Restrictive interventions in the Emergency Department James Fordyce Emergency Physician March 27 2019

Robert Plasto

What are restrictive interventions? Parenteral sedation Physical restraint Mechanical restraint Seclusion

Who should have restrictive interventions? To prevent imminent and serious harm to patients or others To administer necessary treatment Only undertaken when other less restrictive options tried or considered, found to be unsuitable Clinical interventions Risk assessment De-escalation

Mental Health Act vs Duty of Care Within context of MMC ED, start most patients under duty of care provisions Logistic issues If clear mental illness, pre-existing treatment order, then use Mental Health Act

Chemical restraint IM vs IV Benzodiazepines Antipsychotics Midazolam Lorazapam Antipsychotics Avoid in Parkinsons/Lewy Body Dementia Droperidol Olanzepine

Mechanical restraint ‘extremely restrictive, harmful intervention that can only be used with the immediate safety of the patient or others is compromised’

Who can authorise? Duty of Care Mental Health Act Medical practitioner Senior registered nurse on duty Registered nurse can initiate if medical practitioner and Senior registered nurse on duty unavailable Authorised psychiatrist

Who needs to be notified? Duty of Care Consultant in charge Mental Health Act Authorised psychiatrist Via ECATT Family/Next of Kin If possible/appropriate May aid management

What paperwork? Duty of Care Mental Health Act Riskman entry MRK 72 – Restraint Order and Review MRK 70 – Restraint Order and Assessment MRK 70(II) – Restraint Assessment Continuation Mental Health Act MHA 140 - Authority for Use of Restrictive Interventions MHA 141 – Approval for Urgent Physical Restraint MHA 142 – Restrictive Interventions Observations Riskman entry

How do we physically do it Code Grey Team approach Clear plan Approved restraints Patient supine, not prone

What observation once restraint is in place? Constant visual observation MHA requires a registered nurse, DOC does not specify, EN sometimes used Every 15 minutes Documented observation Every hour Documented assessment Every 4 hours Medical assessment, review of plan, appropriate documentation

What observation once restraint is in place? Well protocolised on DOC forms, less so on MHA forms Vital signs Behaviour Skin integrity Hydration/nutrition

AS SOON AS POSSIBLE! When do we take it off? When patient de-escalated, sedation on board Consider removal of restraints as soon as patient sedated Can be removed in stages

What do we do after taking it off? Ensure documentation complete Debrief staff Debrief/counsel patient if appropriate