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Luccarelli J, Kalluri AS, Kalluri NS, McCoy TH. Pediatric Physical Restraint Coding in US Hospitals: A 2019 Kids Inpatient Database Study. Hosp Pediatr 2024; 14:337-347. [PMID: 38567417 DOI: 10.1542/hpeds.2023-007562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Reduction of physical restraint utilization is a goal of high-quality hospital care, but there is little nationally-representative data about physical restraint utilization in hospitalized children in the United States. This study reports the rate of physical restraint coding among hospitalizations for patients aged 1 to 18 years old in the United States and explores associated demographic and diagnostic factors. METHODS The Kids' Inpatient Database, an all-payors database of community hospital discharges in the United States, was queried for hospitalizations with a diagnosis of physical restraint status in 2019. Logistic regression using patient sociodemographic characteristics was used to characterize factors associated with physical restraint coding. RESULTS A coded diagnosis of physical restraint status was present for 8893 (95% confidence interval [CI]: 8227-9560) hospitalizations among individuals aged 1 to 18 years old, or 0.63% of hospitalizations. Diagnoses associated with physical restraint varied by age, with mental health diagnoses overall the most frequent in an adjusted model, male sex (adjusted odds ratio [aOR] 1.56; 95% CI: 1.47-1.65), Black race (aOR 1.43; 95% CI: 1.33-1.55), a primary mental health or substance diagnosis (aOR 7.13; 95% CI: 6.42-7.90), Medicare or Medicaid insurance (aOR 1.33; 95% CI: 1.24-1.43), and more severe illness (aOR 2.83; 95% CI: 2.73-2.94) were associated with higher odds of a hospitalization involving a physical restraint code. CONCLUSIONS Physical restraint coding varied by age, sex, race, region, and disease severity. These results highlight potential disparities in physical restraint utilization, which may have consequences for equity.
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Affiliation(s)
- James Luccarelli
- Departments of Psychiatry
- Harvard Medical School, Boston, Massachusetts
| | - Aditya S Kalluri
- Harvard Medical School, Boston, Massachusetts
- Boston Combined Residency Program in Pediatrics, Boston, Massachusetts; and
| | - Nikita S Kalluri
- Harvard Medical School, Boston, Massachusetts
- Department of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Thomas H McCoy
- Departments of Psychiatry
- Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Birkeland S, Bogh SB, Pedersen ML, Kerring JH, Morsø L, Tingleff EB, Gildberg FA. Variation in opinions on coercion use among mental healthcare professionals: a questionnaire study. Nord J Psychiatry 2024:1-8. [PMID: 38626028 DOI: 10.1080/08039488.2024.2341928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/06/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Even if coercive measures are widely applied in psychiatry and have numerous well-known drawbacks, there is limited known on the agreement among mental healthcare professionals' opinions on their use. In a questionnaire study using standardized scenarios, we investigated variation in staff opinions on coercion. METHODS In a web-based survey distributed to staff at three psychiatry hospitals, respondents were asked to consider if and what coercion to use by introducing two hypothetical scenarios involving involuntary psychiatric admission and in-hospital coercion. RESULTS One hundred thirty-two out of 601 invited staff members responded to the survey (Response Rate = 22%). There was large variation in participating staff members' opinions on how to best manage critical situations and what coercive measures were warranted. In the first scenario, 57% of respondents (n = 76) believed that the patient should be involuntarily admitted to hospital while the remaining respondents believed that the situation should be managed otherwise. Regarding the second scenario, 62% of respondents responded that some in-hospital coercion should be used. The majority of respondents believed that colleagues would behave similarly (60%) or with a tendency towards more coercion use (34%). Male gender, being nursing staff and having less coercion experience predicted being less inclined to choose involuntary hospital admission. CONCLUSION There is a high degree of variation in coercion use. This study suggests that this variation persists despite staff members being confronted with the same standardized situations. There is a need for evidence-based further guidance to minimize coercion in critical mental healthcare situations.
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Affiliation(s)
- Søren Birkeland
- Forensic Mental Health Research Unit, Middelfart, Faculty of Health Science, Department of Regional Health Research, University of Southern Denmark, Denmark and Open Patient data Explorative Network, Odense University Hospital, Odense C, Denmark
| | - Søren Bie Bogh
- Department of Clinical Medicine, Faculty of Health Sciences, University of Southern Denmark and Open Patient data Explorative Network, Odense University Hospital, Denmark
| | - Martin Locht Pedersen
- Forensic Mental Health Research Unit, Middelfart, Faculty of Health Science, Department of Regional Health Research, University of Southern Denmark, Denmark
| | - Jonas Harder Kerring
- Forensic Mental Health Research Unit, Middelfart, Faculty of Health Science, Department of Regional Health Research, University of Southern Denmark, Denmark
| | - Lars Morsø
- Department of Clinical Medicine, Faculty of Health Sciences, University of Southern Denmark and Open Patient data Explorative Network, Odense University Hospital, Denmark
| | - Ellen Boldrup Tingleff
- Forensic Mental Health Research Unit, Middelfart, Faculty of Health Science, Department of Regional Health Research, University of Southern Denmark, Denmark
| | - Frederik Alkier Gildberg
- Forensic Mental Health Research Unit, Middelfart, Faculty of Health Science, Department of Regional Health Research, University of Southern Denmark, Denmark
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Belayneh Z, Chavulak J, Lee DCA, Petrakis M, Haines TP. Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta-analysis. J Clin Nurs 2024; 33:1256-1281. [PMID: 38304928 DOI: 10.1111/jocn.17041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/15/2023] [Accepted: 01/07/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND There is a growing consensus to reduce the use of restrictive care practices in mental health settings to minimise the physical and psychological complications for patients. However, data regarding restrictive care practice use and factors contributing to variations in the proportion estimates has not previously been synthesised. AIMS This study aimed to synthesise evidence on (1) the pooled proportions of physical restraint, seclusion or chemical restraint in adult mental health inpatients and (2) sources of variability in these proportion estimates. METHODS Studies were identified from Scopus, MEDLINE, PsycINFO, Web of Science, Embase and CINAHL databases following the PRISMA 2020 guidelines. We conducted a meta-analysis of studies published in English language from 1 January 2010 to 15 August 2022. Binomial data were pooled using a random effect model, with 95% confidence intervals. Meta-regression was also computed to identify factors that may contribute to variations in the proportion estimates. RESULTS A total of 77 studies were included in this meta-analysis. The pooled prevalence of physical restraint, seclusion and chemical restraint was 14.4%, 15.8% and 25.7%, respectively. Data were heterogeneous across studies (I2 > 99%). Reporting practices and geographical locations contributed to the variability in the reported estimates of restrictive care practices, with studies from Asian countries reporting higher proportions. CONCLUSION There appear differences between geographical locations in the proportion of restrictive practices in mental health inpatients; however, this is complicated by how these prevalence data have been measured and defined. Consistency in the reporting of restrictive care practices in mental health is required to make valid comparisons between geographical regions, policy settings and practice innovations. RELEVANCE TO CLINICAL PRACTICE Efforts are needed to develop training programmes and policy changes to ensure consistency in defining and reporting of restrictive care practices in mental health facilities. PATIENT/PUBLIC CONTRIBUTION This is a systematic review that analysed data from previously published studies, and there was no patient/public contribution in this study. PROTOCOL REGISTRATION The protocol for this review has been registered to PROSPERO: CRD42022335167.
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Affiliation(s)
- Zelalem Belayneh
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- Department of Psychiatry, College of Health, and Medical Sciences, Dilla University, Dila, Ethiopia
| | - Jacinta Chavulak
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
| | - Den-Ching A Lee
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, Monash University (Peninsula Campus), Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Monash University, Frankston, Victoria, Australia
| | - Melissa Petrakis
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- St Vincent's Hospital Mental Health Service, Melbourne, Victoria, Australia
| | - Terry P Haines
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- National Centre for Healthy Ageing, Monash University, Frankston, Victoria, Australia
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Chang-Sing E, Smith CM, Gagliardi JP, Cramer LD, Robinson L, Shah D, Brinker M, Jivalagian P, Hu Y, Turner NA, Wong AH. Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status. JAMA Netw Open 2024; 7:e240098. [PMID: 38381433 PMCID: PMC10882414 DOI: 10.1001/jamanetworkopen.2024.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/03/2024] [Indexed: 02/22/2024] Open
Abstract
Importance Black patients are more likely than White patients to be restrained during behavioral crises in emergency departments (EDs). Although the perils of policing mental health for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the association between Black race and use of physical restraint in EDs. Objective To evaluate the degree to which police transport mediates the association between Black race and use of physical restraint in EDs. Design, Setting, and Participants This retrospective, cross-sectional study used electronic health record data from ED visits by adults (aged ≥18 years) to 3 hospitals in the southeastern US and 10 in the northeastern US between January 1, 2015, and December 31, 2022. Data were analyzed from September 1, 2022, to May 30, 2023. Exposures Race, ethnicity, and police transport to the hospital. Main Outcomes and Measures The primary outcome variable was the presence of an order for restraints during an ED visit. Results A total of 4 263 437 ED visits by 1 257 339 patients (55.5% of visits by female and 44.5% by male patients; 26.1% by patients 65 years or older) were included in the study. Black patients accounted for 27.5% of visits; Hispanic patients, 17.6%; White patients, 50.3%; and other or unknown race or ethnicity, 4.6%. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of experiencing restraint compared with White patients (adjusted odds ratio [AOR], 1.33 [95% CI, 1.28-1.37]). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared with all other patients (AOR, 1.38 [95% CI, 1.34-1.42]). Patients brought to the ED under police transport had increased odds of experiencing restraint compared with all other modes of transport (AOR, 5.51 [95% CI, 5.21-5.82]). The estimated proportion of use of restraints for Black patients mediated by police transport was 10.70% (95% CI, 9.26%-12.53%). Conclusions and Relevance In this cross-sectional study of ED visits across 13 hospitals, police transport may have mediated the association between Black race and use of physical restraint. These findings suggest a need to further explore the mechanisms by which transport to emergency care may influence disparate restrictive interventions for patients experiencing behavioral emergencies.
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Affiliation(s)
| | - Colin M. Smith
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina
| | - Jane P. Gagliardi
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Laura D. Cramer
- Yale National Clinician Scholars Program, New Haven, Connecticut
| | - Leah Robinson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Patelle Jivalagian
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yue Hu
- Yale School of Public Health, New Haven, Connecticut
| | - Nicholas A. Turner
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Agboola IK, Rosenberg A, Robinson L, Brashear TK, Eixenberger C, Shah D, Pavlo AJ, Im DD, Ray JM, Coupet E, Wong AH. A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department. Ann Emerg Med 2024; 83:108-119. [PMID: 37855791 PMCID: PMC10843036 DOI: 10.1016/j.annemergmed.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
STUDY OBJECTIVE Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.
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Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, NorthShore University Health System, Evanston, Illinois; Department of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alana Rosenberg
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut
| | - Leah Robinson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Taylor K Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica M Ray
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
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Im DD, Bukhman AK, Joseph JW, Dziobek JC, Grant J, Clifford KC, Kim I, Chen PC, Schmelzer NA, Powell R, Waters B, Dundin A, Askman N, Lassiter T, Baymon DE, Shankar K, Sanchez LD. Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department. Am J Emerg Med 2024; 76:193-198. [PMID: 38091903 DOI: 10.1016/j.ajem.2023.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.
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Affiliation(s)
- Dana D Im
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA.
| | - Alice K Bukhman
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Josh W Joseph
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Jim C Dziobek
- Mass General Brigham, Office of the Chief Medical Officer, 399 Revolution Drive, Somerville, MA 02145, USA
| | - Jill Grant
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Kathleen C Clifford
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Inkyu Kim
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Naomi A Schmelzer
- Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, 2(nd) floor, Boston, MA 02130, USA
| | - Robin Powell
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Beth Waters
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Andrew Dundin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Noah Askman
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Terrance Lassiter
- Department of Police, Security, Safety, and Parking, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Da'Marcus E Baymon
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Kalpana Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
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Pino EC, Gonzalez F, Nelson KP, Jaiprasert S, Lopez GM. Disparities in use of physical restraints at an urban, minority-serving hospital emergency department. Acad Emerg Med 2024; 31:6-17. [PMID: 37597262 DOI: 10.1111/acem.14792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority-serving, safety-net institution. METHODS For this cross-sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints. RESULTS Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20-0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49-2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49-3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34-1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73-1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic. CONCLUSIONS Racial disparities exist in restraint utilization at this minority-serving safety-net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation.
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Affiliation(s)
- Elizabeth C Pino
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Felisha Gonzalez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sorraya Jaiprasert
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gina M Lopez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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Haran M, Killeen D, Healy M, Brophy P, Donohue A, Whyte I, Doody B. Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study. Ir J Med Sci 2023; 192:2929-2936. [PMID: 36813877 PMCID: PMC10692034 DOI: 10.1007/s11845-023-03316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND There has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland. AIMS The purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics. METHODS This is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed. RESULTS Of 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively. CONCLUSIONS Identifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.
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Affiliation(s)
- Maeve Haran
- Department of Psychiatry, School of Medicine, University College Dublin, Dublin, Ireland.
- Children's Health Ireland at Crumlin, Dublin, D12N512, Ireland.
| | - David Killeen
- Dublin North City and County CAMHS - Ballymun CAMHS, Ballymun Civic Centre, Dublin, Ireland
| | - Mike Healy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Peadar Brophy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Aoife Donohue
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Imelda Whyte
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Brendan Doody
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
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Soto J, Mitchell TO, Masters KJ, Millard H. The Role of Psychiatrists in Seclusion and Restraint Episodes: a Curriculum for Psychiatric Trainees. Acad Psychiatry 2023; 47:676-679. [PMID: 36952217 DOI: 10.1007/s40596-023-01767-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Jessica Soto
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Kim J Masters
- College of Health Professions Medical University of South Carolina, Charleston, SC, USA
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Andreoli A, Bianchi A, Campbell A, Bernhardt J, Bayley M, Guo M. In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation. Disabil Rehabil 2023; 45:3783-3787. [PMID: 36262023 DOI: 10.1080/09638288.2022.2135777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 09/30/2022] [Accepted: 10/09/2022] [Indexed: 11/03/2022]
Abstract
Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.
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Affiliation(s)
- Angie Andreoli
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Andria Bianchi
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
- National Health and Medical Research Council Centre, University of Melbourne, Melbourne, Australia
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
| | - Meiqi Guo
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
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11
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Eswaran V, Molina MF, Hwong AR, Dillon DG, Alvarez L, Allen IE, Wang RC. Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis. JAMA Intern Med 2023; 183:1229-1237. [PMID: 37747721 PMCID: PMC10520842 DOI: 10.1001/jamainternmed.2023.4832] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/28/2023] [Indexed: 09/26/2023]
Abstract
Importance Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability. Objective To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds. Data Sources A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022. Study Selection Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable. Data Extraction and Synthesis Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022. Main Outcome(s) and Measure(s) Risk of physical restraint use in adult ED patients by racial and ethnic background. Results The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89). Conclusions and Relevance Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
- Section of Health Services Research, Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety, DeBakey VA Medical Center; Houston, Texas
- Department of Emergency Medicine, University of California, San Francisco
| | - Melanie F. Molina
- Department of Emergency Medicine, University of California, San Francisco
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Alison R. Hwong
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Department of Psychiatry and Behavioral Sciences, University of California; San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - David G. Dillon
- Department of Emergency Medicine, University of California, Davis, Sacramento
| | - Lizbeth Alvarez
- School of Medicine, University of California, Davis, Sacramento
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
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12
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Stillman K, Mirocha J, Geiderman J, Torbati S. Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care. J Emerg Med 2023; 65:e393-e402. [PMID: 37722949 DOI: 10.1016/j.jemermed.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/04/2023] [Accepted: 05/26/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Physical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use. OBJECTIVES The primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers. METHODS This was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test. RESULTS Restraints were used in 1228 (0.9%) visits. Younger age, male gender, "unknown" ethnicity, self-pay or "other" nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79-1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95-2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively). CONCLUSION At this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use.
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Affiliation(s)
| | - James Mirocha
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
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13
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Luccarelli J, Sacks CA, Snydeman C, Luccarelli C, Smith F, Beach SR, McCoy TH. Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis. J Gen Intern Med 2023; 38:2461-2469. [PMID: 37002459 PMCID: PMC10064960 DOI: 10.1007/s11606-023-08179-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/17/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. OBJECTIVE This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. DESIGN The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. PARTICIPANTS Hospitalized patients aged 18 and older. MAIN MEASURES Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. KEY RESULTS In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. CONCLUSIONS In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Chana A Sacks
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colleen Snydeman
- Patient Care Services Office of Quality & Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Luccarelli
- Department of Medicine and Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Felicia Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas H McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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14
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Shields MC, Hollander MA. Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018. J Patient Exp 2023; 10:23743735231179072. [PMID: 37323757 PMCID: PMC10265359 DOI: 10.1177/23743735231179072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.
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Affiliation(s)
| | - Mara A.G. Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
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15
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Lacambre M, Péchillon É, Fovet T. [Isolation and mechanical restraint in psychiatry]. Rev Infirm 2023; 72:16-19. [PMID: 37364969 DOI: 10.1016/j.revinf.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Since 2016, there has been a succession of legal texts aimed at framing the use of seclusion and mechanical restraint in psychiatric services. These legal evolutions are not without consequence on the practice of caregivers. We propose here a practical summary of this issue.
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Affiliation(s)
- Mathieu Lacambre
- Unité de soins intensifs de psychiatrie, Filière de psychiatrie légale, CHU Montpellier, 191 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, cedex 5, France; Section psychiatrie légale, Association française de psychiatrie biologique et de neuropsychopharmacologie (AFPBN), Centre hospitalier Sainte-Anne, 1 rue Cabanis, 75674 Paris, France.
| | - Éric Péchillon
- Faculté DSEG de Vannes, Lab-LEX/UR 7480, Université Bretagne Sud, rue André-Lwoff, 56000 Vannes, France
| | - Thomas Fovet
- Section psychiatrie légale, Association française de psychiatrie biologique et de neuropsychopharmacologie (AFPBN), Centre hospitalier Sainte-Anne, 1 rue Cabanis, 75674 Paris, France; University Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition, 59000 Lille, France
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16
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González-Rodríguez A, Seeman MV, Román E, Natividad M, Pagés C, Ghigliazza C, Ros L, Monreal JA. Critical Issues in the Management of Agitation, Aggression, and End-of-Life in Delusional Disorder: A Mini-Review. Healthcare (Basel) 2023; 11. [PMID: 36832992 DOI: 10.3390/healthcare11040458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/15/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
Background: Compared to other psychotic disorders, there is little information about staging care in delusional disorder (DD). Unlike schizophrenia, this is a disorder that begins in middle age, a time at which chronic medical comorbidities have already begun to impact global functioning. With age, the combination of psychological and somatic conditions leads to new behaviours, e.g., agitation, aggression, and behaviours that require specific preventive and interventive measures. With further age, knowledgeable end-of-life care becomes necessary for this population. Aim: The aim of this article was to review existing evidence on the management of these successive phases. Methods: We conducted a narrative review using PubMed and ClinicalTrials.gov and searched for the following terms: (agitation OR aggressivity OR aggression OR palliative OR "end-of-life") AND ("delusional disorder"). Results: We found that the literature was sparse. Existing evidence suggests that medical causes are frequently at the root of agitation and aggression. With respect to management, de-escalation strategies are generally preferred over pharmacotherapy. Specific delusional syndromes, e.g., de Clérambault, Othello, Capgras, Fregoli, as well as folie à deux, are associated with aggression. The somatic subtype of DD is the one most often requiring palliative care at the end of life. Conclusions: We conclude that insufficient attention has been given to the care needs of the accelerated aging process in DD.
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17
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Bachmann L, Vatne S, Mundal IP. Safeguarding patients while implementing mechanical restraints: A qualitative study of nurses and ward staff's perceptions and assessment. J Clin Nurs 2023; 32:438-451. [PMID: 35178794 PMCID: PMC10078747 DOI: 10.1111/jocn.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 01/17/2023]
Abstract
AIMS AND OBJECTIVES To explore nurses' and ward staff's perceptions and assessments of patient care while implementing mechanical restraints. BACKGROUND To prevent the risks associated with the use of restraints in psychiatry and ensure safe mental health care, it is necessary to know more about how the nursing staff experiences, comprehends and intervenes in managing patients subjected to coercive measures. DESIGN This study employed a qualitative descriptive design, in accordance with the COREQ guidelines. METHODS Semi-structured interviews were conducted with 18 nurses and ward staff aged between 22 and 45 years old, who had experience implementing mechanical restraints. Data were digitally audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted using NVivo 12. RESULTS The participants believed that mechanical restraints should be used as a last resort and that safeguarding patients during implementation is important; however, their assessments of the patients' physical and mental conditions varied. A clear difference emerged in how management qualified professionals handled situations prior to and during the implementation of mechanical coercive measures. CONCLUSIONS The findings emphasise the need to focus on the assessment of patients prior to and during restraint, ensure the quality of safe implementation in a risk-of-harm situation, prioritise competence in education, and practice, and improve management. RELEVANCE TO CLINICAL PRACTICE The findings highlight the importance of assessing the physical and mental condition of patients while implementing restraints, as well as aiding the management, nurses and ward staff in tailoring safety procedures.
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Affiliation(s)
- Liv Bachmann
- Department of Health and Social Sciences, Molde University College, Molde, Norway
| | - Solfrid Vatne
- Department of Health and Social Sciences, Molde University College, Molde, Norway
| | - Ingunn Pernille Mundal
- Department of Health and Social Sciences, Molde University College, Molde, Norway.,Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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18
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Jin RO, Anaebere TC, Haar RJ. Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department. Focus (Am Psychiatr Publ) 2023; 21:100-105. [PMID: 37205039 PMCID: PMC10172532 DOI: 10.1176/appi.focus.23022007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.
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Affiliation(s)
- Rowen O. Jin
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Tiffany C. Anaebere
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Rohini J. Haar
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
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19
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Reppas-Rindlisbacher C, Shin S, Purohit U, Verma A, Razak F, Rochon P, Sheehan K, Rawal S. Association between non-English language and use of physical and chemical restraints among medical inpatients with delirium. J Am Geriatr Soc 2022; 70:3640-3643. [PMID: 35932190 DOI: 10.1111/jgs.17989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Christina Reppas-Rindlisbacher
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Saeha Shin
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ushma Purohit
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Amol Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Paula Rochon
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Kathleen Sheehan
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Shail Rawal
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Appleby R, Wright S, Williams L, Stanley M. Australian parents' experiences of owning an autism assistance dog. Health Soc Care Community 2022; 30:e4113-e4121. [PMID: 35352418 PMCID: PMC10084065 DOI: 10.1111/hsc.13805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/14/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
Autism assistance dogs (AADs) increase safety for children with autism and their families. Autism assistance dogs can also decrease familial stress and the isolation which families may experience due to fear for their child's safety and judgement from others within the community. Currently there is a paucity of literature on parents' experiences of AADs. Therefore, this study aimed to develop a rich understanding of parents' experiences of owning an AAD. A mixed methods design was utilised, with a qualitative descriptive design and the use of occupational mapping. Eight families were recruited through an Australian AAD programme and participated in semi-structured in-depth interviews throughout 2017. The interviews were analysed thematically. Mobility in the community before and after introduction of the dog was measured using occupational mapping. Families plotted on Google Map printouts the places they frequented before and after placement of their dog. Five major themes emerged from the analysis of the interviews: freedom through restraint; expanding our world; a calming/sensory tool (AAD); "at the end of the day they're dogs"; and, friendship and personal growth. The occupational maps demonstrated a median increase of 8.5 more places and 20.50 km further travelled from home after having the dog for over a year. Families with an AAD experienced an expanded world for the child and their family. Families experienced freedom in the places they could go, decreased isolation due to the safety which the dog provides. Occupational mapping supported the qualitative data, showing increased mobility and decreased isolation of the family. The paradox of freedom through restraint is a new and key finding which requires further exploration. The results provide support for funding and increased awareness of AAD programmes. Future longitudinal comparative studies are needed to explore the long-term impact of AADs on the child and family.
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Affiliation(s)
- Rebecca Appleby
- Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Present address:
Novita422 Salisbury HighwayParafield GardensSouth AustraliaAustralia
| | - Shelley Wright
- Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Lindy Williams
- Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Mandy Stanley
- Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Present address:
Occupational TherapySchool of Medical and Health SciencesEdith Cowan UniversityPerthWestern AustraliaAustralia
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21
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Jones A, Goodarzi Z, Lee J, Norman R, Wong E, Dasgupta M, Liu B, Watt J. Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis. PLoS One 2022; 17:e0276504. [PMID: 36288382 PMCID: PMC9604990 DOI: 10.1371/journal.pone.0276504] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited. Objectives To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use. Design Retrospective cohort study with a time series analysis. Participants Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020. Main measures We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR). Key results We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83). Conclusions The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University Hamilton, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- * E-mail: (AJ); (JW)
| | - Zahra Goodarzi
- Division of Geriatric Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Norman
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Monidipa Dasgupta
- Division of Geriatric Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Watt
- ICES, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- * E-mail: (AJ); (JW)
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22
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Smith CM, Turner NA, Thielman NM, Tweedy DS, Egger J, Gagliardi JP. Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation. Psychiatr Serv 2022; 73:730-736. [PMID: 34932385 DOI: 10.1176/appi.ps.202100474] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their White counterparts. METHODS This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood alcohol concentration, and diagnosis of a bipolar or psychotic disorder. RESULTS A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07-1.72) and chemically (AOR=1.33; 95% CI=1.15-1.55) restrained than White patients. CONCLUSIONS After analyses were adjusted for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with White patients, which is consistent with the growing body of evidence revealing racial disparities in psychiatric care.
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Affiliation(s)
- Colin M Smith
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Nicholas A Turner
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Nathan M Thielman
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Damon S Tweedy
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Joseph Egger
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Jane P Gagliardi
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
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23
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Hammervold UE, Norvoll R, Sagvaag H. Post-incident reviews after restraints-Potential and pitfalls. Patients' experiences and considerations. J Psychiatr Ment Health Nurs 2022; 29:472-483. [PMID: 34060178 DOI: 10.1111/jpm.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ABOUT THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and care providers. Several countries have implemented seclusion and restraint (S/R) reduction programmes in which post-incident reviews (PIRs) including patients and care providers are one of several strategies. Existing knowledge indicates that PIRs have the potential to contribute to S/R prevention, but knowledge of the patients' perspectives on PIRs is scarce. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides in-depth knowledge about patients' experiences of being participants in PIRs after restraint events. Patients experience PIRs to result in being strengthened and developing new coping strategies. The paper reveals pitfalls when planning and conducting PIRs that make patients experience PIRs as meaningless, feel objectified or long for living communication and closeness. The patients' mental state, the quality of the relationships and the services' care philosophies, influence patients' experiences of PIRs as supporting their personal recovery processes or as continuation of coercive contexts. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Patients' vulnerability during the PIRs must be acknowledged. Trusted persons or advocacy must support the patient in the PIR and thus reduce the power-dependence imbalance. The PIR must be conducted in a supportive, non-punishing atmosphere. Patients must influence planning for the PIR concerning time point and participants and themes to be discussed. The PIR forms should be extended to support the patients' empowerment and well-being. ABSTRACT: Introduction Post-incident reviews (PIRs), including patients, nurses and other care providers, following incidents of restraints are recommended in mental health services. Few studies have examined patients' experiences and considerations concerning PIRs. Aim The study aims to explore patients' perspectives on PIRs in relation to how they experience participation in PIRs and further view PIRs' potential for care improvement and restraint prevention. Method We conducted a qualitative study based on individual interviews. Eight current and previous inpatients from two Norwegian mental health services were interviewed. Results The patients experienced PIRs as variations on a continuum from being strengthened, developing new coping strategies and processing the restraint event to at the other end of the continuum; PIRs as meaningless, feeling objectified and longing for living communication and closeness. Discussion PIRs' beneficial potential is extended in the study. The findings highlight however that personal and institutional conditions influence whether patients experience PIRs as an arena for recovery promotion or PIRs as continuation of coercive contexts. Implications for practice We recommend patients' active participation in planning the PIR. PIRs should be conducted in a supportive atmosphere, including trusted persons, emphasizing and acknowledging a dialogical approach.
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Affiliation(s)
- Unn Elisabeth Hammervold
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Reidun Norvoll
- Work Research Institute, Oslo Metropolitan University, Oslo, Norway
| | - Hildegunn Sagvaag
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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24
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Wong AH, Ray JM, Cramer LD, Brashear T, Eixenberger C, McVaney C, Haggan J, Sevilla M, Costa DS, Parwani V, Ulrich A, Dziura JD, Bernstein SL, Venkatesh AK. Design and Implementation of an Agitation Code Response Team in the Emergency Department. Ann Emerg Med 2022; 79:453-464. [PMID: 34863528 PMCID: PMC9038629 DOI: 10.1016/j.annemergmed.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanie Haggan
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mark Sevilla
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Donald S. Costa
- Department of Protective Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James D. Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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25
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Varpula J, Välimäki M, Lantta T, Berg J, Soininen P, Lahti M. Safety hazards in patient seclusion events in psychiatric care: A video observation study. J Psychiatr Ment Health Nurs 2022; 29:359-373. [PMID: 34536315 DOI: 10.1111/jpm.12799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.
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Affiliation(s)
- Jaakko Varpula
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland.,Xiangya School of Nursing, Central South University, Hunan, China
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Johanna Berg
- Department of Nursing Science, University of Turku, Turku, Finland.,Turku University of Applied Sciences, Turku, Finland
| | | | - Mari Lahti
- Department of Nursing Science, University of Turku, Turku, Finland.,Turku University of Applied Sciences, Turku, Finland
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26
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Abstract
Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.
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Affiliation(s)
| | - Beata Bäckström
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
| | - Björn Axel Johansson
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
- Skåne Child & Adolescent Psychiatry, Regional Inpatient Care, Emergency Unit, Malmö, Sweden
| | - Olof Rask
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
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27
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Wong AH, Sabounchi NS, Roncallo HR, Ray JM, Heckmann R. A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department. BMC Health Serv Res 2022; 22:75. [PMID: 35033071 PMCID: PMC8760708 DOI: 10.1186/s12913-022-07472-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022] Open
Abstract
Abstract Background Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation. Methods We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model. Results The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop. Conclusions Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07472-x.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave Suite 260, New Haven, CT, 06519, USA.
| | - Nasim S Sabounchi
- Department of Health Policy and Management, Center for Systems and Community Design, CUNY Graduate School of Public Health & Health Policy, 55 W. 125th Street, 7th Floor, New York, NY, 10027, USA
| | - Hannah R Roncallo
- Department of Emergency Services, Yale New-Haven Hospital, 20 York Street, New Haven, CT, 06510, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave Suite 260, New Haven, CT, 06519, USA
| | - Rebekah Heckmann
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave Suite 260, New Haven, CT, 06519, USA
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28
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Kim MK, Oh J, Kim JJ, Park JY. Development and Validation of Simplified Delirium Prediction Model in Intensive Care Unit. Front Psychiatry 2022; 13:886186. [PMID: 35845446 PMCID: PMC9277122 DOI: 10.3389/fpsyt.2022.886186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The intensive care unit (ICU) is where various medical staffs and patients with diverse diseases convene. Regardless of complexity, a delirium prediction model that can be applied conveniently would help manage delirium in the ICU. OBJECTIVE This study aimed to develop and validate a generally applicable delirium prediction model in the ICU based on simple information. METHODS A retrospective study was conducted at a single hospital. The outcome variable was defined as the occurrence of delirium within 30 days of ICU admission, and the predictors consisted of a 12 simple variables. Two models were developed through logistic regression (LR) and random forest (RF). A model with higher discriminative power based on the area under the receiver operating characteristics curve (AUROC) was selected as the final model in the validation process. RESULTS The model was developed using 2,588 observations (training dataset) and validated temporally with 1,109 observations (test dataset) of ICU patients. The top three influential predictors of the LR and RF models were the restraint, hospitalization through emergency room, and drainage tube. The AUROC of the LR model was 0.820 (CI 0.801-0.840) and 0.779 (CI 0.748-0.811) in the training and test datasets, respectively, and that of the RF model was 0.762 (CI 0.732-0.792) and 0.698 (0.659-0.738), respectively. The LR model showed better discriminative power (z = 4.826; P < 0.001). CONCLUSION The LR model developed with brief variables showed good performance. This simplified prediction model will help screening become more accessible.
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Affiliation(s)
- Min-Kyeong Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jooyoung Oh
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea.,Center for Digital Health, Yongin Severance Hospital, Yongin, South Korea
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29
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Okuno T, Itoshima H, Shin JH, Morishita T, Kunisawa S, Imanaka Y. Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan. PLoS One 2021; 16:e0260446. [PMID: 34807945 PMCID: PMC8608313 DOI: 10.1371/journal.pone.0260446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/09/2021] [Indexed: 01/10/2023] Open
Abstract
Introduction The coronavirus disease (COVID-19) pandemic has caused unprecedented challenges for the medical staff worldwide, especially for those in hospitals where COVID-19-positive patients are hospitalized. The announcement of COVID-19 hospital restrictions by the Japanese government has led to several limitations in hospital care, including an increased use of physical restraints, which could affect the care of elderly dementia patients. However, few studies have empirically validated the impact of physical restraint use during the COVID-19 pandemic. We aimed to evaluate the impact of regulatory changes, consequent to the pandemic, on physical restraint use among elderly dementia patients in acute care hospitals. Methods In this retrospective study, we extracted the data of elderly patients (aged > 64 years) who received dementia care in acute care hospitals between January 6, 2019, and July 4, 2020. We divided patients into two groups depending on whether they were admitted to hospitals that received COVID-19-positive patients. We calculated descriptive statistics to compare the trend in 2-week intervals and conducted an interrupted time-series analysis to validate the changes in the use of physical restraint. Results In hospitals that received COVID-19-positive patients, the number of patients who were physically restrained per 1,000 hospital admissions increased after the government’s announcement, with a maximum incidence of 501.4 per 1,000 hospital admissions between the 73rd and 74th week after the announcement. Additionally, a significant increase in the use of physical restraints for elderly dementia patients was noted (p = 0.004) in hospitals that received COVID-19-positive patients. Elderly dementia patients who required personal care experienced a significant increase in the use of physical restraints during the COVID-19 pandemic. Conclusion Understanding the causes and mechanisms underlying an increased use of physical restraints for dementia patients can help design more effective care protocols for similar future situations.
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Affiliation(s)
- Takuya Okuno
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Hisashi Itoshima
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Jung-ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Tetsuji Morishita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
- * E-mail:
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30
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Abstract
In the context of psychiatric emergencies, it is important to distinguish between so-called controllable agitation and uncontrollable agitation. In this context, physical restraint of the adult patient is sometimes necessary, but remain an exceptional measure. Restraints must be applied rapidly and in a protocolised manner. It should be used sparingly in the elderly patient. Physical restraint is a medical prescription that must be accompanied by chemical restraint.
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Affiliation(s)
| | | | - Jorge Lopez-Castroman
- Service d'urgences et liaison psychiatriques, service de pédopsychiatrie, centre hospitalier universitaire de Nîmes, hôpital Carémeau, place du Professeur-Robert-Debré, 30900 Nîmes, France
| | - Caroline Zanker
- Structures des urgences, centre hospitalier franco-britannique, 4 rue Kléber, 92300 Levallois-Perret, France
| | - Anthony Chauvin
- Structure des urgences, centre hospitalier universitaire Lariboisière, 2 rue Ambroise-Paré, 75010 Paris, France
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Hirose N, Morita K, Nakamura M, Fushimi K, Yasunaga H. Association between the duration of physical restraint and pulmonary embolism in psychiatric patients: A nested case-control study using a Japanese nationwide database. Arch Psychiatr Nurs 2021; 35:534-540. [PMID: 34561070 DOI: 10.1016/j.apnu.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary embolism is the most life-threatening adverse event following physical restraint. However, little is known about the associaton between the duration of physical restraint and pulmonary embolism in psychiatric patients. OBJECTIVE The purpose of this study is to evaluate whether more total days of physical restraint is associated with a higher risk of pulmonary embolism. METHOD This is a retrospective nested case-control study using a Japanese nationwide administrative inpatient database. We identified patients who were admitted to psychiatric departments from July 2010 to March 2017. One-to-four case-control matching was performed with patients with and without pulmonary embolism. We performed multivariable conditional logistic regression analyses to assess the odds ratios of total days of physical restraint regarding pulmonary embolism. RESULTS We identified 223,285 eligible psychiatric patients; 132 (0.059%) patients developed pulmonary embolism during hospitalization. Overall, 13.2% of the psychiatric patients experienced physical restraint for at least 1 day. More total days of physical restraint was significantly associated with a higher risk of pulmonary embolism. CONCLUSIONS Longer exposure to physical restraint may increase the risk of pulmonary embolism in psychiatric patients.
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Affiliation(s)
- Naoki Hirose
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan; Global Health Nursing, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima 7348551, Japan.
| | - Kojiro Morita
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
| | - Mitsuhiro Nakamura
- Department of Psychiatry, Yokohama Camellia Hospital, 920 Shirane-Cho, Asahi-Ku, Yokohama, Kanagawa 2410003, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
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Ilha MC, Feldens CA, Razera J, Vivian AG, de Rosa Barros Coelho EM, Kramer PF. Protective stabilization in pediatric dentistry: A qualitative study on the perceptions of mothers, psychologists, and pediatric dentists. Int J Paediatr Dent 2021; 31:647-656. [PMID: 33220112 DOI: 10.1111/ipd.12751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence regarding the feelings evoked, distress caused, and the best way to conduct protective stabilization for the management of young children is lacking. AIM Describe the perceptions of mothers, psychologists, and pediatric dentists regarding the use of protective stabilization during the dental care of children up to three years of age attending a University Dental Clinic in southern Brazil. DESIGN After watching a video of dental care involving the protective stabilization technique, individualized qualitative interviews were held with three groups [mothers (n = 5), psychologists (n = 7), and pediatric dentists (n = 4)] to investigate four categories of interest: importance of the technique, affective attitude, distress caused to the child, and participation of parents. After the transcription of the recorded comments, qualitative content analysis was performed. RESULTS Protective stabilization generated emotional discomfort but was well accepted by all groups. All expressed the need to create a bond between the dentist and caregiver; and the active participation of the caregiver was considered fundamental. The mothers and psychologists rejected other options, such as passive restraint, general anesthesia, and sedation. CONCLUSION The three groups admitted having negative feelings, recognized the importance of protective stabilization, and suggested conditions for its use.
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Affiliation(s)
- Mariana Cezar Ilha
- Department of Pediatric Dentistry, Universidade Luterana do Brasil, Canoas, Brazil
| | | | - Josiane Razera
- Department of Psychology, Faculdade Meridional, Passo Fundo, Brazil
| | - Aline Groff Vivian
- Departament of Pyschology, Universidade Luterana do Brasil, Canoas, Brazil
| | | | - Paulo Floriani Kramer
- Department of Pediatric Dentistry, Universidade Luterana do Brasil, Canoas, Brazil.,Department of Pediatric Dentistry, Pontifícia Universidade Católica, Porto Alegre, Brazil
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Abstract
Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.
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Affiliation(s)
- Simon Nielson
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Lucy Bray
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Joann Kiernan
- Faculty of Health and Social Care, Edge Hill University, UK
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Carreras Tartak JA, Brisbon N, Wilkie S, Sequist TD, Aisiku IP, Raja A, Macias‐Konstantopoulos WL. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med 2021; 28:957-965. [PMID: 34533261 DOI: 10.1111/acem.14327] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Research regarding disparities in physical restraint use in the emergency department (ED) is limited. We evaluated the role of race, ethnicity, and preferred language on the application of physical restraint among ED patients held under a Massachusetts section 12(a) order for mandatory psychiatric evaluation. METHODS We identified all ED patient encounters with a section 12(a) order across a large integrated 11-hospital health system from January 2018 through December 2019. Information on age, race, ethnicity, preferred language, insurance, mental illness, substance use, history of homelessness, and in-network primary care provider was obtained from the electronic health record. We evaluated for differences in physical restraint use between subgroups via a mixed-effect logistic regression with random-intercept model. RESULTS We identified 32,054 encounters involving a section 12(a) order. Physical restraints were used in 2,458 (7.7%) encounters. Factors associated with physical restraint included male sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.28 to 1.63), Black/African American race (aOR = 1.22, 95% CI = 1.01 to 1.48), Hispanic ethnicity (aOR = 1.45, 95% CI = 1.22 to 1.73), Medicaid insurance (aOR = 1.21, 95% CI = 1.05 to 1.39), and a diagnosis of bipolar disorder or psychotic disorder (aOR = 1.51, 95% CI = 1.31 to 1.74). Across all age groups, patients who were 25 to 34 years of age were at highest risk of restraint (aOR = 2.01, 95% CI = 1.69 to 2.39). Patients with a primary care provider within our network (aOR = 0.81, 95% CI = 0.72 to 0.92) were at lower risk of restraint. No associations were found between restraint use and language, history of alcohol or substance use, or homelessness. CONCLUSION Black/African American and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order experience higher rates of physical restraint in the ED. Factors contributing to racial disparities in the use of physical restraint, including the potential role of structural racism and other forms of bias, merits further investigation.
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Affiliation(s)
| | - Nicholas Brisbon
- Data and Analytics Organization Mass General Brigham Boston Massachusetts USA
| | - Sarah Wilkie
- Department of Quality and Patient Experience Mass General Brigham Boston Massachusetts USA
| | - Thomas D. Sequist
- Department of Quality and Patient Experience Mass General Brigham Boston Massachusetts USA
| | - Imoigele P. Aisiku
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Ali Raja
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Wendy L. Macias‐Konstantopoulos
- Department of Emergency Medicine Center for Social Justice and Health Equity Massachusetts General Hospital Boston Massachusetts USA
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Jin RO, Anaebere TC, Haar RJ. Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department. Acad Emerg Med 2021; 28:1061-1066. [PMID: 33977591 DOI: 10.1111/acem.14277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 12/17/2022]
Abstract
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.
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Affiliation(s)
- Rowen O. Jin
- Department of Emergency Medicine LAC+USC Medical Center Los Angeles California USA
| | - Tiffany C. Anaebere
- Special Projects and Innovation Emergency Medicine Residency Program Dignity Health–St. Joseph’s Medical Center Stockton California USA
| | - Rohini J. Haar
- Department of Epidemiology and Biostatistics University of California at Berkeley Berkeley California USA
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Nunno MA, Mccabe LA, Izzo CV, Smith EG, Sellers DE, Holden MJ. A 26-Year Study of Restraint Fatalities Among Children and Adolescents in the United States: A Failure of Organizational Structures and Processes. Child Youth Care Forum. [DOI: 10.1007/s10566-021-09646-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Physical and mechanical restraints used in treatment, care, education, and corrections programs for children are high-risk interventions primarily due to their adverse physical, emotional, and fatal consequences.
Objective
This study explores the conditions and circumstances of restraint-related fatalities in the United States by asking (1) Who are the children that died due to physical restraint? and (2) How did they die?
Method
The study employs internet search systems to discover and compile information about restraint-related fatalities of children and youth up to 18 years of age from reputable journalism sources, advocacy groups, activists, and governmental and non-governmental agencies. The child cohort from a published study of restraint fatalities in the United States from 1993 to 2003 is combined with restraint fatalities from 2004 to 2018. This study’s scope has expanded to include restraint deaths in community schools, as well as undiscovered restraint deaths from 1993 to 2003 not in the 2006 study.
Results
Seventy-nine restraint-related fatalities occurred over the 26-year period from across a spectrum of children’s out-of-home child welfare, corrections, mental health and disability services. The research provides a data snapshot and examples of how fatalities unfold and their consequences for staff and agencies. Practice recommendations are offered to increase safety and transparency.
Conclusions
The study postulates that restraint fatalities result from a confluence of medical, psychological, and organizational causes; such as cultures prioritizing control, ignoring risk, using dangerous techniques, as well as agencies that lack structures, processes, procedures, and resources to promote learning and to ensure physical and psychological safety.
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Franks ZM, Alcock JA, Lam T, Haines KJ, Arora N, Ramanan M. Physical Restraints and Post-Traumatic Stress Disorder in Survivors of Critical Illness. A Systematic Review and Meta-analysis. Ann Am Thorac Soc 2021; 18:689-97. [PMID: 33075240 DOI: 10.1513/AnnalsATS.202006-738OC] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Physical restraints are used liberally in some intensive care units (ICUs) to prevent patient harm from device removal or falls. Although the intention of restraint use is patient safety, their application may inadvertently cause physical or psychological harm. Physical restraints may contribute to post-traumatic stress disorder (PTSD), but there is a paucity of supportive data.Objectives: To investigate the association between physical restraint use and PTSD symptoms in ICU survivors. Secondary objectives were to examine the cognitive and physical outcomes associated with physical restraint use and to assess interventions that may be effective in reducing restraint use.Methods: A systematic review of English language studies in PubMed, Medline, Embase, CINAHL, and CENTRAL between January 1, 1990, to February 8, 2020 was performed. Observational or randomized studies that reported on restraint use and associated outcomes, or interventions to reduce restraint use, in critically ill adult patients were identified. Two independent reviewers completed the review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Results: We identified 794 articles, of which 37 met inclusion criteria and were included. Thirty of these studies related to patient outcomes including PTSD, delirium, mechanical ventilation hours, and physical injury. Seven related to interventions to reduce physical restraint use. The quality of studies was not high; only four of the included studies were assessed to have a low risk of bias. Three studies found a significant relationship between restraint use and PTSD, but their results could not be pooled for analysis. Pooled data indicated a significant association between physical restraint use and delirium (odds ratio [OR], 11.54; 95% confidence interval [CI], 6.66-20.01; P < 0.001) and duration of mechanical ventilation (mean difference in days, 3.35; 95% CI, 1.95-4.75; P < 0.001). We also found that interventions, such as nursing education, may effectively reduce restraint use by approximately 50% (OR, 0.48; 95% CI, 0.32-0.73; P < 0.001). The impact that a reduction in restraint use may have on associated outcomes was not examined.Conclusions: Physical restraint use may be associated with PTSD in ICU survivors and is associated with delirium and longer duration of mechanical ventilation. Nurse education is likely effective in reducing rates of physical restraint among ICU patients.
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Chauvin A, Massoubre C, Gil-Jardine C, Sicot R, Le Conte P, Varin L, Lefort H, Camus V, Martinez M, Bied C, Oberlin M, Valdenaire G, Villoing B, Zanker C, Lopez-Castroman J, Claret PG. Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences. Ann Fr Med Urgence 2021. [DOI: 10.3166/afmu-2021-0321] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.
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Albers C, Nair N, Shankar R. Antipsychotics in Inpatient Children and Adolescents with Seclusion and Restraint: A Preliminary Exploratory Retrospective Chart Review. J Child Adolesc Psychopharmacol 2021; 31:358-363. [PMID: 34143681 DOI: 10.1089/cap.2020.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: This study is a retrospective review of patients 5-17 years of age experiencing seclusion and/or restraint (S&R) in a pediatric psychiatric inpatient setting and an exploratory analysis of antipsychotic use on S&R duration. We examined whether administration of antipsychotics would possibly decrease the time spent in S&R. Methods: Reports of patients who underwent S&R in an acute care inpatient child and adolescent psychiatric unit from 2012 to 2014 were reviewed. Demographic information related to age, gender, and race as well as information on diagnosis, current medications (including antipsychotics) were obtained. Independent samples t-tests were used to determine whether there were differences in how much time patients spent in S&R based on whether they were administered antipsychotics or not. Odds ratios (ORs) of being administered antipsychotics during S&R were computed for factors such as gender, race, and diagnosis group. Results: Ninety-six patients (68 males, age range 5-17 years) were involved in 232 S&R events that occurred between 2012 and 2014. Results indicate that patients who were administered antipsychotics during S&R still spent significantly more time in S&R compared with those who were given medications other than antipsychotics (e.g., Benadryl) (t = 3.161; p = 0.002) and those who were not administered any medication (t = 3.54; p = 0.001). Binary logistic regression showed that female patients were at more than two times (OR(adjusted) = 2.86; 95% confidence interval = 1.234-6.655) higher risk of being administered antipsychotics while in S&R compared with their male counterparts within this particular sample. Conclusions: The results of our study indicate that, contrary to our hypothesis, antipsychotic administration did not appear to reduce the time spent in S&R compared with groups that were administered medications other than antipsychotics and those that were not administered any medication during S&R. We also found an increased risk of antipsychotic administration in female patients compared with male patients in S&R events, indicating the need for larger studies examining these effects in greater detail.
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Affiliation(s)
- Cecilia Albers
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Neetu Nair
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Ravi Shankar
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
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Burrin C, Daniels NF, Cardinal RN, Hayhurst C, Christmas D, Zimbron J. Iatrogenic Complications of Compulsory Treatment in a Patient Presenting with an Emotionally Unstable Personality Disorder and Self-Harm. Case Rep Psychiatry 2021; 2021:6615723. [PMID: 34136300 DOI: 10.1155/2021/6615723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 11/18/2022] Open
Abstract
Attempted suicide and deliberate self-harm are common and challenging presentations in the emergency department. A proportion of these patients refuse interventions and this presents the clinical, legal, and ethical dilemma as to whether treatment should be provided against their will. Multiple factors influence this decision. It is difficult to foresee the multitude and magnitude of complications that can arise once it has been decided to treat individuals who do not consent. This case illustrates a particularly complex chain of events that occurred after treating someone against their will who presented with self-harm and suicidal ideation. These consequences are contrasted with those of not intervening when similar situations arose with the same patient.
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Abstract
Over the past decade, there have been widespread efforts to raise awareness about maltreatment of children. Pediatric providers have received education about factors that make a child more vulnerable to being abused and neglected. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population at increased risk for maltreatment. This report updates the 2007 American Academy of Pediatrics clinical report "Maltreatment of Children With Disabilities." Since 2007, new information has expanded our understanding of the incidence of abuse in this vulnerable population. There is now information about which children with disabilities are at greatest risk for maltreatment because not all disabling conditions confer the same risks of abuse or neglect. This updated report will serve as a resource for pediatricians and others who care for children with disabilities and offers guidance on risks for subpopulations of children with disabilities who are at particularly high risk of abuse and neglect. The report will also discuss ways in which the medical home can aid in early identification and intervene when abuse and neglect are suspected. It will also describe community resources and preventive strategies that may reduce the risk of abuse and neglect.
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Affiliation(s)
- Lori A Legano
- Department of Pediatrics, Grossman School of Medicine, New York University, New York, New York;
| | - Larry W Desch
- Department of Pediatrics, Chicago Medical School, Rosalind Franklin University of Medicine and Science and Advocate Children's Hospital, Oak Lawn, Illinois
| | - Stephen A Messner
- Stephanie V. Blank Center for Safe and Healthy Children, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Sheila Idzerda
- Billings Clinic, Department of Medicine, University of Washington School of Medicine, Bozeman, Montana; and
| | - Emalee G Flaherty
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Nocete Navarro L, López de Loma Osorio V, Bravo Ortiz MF, Fernández Liria A. [Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]. Salud Colect 2021; 17:e3045. [PMID: 33822542 DOI: 10.18294/sc.2021.3045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/28/2020] [Indexed: 11/24/2022] Open
Abstract
Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.
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Shields MC. Effects of the CMS' Public Reporting Program for Inpatient Psychiatric Facilities on Targeted and Nontargeted Safety: Differences Between For-Profits and Nonprofits. Med Care Res Rev 2021; 79:233-243. [PMID: 33709840 DOI: 10.1177/1077558721998924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The Centers for Medicare and Medicaid Services implemented the Inpatient Psychiatric Facility Quality Reporting Program in 2012, which publicly reports facilities' performance on restraint and seclusion (R-S) measures. Using data from Massachusetts, we examined whether nonprofits and for-profits responded differently to the program on targeted indicators, and if the program had a differential spillover effect on nontargeted indicators of quality by ownership. Episodes of R-S (targeted), complaints (nontargeted), and discharges were obtained for 2008-2017 through public records requests to the Commonwealth of Massachusetts. Using difference-in-differences estimators, we found no differential changes in R-S between for-profits and nonprofits. However, for-profits had larger increases in overall complaints, safety-related complaints, abuse-related complaints, and R-S-related complaints compared with nonprofits. This is the first study to examine the effects of a national public reporting program among psychiatric facilities on nontargeted measures. Researchers and policymakers should further scrutinize intended and unintended consequences of performance-reporting programs.
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Thompson A, Simmons S, Wolff J. Nowhere to Go: Providing Quality Services for Children With Extended Hospitalizations on Acute Inpatient Psychiatric Units. J Am Acad Child Adolesc Psychiatry 2021; 60:329-331. [PMID: 32976953 DOI: 10.1016/j.jaac.2020.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/22/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
The US mental health system is in crisis because of inadequate treatment resources. The number of youths hospitalized for suicidality more than doubled during the last decade,1 and the suicide rate for 10- to 14-year-olds nearly tripled from 2007 to 2017.2 Although hospitalization is intended as a short-term stabilization setting reserved for the most acute and serious mental health problems, discharge is often delayed because of a lack of suitable step-down care such as outpatient, intensive outpatient (IOP), partial hospitalization programs (PHP), or residential psychiatric care. The availability of step-down care options differs vastly depending on region, insurance, and other factors, and the result is a subset of patients who remain hospitalized in acute inpatient units simply because of the absence of safe alternatives.
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Affiliation(s)
- Alysha Thompson
- Seattle Children's Hospital and University of Washington, Seattle.
| | - Shannon Simmons
- Seattle Children's Hospital and University of Washington, Seattle
| | - Jennifer Wolff
- Rhode Island Hospital, Bradley Hospital and Brown University, Providence
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Agboola IK, Coupet E, Wong AH. "The Coats That We Can Take Off and the Ones We Can't": The Role of Trauma-Informed Care on Race and Bias During Agitation in the Emergency Department. Ann Emerg Med 2021; 77:493-498. [PMID: 33579587 DOI: 10.1016/j.annemergmed.2020.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Wong AH, Whitfill T, Ohuabunwa EC, Ray JM, Dziura JD, Bernstein SL, Taylor RA. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open 2021; 4:e2035241. [PMID: 33492372 PMCID: PMC7835716 DOI: 10.1001/jamanetworkopen.2020.35241] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This cross-sectional study assesses the association of race/ethnicity and other demographic factors with risk of receiving physical restraint during an emergency department (ED) visit.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Travis Whitfill
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James D. Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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De Berardis D, Ventriglio A, Fornaro M, Vellante F, Martinotti G, Fraticelli S, Di Giannantonio M. Overcoming the Use of Mechanical Restraints in Psychiatry: A New Challenge in the Everyday Clinical Practice at the Time of COVID-19. J Clin Med 2020; 9:jcm9113774. [PMID: 33238428 PMCID: PMC7700144 DOI: 10.3390/jcm9113774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/17/2022] Open
Abstract
Restraining interventions, which comprise physical (PR) and mechanical restraint (MR), have a long history in mental health services [...].
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Affiliation(s)
- Domenico De Berardis
- Department of Mental Health, NHS, Psychiatric Service for Diagnosis and Treatment, Hospital “G. Mazzini”, ASL 4, 64100 Teramo, Italy
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (G.M.); (S.F.); (M.D.G.)
- Correspondence:
| | | | - Michele Fornaro
- Department of Psychiatry, Federico II University, 80131 Naples, Italy;
| | - Federica Vellante
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (G.M.); (S.F.); (M.D.G.)
| | - Giovanni Martinotti
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (G.M.); (S.F.); (M.D.G.)
| | - Silvia Fraticelli
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (G.M.); (S.F.); (M.D.G.)
| | - Massimo Di Giannantonio
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy; (F.V.); (G.M.); (S.F.); (M.D.G.)
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Hoffmann U, Clemens V, König E, Brähler E, Fegert JM. Violence against children and adolescents by nursing staff: prevalence rates and implications for practice. Child Adolesc Psychiatry Ment Health 2020; 14:43. [PMID: 33292414 PMCID: PMC7648387 DOI: 10.1186/s13034-020-00350-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/23/2020] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND International studies show that child maltreatment is a widespread but often underestimated problem that causes high individual, social and economic costs. Child maltreatment is an important topic for the medical sector as well. On the one hand, affected persons often seek support and help from healthcare professionals, but on the other hand, assaults can also occur in medical institutions by healthcare professionals. Surprisingly, there is hardly any data on the frequency of child maltreatment by healthcare professionals in general and particularly by nursing staff. METHODS Therefore, in a large representative survey of the German population of 2,516 subjects aged between 14 and 91, the experience of child maltreatment in medical institutions by nursing staff was assessed retrospectively. RESULTS Of the 46 subjects who had an inpatient stay in a child and adolescent psychiatry before the age of 18, 33.3% reported to have experienced maltreatment by nursing staff, while 17.3% of the 474 persons who had an inpatient stay in general or pediatric hospitals experienced maltreatment by nursing staff. All forms of maltreatment were significantly more frequent in psychiatric compared to general and pediatric hospitals. CONCLUSIONS The results of our representative retrospective survey demonstrate that maltreatment by nursing staff are not rare individual cases, but that medical facilities bear systemic risks for assault. Therefore, it is necessary that all medical institutions, in particular psychiatric hospitals, address this issue. In order to reduce the risk for assaults, it is important not only to implement structural measures but also to develop an attitude that emphasizes zero tolerance for violence against children and adolescents.
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Affiliation(s)
- Ulrike Hoffmann
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073, Ulm, Germany.
| | - Vera Clemens
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
| | - Elisa König
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
| | - Elmar Brähler
- grid.410607.4Department for Psychosomatic Medicine and Psychotherapy, University Medical Center of Johannes Gutenberg University of Mainz, Maniz, Germany ,grid.9647.c0000 0004 7669 9786Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Jörg M. Fegert
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
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Bystrynski J, Braun MT, Corr C, Miller D, O’Grady C. Predictors of Injury to Youth Associated with Physical Restraint in Residential Mental Health Treatment Centers. Child Youth Care Forum 2020. [DOI: 10.1007/s10566-020-09585-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schnitzer K, Merideth F, Macias-Konstantopoulos W, Hayden D, Shtasel D, Bird S. Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Acad Emerg Med 2020; 27:943-950. [PMID: 32691509 DOI: 10.1111/acem.14092] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. METHODS Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. RESULTS Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p < 0.0001). The risk ratio (RR) for Asian patients compared to white patients was 0.71 (95% confidence interval [CI] = 0.55 to 0.92, p = 0.009). The RR for Black patients compared to white patients was 1.22 (95% CI = 1.05 to 1.40, p = 0.007). Visits with patients having characteristics of male sex, public or no insurance, younger age, diagnoses pertaining to substance use, diagnoses pertaining to psychotic or bipolar disorders, current homelessness, and a history of violence were more likely to result in physical restraint. CONCLUSIONS There was a significant effect of race on restraint that remained when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence, all of which additionally conferred independent effects on risk. These results warrant a careful examination of current practices and potential biases in utilization of restraint in emergency settings.
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Affiliation(s)
- Kristina Schnitzer
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Flannery Merideth
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Wendy Macias-Konstantopoulos
- and, Harvard Medical School, Boston, MA, USA
- the, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- the, Center for Social Justice and Health Equity, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas Hayden
- and, Harvard Medical School, Boston, MA, USA
- and the, Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Derri Shtasel
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Suzanne Bird
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
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