Since the beginning of the COVID-19 pandemic, mental health needs have increased dramatically, which has been reflected in EDs, where use of restraint is sometimes needed.
Data analysis can help EDs deal with a higher incidence of behavioral health emergencies.
In recent years, emergency departments (EDs) have seen a dramatic increase in behavioral emergencies, and the trend has been exacerbated by the COVID-19 pandemic and its after-effects.
Research and evidence-based strategies may help ED nursing staff identify patients who are more likely to need to be restrained. Here are some guidelines for ED patient restraint processes, information on how the ED climate is changing post-pandemic, and thoughts on how an advanced performance analytic application can help staff monitor protocol compliance, and reduce injury and liability risk.
Restraint Basics
In a medical setting, restraint usage falls into three categories: physical, chemical, and seclusion. In all categories, the AMA recommends that the least restrictive restraint be used, depending on the situation. It also says the patient must be frequently assessed and that restraints should be removed as soon as possible.
- Physical restraint is used for both violent and nonviolent patients, including for self-destructive behavior. A number of devices and techniques, including therapeutic physical holds, are used to restrict movement.
- Chemical restraint, or using medication to restrict a patient’s movement or behavior, is less common and even prohibited in some health care facilities. This involves temporarily sedating a patient to restrict movement in the case of potential harm.
- Seclusion is a last-resort type of restraint, used only for patients who are behaving violently. It requires continuous, close monitoring by nursing staff and sometimes is used in combination with physical restraint. The seclusion environment is used to prevent self-harm and de-escalate violent behavior.
Primary Restraint Standards
The Joint Commission has outlined the 2021 primary standards for restraint and seclusion of patients. These standards, which align with the American Psychiatric Nurses Association (APNA)’s “Seclusion & Restraint Standards of Practice,” were designed to help guide future research, practice, and policy. According to APNA standards, restraints “must not be used for coercion, punishment, discipline, or staff convenience.”
Not only is it an ethical obligation to respect patient rights, but improper restraint use can lead to sanctions from state health departments and The Joint Commission. Restraint and seclusion should be:
- Clinically justified
- Implemented safely and lawfully, adhering to written hospital guidelines
- Based on the order of an individual doctor for a specific patient
- Continually monitored and evaluated by medical staff trained in best practices
- Documented, with negative health outcomes reported
Recent published reports suggest that restraint usage has risen during the COVID-19 pandemic for many reasons. With ever-increasing efforts to reduce restraint usage — while minimizing patient harm to self and others — it is clear that trustworthy compliance data and usage trends can be valuable tools for HCOs.
Behavioral Health Issues on the Rise
In 2016, mental health disorders affected as many as 1 in 4 adults in the United States. Research revealed that comorbidities play a significant role in the increasing number of ED visits, regardless of insurance coverage.
Flash forward to 2021, and the numbers are staggering. A 2021 McKinsey report has shown that at least one in three adults could have a behavioral health need, which equates to an additional 35 million people experiencing behavioral health conditions, including more than 1.6 million people who have been directly impacted by COVID-19 illness and loss.
Increasing incidences of anxiety and depression have many causes and affect a wide range of people, for example, frontline health care workers, those suffering loss and isolation, the unemployed, those abusing alcohol and other substances, as well as those with sleep disorders.
Connections to Workplace Violence
Just as the incidence of behavioral and mental health emergencies has risen, so have incidents of violence by patients toward health care workers. Some of the same assessment and de-escalation techniques used for patients needing restraints can be used to help prevent violence toward health care workers.
A review of studies reveals that incidents happened the most to nurses, at 39.8%, then security staff at 15.9%, and nurse assistants at 14.4%. Some very specific patterns of patient conditions and behavior have been shown to lead to violence, including cognitive impairment and demanding to leave.
Immediate catalysts often were the use of needles, patient pain and discomfort, and physical patient transfer. Situational factors included the usage of restraints, transitions in care, and redirecting patients.
Analyzing workplace violence incidents can identify catalysts and situational factors that can help inform and create targets for intervention. Hospital staff can be trained to increase their awareness of specific risk factors, including restraint, and learn how to best mitigate violence and prevent harmful behavior.
When it comes to finding these important patterns and creating actionable strategies, data analysis tools from d2i can help in identifying new possibilities for safer care environments for all.
Reducing Potential Negative Outcomes
Knowing the characteristics of patients who are more likely to require restraint in the ED can be very helpful on several levels.
Adverse events associated with the restraint process, and agitation management in particular, can have severe consequences for patients, including long-lasting psychological distress, respiratory depression, blunt chest trauma, and even asphyxiation and cardiac arrest. And health care professionals and other patients risk being exposed to violence.
Delving into the characteristics of patients who are likely to need restraint can help staff understand patients’ motivations, manage expectations, and streamline logistical challenges and long-term care outcomes. Several factors impact a patient’s agitation level. Some that can be monitored and mitigated include:
- Interpersonal communication
- Environment
- Wait Times
- Drug and alcohol intoxication or withdrawal
- Metabolic conditions such as hypoglycemia
- Neurologic conditions such as dementia
- Psychiatric disorders such as schizophrenia
The first step in de-escalating the patient’s behavior and reducing risk is to understand the motivations behind it. Some patients will still need to be restrained, but this understanding can prevent some cases.
Monitoring Compliance with Analytics
Monitoring compliance with The Joint Commission standards for restraint, as well as hospital policies and care improvement strategies, can reveal opportunities for reducing restraint usage and liability. As the behavioral health needs of our country continue to increase there’s a clear need for EDs to make use of a robust data application to create strategies for prevention and consistency.
Advanced data analytics can help HCOs understand and prove the impact that behavioral health patients have on ED crowding, including lower patient satisfaction and increased patient walkouts. It also can help identify where and when additional resources should be applied.
If you’re interested in improving the quality of your ED mental health services and providing a safer environment for both patients and staff, contact us to learn how our tools can help, or to schedule a request a demo.