January 30, 2020

When a patient presents at the ED in a mental health crisis, staff may need to take measures to restrain the patient to keep both the patient and provider safe—but a new study highlights the trauma restrained patients can endure, and ultimately how it affects their care, Megan Thielking reports for STAT News.  

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Background

EDs are often the first stop for people in the midst of psychiatric crisis, but between a short supply of beds and overcrowded waiting rooms, hospitals have struggled to accommodate these patients' needs.

Between 2006 and 2013, the rate of ED visits involving bipolar disorder, depression, anxiety, or psychoses increased by more than 50%, according to data from the Agency for Healthcare Research and Quality. About one in eight ED visits are related to mental illness, the data show.

In some cases, patients may experience acute agitation, which is a major lapse in behavioral control that can present a safety concern for both the patient and provider. As "a last resort," Thielking writes staff will restrain the patient with cuffs or a chemical sedative. While the practice is seen as a safety measure, Thielking that for providers it can be "an exceedingly difficult process" and research has shown in some cases it can be tied to patient harm. But what's less known is how patients themselves feel about being restrained.  

Study details and key findings

For the study published Friday in JAMA Network Open, researchers from Yale University interviewed 25 patients who'd been restrained in two urban EDs—many of whom arrived at the ED unwillingly. The researchers sought to understand what patients feel during that experience and how the experience influences the episode of care and the patient's recovery.

Of the patients interviewed, nine had negative feelings about the use of restraints, while 10 had mixed feelings, and six reported positive feelings. Patients who had negative feelings reported experiencing a loss of dignity and self-determination, Thielking reports.

"The experience in the [ED], it's traumatic as hell," one patient said.

Another noted, "It was scary for me. I had no control over my body."

Another patient said that the use of restraints can actually exacerbate mental health conditions. "After all the times I've been restrained in the [ED], it makes my PTSD and anxiety worse," the patient said. "My provider increases my anxiety medication for a few days until I can adjust to being back outside and get it out of my mind."

Meanwhile, some patients had grown to normalize the experience, Thielking reports. For instance, one participant said, "I already experienced so many times when they go right to the straps, to me it's a ritual. It's just what it is. There's nothing I can do about it."

Several study participants said their ED experiences caused them to lose trust in the health care system completely, according to Thielking

Discussion

Ambrose Wong, an author of the new study and an emergency medicine physician, said the study findings underscore a need for systemic approaches to patient and provider safety. "It's not [only] just that individual staff member or patient's responsibility to make sure that experience goes well," Wong said.

The authors said one of the most alarming findings was patients losing trust in the health care system, as these patients are often ones who struggle the most to access the care they need.

"These patients [who are restrained] are unfortunately already vulnerable. This probably doesn't happen in isolation," Wong said.

Matthew Wynia, a physician and bioethicist at the University of Colorado Anschutz Medical Campus, and Abraham Nussbaum of Denver Health Medical Center in an accompanying editorial wrote, "Caring and committed people staff our EDs, and when a person with a mental illness presents there—especially when they present involuntarily, like 68% of the participants in [Wong's study]—the ED and its staff should be prepared for the possibility of agitation, including with appropriate physical space and trained personnel."

As Thielking reports, some health centers have specialized teams that are trained to deescalate situations, such as when an ED patient experiences acute agitation, and determine when restraints are necessary.   

However, some experts said EDs also should consider creating a designated space where staff can work to help the patient without restraints. In cases when restraints are necessary, Wynia said it might help minimize the patient's feelings of abandonment and isolation to have a provider sit next to them while they're restrained.

Nicole Visaggio, a nurse who specializes in mental health care at McLean Hospital and has studied the use of restraints, also noted that research has supported using a chair-based restraint over one in which a patient is cuffed to a bed. "It's much more humane to be in a seated position," Visaggio said. "You can make eye contact with staff as they talk to you, and you can see what is going on around you" (Thielking, STAT News, 1/24; Nussbaum/Wynia, JAMA Network Open, 1/24).

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