi, did you prefer SAMA or TCI? I found both the verbal intervention of SAMA as well as the physical restraint portion much more effective. I also really felt that SAMA was concerned about pressure points of patients, where to hold them (wrist vs upper arm), how long to hold, concerned about how restraints could mentally harm patients, and how to properly do a hold for children, instead of placing them face down. I've done the small child hold many times in the RTC where I worked (although it was the locked unit of the adolescent RTC) and it was very effective.
I was pretty unimpressed with TCI
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  #13  
March 1st, 2010, 06:47 AM
rachna's Avatar Platinum Supermommy
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Quote:
Originally Posted by Lash View Post
Randi, did you prefer SAMA or TCI? I found both the verbal intervention of SAMA as well as the physical restraint portion much more effective. I also really felt that SAMA was concerned about pressure points of patients, where to hold them (wrist vs upper arm), how long to hold, concerned about how restraints could mentally harm patients, and how to properly do a hold for children, instead of placing them face down. I've done the small child hold many times in the RTC where I worked (although it was the locked unit of the adolescent RTC) and it was very effective.
I was pretty unimpressed with TCI

I prefer SAMA as well, I find it is more focused on the client and how to do the restraint in a way that is most appropriate for that client, where TCI seems more general. I felt when I was trained in TCI that the verbal stuff was useful, and I like it, but it didn't seem to take into account the mental state of the client as much. I think SAMA takes into account more that you do not want to retraumatize the individual. Personally though I felt comfortable with the small child hold in TCI, I am small, so it feels comfortable to me, and since I am small I am not perceived as being as threatening.
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  #14  
March 1st, 2010, 09:17 AM
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Have you ladies had any MANDT training? My dad is an instructor and travels all over teaching that restraint system, although I don't like that term to describe MANDT. Dad loves that one, it works well with the kids and for adults as well.
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  #15  
March 1st, 2010, 02:02 PM
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In MA we used PAC and in NJ I used Crisis Managment. It's interesting to read what the rest of the country is using. Face down restraints have been a big NO NO in these parts for quite some time, there was a death and law suit in MA many years ago.

With Pac it was a 2 day training CM is 3 both heavily cover verbal redirection for a large part of the training.
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  #16  
March 1st, 2010, 03:27 PM
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I work in a postsurgical unit at a veterans hospital, so we deal with a lot of PTSD triggered situations. Planning, low stimulation rooms are much more helpful than physical restraints, as loss of control creates larger issues. To protect surgery sites, we more often use sedatives like haldol or ativan as it can get the patient though the crises point, and they aren't as aware of the loss of control. I've seen younger veterans break the beds when using wrist and ankle restraints. On the flip side, chemical restraints are often unpredictable and unsafe in the elderly. I don't even know how debate this topic, other than far more research and funding should be devoted to it.
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