Physical restraints vs. seclusion in hospitalized patients Josha Harvey COHP 450

Introduction PICO Question: In hospitalized patients, how does the use of seclusion compared to physical restraints, affect aggressive behavior?

Search words: physical restraints, seclusion, aggressive, behavior Search Engines: Cinahl, PubMed, Flite Library Cinahl results- 564; PubMed results- 7; Flite results- 9

Articles Study #1: Huf, G., Coutinho, E. S. F., & Adams, C. E. (2012). Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): A randomized trial. Psychological medicine, 42, 2265-2273. doi: 10.1017/S0033291712000372 Study #2: Vishnivetsky, S., Shoval, G., Leibovich, V., Giner, L., Mitrany, M., Cohen, D., Barzilay, A., Volovick, L., Weizman, A., & Zalsman, G. (2013). Seclusion room vs. physical restraint in an adolescent inpatient setting: Patients’ attitudes. The Israel Journal of Psychiatry and related sciences, 50(1), 6-10.

I chose these two articles because they talk about patient perception of physical restraints compared to seclusion and how they managed their behavior.

Study #1 Theory suggests that the least restrictive option (seclusion) is best for the patient Quantitative study Randomized trial, two-arm trial with 14 days of follow-up 105 people were used in the study All procedures were tested before the trial in a pilot study, using 10 people who needed seclusion or restraints

Study #2 This study compared the attitudes of adolescent patients when having to use seclusion or physical restraints to manage their behavior Qualitative study/Cross sectional design A structured questionnaire was used 50 adolescent patients in psychiatric ward

Results Study #1- In the majority of patients studied, seclusion was able to manage behavior without having to be put into restraints. Study #2- Seclusion is the preferred method in adolescent hospitalized patients. Study #1: Patients who had nurses that were unsure of which method to use, and used restraints, were more likely to stay in restraints than those put in seclusion. One third of the patients placed into seclusion had to be put into restraints because the seclusion was not helping their behavior. Two thirds of the seclusion group were able to be managed without going into restraints. People who had to be put in restraints or transferred from seclusion did not spend more time in restrictions overall. Giving people the benefit of the doubt and choosing seclusion over restraints does not increase the risk of a longer hospital stay. There is a suggestion that patients feel less satisfied with restraints, however this finding did not reach statistical significance. Study #2: 70% of adolescent patients preferred seclusion over physical restraint. 82% described seclusion as being less frightening than physical restraint. 74% reported that the seclusion room improved their behavior to a larger extent than using physical restraint. They reported that it took a shorter amount of time to get calm when using seclusion.

Ethical Considerations Informed consent Length of time in seclusion/restraints Transfer from seclusion to restraints Lack of evaluation in other studies In Study #1, participants were not asked for informed consent because seclusion and restraints are part of standard care in that institution. The hospital has a track record to ensure proper care of patients based on the best evidence. This study met all requirements of studies possible to do without informed consent and was approved by ethics committees. In study #2, participants had informed, voluntary written consent by themselves and their parents and was approved by the Geha Mental Health Center’s Human Subjects Review Committee. In study #2, participants reported that they were in the seclusion room for too long. They stated that no more than 15 minutes is an appropriate time to manage their behavior. There are policies for each hospital regarding length of time for patients to be put into restraints or seclusion and mandatory time checks for each one. Study #1 talked about patients having to be transferred from seclusion to restraints because their behavior did not get any better. This could be an ethical consideration because some nurses may have a difference of opinion. Some may place a patient in restraints quicker than another one. This would bring up the question of whether or not the person even had to go into restraints in the first place. This study also mentioned that questions regarding restraint techniques, nurse handling, duration of restraints, type of restraints, etc. has not been evaluated enough in trials and that under-evaluated techniques are often used which leads to death in some cases.

Study #1 Small trial of short duration with small population Study of the design took into account most outcomes of importance to experienced staff although some seclusion rooms may differ elsewhere Inclusion criteria: risk of aggressive/violent behavior that put themselves or others at risk, considered to need some form of physical restriction by medical staff, medical staff had doubt about which method to use for the person (seclusion or restraints) “For this group of people, for whom there is doubt regarding which restriction to use, the least restrictive option of the seclusion room is now more based on evidence than before” (Huf et. Al, 2012). With a larger study, there may have been statistical significance regarding the suggestion that patients feel less satisfied with restraints as opposed to seclusion. Therefore, that part of the study is less credible.

Study #2 Small population Limited conclusions Questions used Criteria: participants required to have at least one time that they were in seclusion and restraints during their hospital stay. “It is based on cross-sectional design, which limits conclusions concerning the directionality between either restraint or seclusion room and the attitude of the patient” (Vishnivetsky et. Al, 2013). This study asked the participants questions regarding seclusion and physical restraints when used on them. Depending on the questions asked, patients could have reported more positive comments about seclusion just based on the fact that they did not like physical restraints; not necessarily based on which one really improved their mood more.

Relevance to practice These findings would be communicated at a policy and standard of care level Changing practice The policies for seclusion and restraints need to be specific in policies to ensure proper standard of care. There are many ethical concerns regarding the use of both and a firm policy is essential. With these two studies alone, I do not think it would be enough to change practice. Both of these studies use small populations of 105 and 50 participants, which is not enough to conclude generalizability. However, there were results found that could change standard practice if more studies were done. The current policy at my place of employment is to use the least restrictive option when dealing with aggressive patients. Some hospitals do not have seclusion or restraints at all. Therefore, studies like this could change having to use seclusion, or at least physical restraints at all. There would need to be more evidence that seclusion is an effective means of controlling aggressive behavior in a big enough population to generalize.

Potential Barriers Different policies Lack of equipment/money Different hospitals have different policies regarding seclusion and restraints and some hospitals do not utilize either method. This could be a barrier because changing a policy takes time and can be a tough process. Also, some hospitals may lack the proper restraint equipment or may not have seclusion rooms on their unit. In addition to lack of resources, some hospitals may not have the money to get the equipment that they lack.

Additional PICO questions In aggressive patients, how long is seclusion needed to manage aggressive behavior? In hospitalized patients, what are alternative methods other than seclusion and physical restraint that are effective in managing aggressive behavior?

Conclusion In hospitalized patients, the use of seclusion is preferred over physical restraint when managing aggressive behavior. Seclusion was associated with higher patient satisfaction overall, and managed most aggressive behaviors effectively. However, more studies need to be done to confirm these results.