the use of restraints in a pediatric population

Kimberly AllanApril 26, 2015

The Use of Restraints and Seclusion on Pediatric Psychiatric Populations

• By the end of the presentation, students will:• Be able to recognize three different types of restraints

commonly used on a psychiatric unit• Be knowledgeable on the process of initiating and terminating

a restraint• Be able to identify at least two different methods to

implement in a pediatric psychiatric setting in order to reduce the use of restraints and seclusion

Objectives

• There are three main types of restraints used on the Child Assessment Unit at Cambridge Hospital• Physical/Mechanical• Chemical/Medical• Seclusion

Types of Restraints

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Four-Point Restraints

• According to the American Psychiatric Nurses Association, a restraint is defined as:• “Any manual method or physical or mechanical device, material or

equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body or head freely”

• “A drug or medication when it is used as a restriction to manage the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s condition”

• Seclusion or restraint is initiated only when less restrictive measures have proven ineffective and the behavioral emergency poses serious and imminent danger to the person, staff or others and staff involved have been adequately trained and deemed competent to initiate these measures

What is a Restraint?

• Seclusion is the involuntary confinement of a person where the person is physically prevented from leaving in order to manage violent or self-destructive behavior• If used for an extended

period of time, a bathroom must be attached to the seclusion room

Seclusion

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Seclusion Room

Initiation to ReleaseRestraint Process

• Seclusion or restraint is initiated only when less restrictive, non-physical methods have failed and the behavioral emergency poses serious and imminent danger to the person, staff, or others • Staff must be trained to initiate restraint • Never leave a restrained person alone in a locked room

Initiation of a Restraint

• Documentation is required during and after every restraint• Monitor patient according to federal, state, and agency guidelines• At Cambridge Hospital, nurses can initiate a restraint order, but

doctors document it in the computer system• Vital signs/care, circulation/ROM, and current condition must be

documented every 15 minutes by a trained staff person and assessed every 30 minutes by an RN

• The patient must be seen by a doctor within an hour of initiating the restraint

• A new order for restraint must be administered by the doctor every hour• For chemical/medical restraint, the patient needs to be reassessed after

five minutes, and every fifteen minutes thereafter

Monitoring and Assessment

• The person should be released from restraint at the earliest possible time, indicated by physically and verbally calming down

• Physicians, physician’s assistants, and trained registered nurses have the authority to release restraints

• Following the release, staff should debrief as soon as possible• A staff debriefing form can include a list of specific interventions used prior to the

restraint, indication of any physical injury, and evidence of emotional trauma to other patients

• On the CAU, the patient may choose to fill out a debriefing form • “Was you privacy and dignity respected during this restraint or seclusion?”• “How did the restraint or seclusion make you feel?”• The patient can make comments on why they think the restraint happened, what could

be changed, and if they would like to talk to a Human Rights Officer• The patient’s treatment plan can then be modified if needed

Release from a Restraint

Reducing the Use of Seclusion and RestraintResearch

• Approximately half of youth in residential and inpatient child/adolescent treatment facilities manifest aggressive behavior problems• More than 1 out of 4 pediatric patients in a psychiatric

setting has had at least one seclusion episode and 29% has had at least one restraint• Between 1993 and 2003, there have been 45 fatalities

in child and adolescent psychiatric units related to restraint• There is also an impact on staff, with restraint-related

injury, compensation claims, burnout, and turnover

Why Reduce Seclusion & Restraint?

Valenkamp, M., Delaney, K., & Verheij, F. (2014)

• After reviewing literature on child and adolescent seclusion or restraint, three articles that met all criteria set by the authors were found• Two different intervention

models for reducing restrictive measures were presented:• Collaborative Problem Solving • Comprehensive Behavioral

Management

Reducing Seclusion and Restraint During Child and Adolescent Inpatient Treatment: Still an Underdeveloped Area of Research

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Comprehensive Behavioral Management • Milieu-based and focuses on changing

patient behaviors and ward practices• Incorporates individualized plans

detailing signs of escalation and triggers• Methods used at home to manage

challenging behaviors collected• Desirable behavior is supported by the

staff by discussions with the patients on alternative behaviors that would be most effective

• Reports of an 83% decrease in physical restraints following the use of CBM and a decrease in the mean duration per seclusion episode

• Based on cognitive behavioral therapy and anticipating and managing aggression

• Interrupts escalating behavior and promotes problem-solving skills

• Staff collaborates with the child to solve problems on the child’s cognitive level

• Individual plans to prevent escalation and provide awareness of important triggers for aggression

• Reports of up to a 99% reduction in restraint episodes and 69% reduction in seclusion episodes

Collaborative Problem Solving

Reducing Seclusion and Restraint During Child and Adolescent Inpatient Treatment


• The authors studied three different child/family-serving programs which used the Six Core Strategies to reduce the use of restraints and seclusion• Albert J. Solnit Children’s Center in

Middletown, CT• Youth Development Institute in Phoenix,

AZ• Mount Prospect Academy, Becket Family

of Services in Plymouth, NH• Six Core Strategies is the only

evidence-based framework approved by the National Registry of Effective Programs and Practices focused on preventing the use of restraints and seclusion

Successful Seclusion and Restraint Prevention Efforts in Child and Adolescent Programs

Caldwell, B., Albert, C., Azeem, M., Beck, S., Cocoros, D., Cocoros, T., Montes, R., & Reddy, B. (2014)

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Six Core Strategies

• Mechanical restraint beds were deconstructed and rebuilt into “healing benches”

• R/S were discussed in all staff meetings• “Dashboards” shared data on R/S with

all staff in real time• Monthly family dinners• No set visiting hours• All staff offered training on trauma-

informed care• Individualized treatment plan for each

child• Mechanical restraints eliminated

Albert J. Solnit Children’s Center



• Major focus on sensory integration prevention techniques

• R/S rooms converted into “comfort rooms”

• Individualized “comfort box” of sensory items given upon admission

• Staff training on “Collaborative Problem Solving”

• Student Advisory Board• Scheduled sensory regulation breaks

throughout day• Intervention Team to resolve conflict

and repair staff-patient relationship

Youth Development Institute



Number of restraints per month, beginning January 2012.

• Leadership believes prevention of R/S vital to trauma-informed, family-driven, youth-guided culture

• Replaced points and level systems of behavior modification with a strength-based, skill-focused support tool

• Tracked data including number of family contact, prosocial events partook, and satisfaction surveys

• Weekly staff meetings educating on the new principles and practices• Fostered staff cohesiveness

• Eliminated the use of seclusion and timeout rooms

Mount Prospect Academy, Becket Family of Services



Patient ScenariosCase Study

Patient B• 7 year old, Female• Small stature, about 4 feet tall• New admit on the unit• Diagnosis of trichotillomania and

increasing aggression towards parents, as well as absenteeism from school

• Visiting with parents off-unit• When time to go back to unit, had a

difficult time separating from parents

• Began to cry; threw a tantrum

• 9 year old, Female• Average stature, about 5’3”• Has been on the unit for several

months• Possible diagnosis of

schizophrenia• Was watching YouTube on a

computer• Became agitated and threw mouse

at screen• Fought with staff, yelling “I didn’t do

anything!”

Patient A

Case Study

• Would you use a restraint on Patient B?• If so, what kind of restraint

would you use? Why?

• Would you use a restraint on Patient A?• If so, what kind of restraint

would you use? Why?

Discussion

• Patient B did not need a restraint• No imminent danger is present

• Instead, Patient B was “favorably relocated”

• Patient B was picked up (she is a small child and so this action is age-appropriate) and brought back onto the unit

• Patient B de-escalated when picked up, thus a restraint was not necessary

• Patient A was physically put into seclusion• Imminent danger to others is present• The “sensory room”, unlocked from

the inside, was used• The sensory room has many mats,

cushions, and bouncy balls• After a few minutes, Patient A was

offered a PRN medication for agitation• After de-escalating and taking the

PRN, Patient A was taken out of seclusion (approximately fifteen minutes)

What Happened?

Thank You for Your Attention!

• American Psychiatric Nurses Association. (2014). Seclusion & Restraint Standards of Practice. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid=3730• Caldwell, B., Albert, C., Azeem, M., Beck, S., Cocoros, D., Cocoros,

T., Montes, R., & Reddy, B. (2014). Successful seclusion and restraint prevention efforts in child and adolescent programs. Journal of Psychosocial Nursing, 52(11), 30. doi:10.3928/02793695-20140922-01 • Valenkamp, M., Delaney, K., & Verheij, F. (2014). Reducing

seclusion and restraint during child and adolescent inpatient treatment: still an underdeveloped area of research. Journal of Child and Adolescent Psychiatric Nursing, (27), 169. doi:10.1111/jcap.12084

References

http://www.apna.org/i4a/pages/index.cfm?pageid=3730

the use of restraints in a pediatric population

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