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ERs Becoming Less Likely to Lock Up Out of Control Patients

Armen Hareyan's picture

Emergency Rooms (ER)

Results from a survey of U.S. emergency rooms suggest that hospitals are relying less on restraining agitated or violent patients in locked rooms to prevent self-injury or injury to hospital staff.

The new research, published in the September-October issue of General Hospital Psychiatry, found that 123 of 442 (or 27.8 percent) of the reporting emergency rooms use seclusion. A 1988 survey in the Annals of Emergency Medicine found 61 percent said they used seclusion in the emergency department.

The new study provides a snapshot of the use of seclusion in American emergency medicine and reveals some of the challenges medical professionals face when a patient is isolated for safety.

Of the reporting emergency department directors, 29.2 percent said staff injury has resulted when putting patients in seclusion, while 19.8 percent reported patient injury.

Lead researcher Dr. Leslie S. Zun said a dearth of science-based information makes it difficult to determine if those complication levels are significant or not.

"Most emergency physicians could rattle off the complication rate of putting a central line in a patient or a chest tube in a patient, but that is not the same for restraint or seclusion" Zun said. "Why should the behavioral procedures we do be any different than the medical procedures?"

Zun is chairman of the Department of Emergency Medicine at Mount Sinai Hospital in Chicago, which does not use seclusion. Instead of locked seclusion, Mount Sinai staff place out-of-control patients in an unlocked area with a monitor stationed close by, outside the room, or under one-to-one observation.

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Kevin Ann Huckshorn, a program director with the National Association of State Mental Health Program Directors, says the drop in the use of seclusion reflects a philosophy change among many mental health professionals.

"We approach seclusion and restraint as a safety measure of last resort, not as a treatment or the first thing we pull out of our bag of tricks," she says.

Huckshorn says many organizations that use seclusion and other forms of restraint have begun to focus on reducing and preventing its use even as they ensure that staff are trained to perform the procedure safely.

Prevention strategies include: clear leadership from chief executive officers, meticulously documenting the use of restraint, asking consumers for feedback on their restraint experience and rigorous debriefing after restraint is used, Huckshorn says.

Patient seclusion is governed by clear rules from the Joint Commission on Accreditation of Healthcare Organizations. However, Zun says there hasn't been enough research evidence to know if these regulations effectively protect patients or hospital staff.

In the survey, 64.3 percent of responding emergency department directors said their facility has difficulty complying with the Joint Commission rules. Zun and colleagues also found that nearly 19 percent of emergency departments offered no formal training for the staff members who place patients in seclusion.

Zun says he'd like to see more research on the true therapeutic or detrimental value of seclusion to give emergency physicians a better understanding of seclusion's psychological effects on patients.

"Are they demoralized by seclusion? Is their condition improved? Maybe it makes them feel more under control? We don't know," Zun says.