Approach to acute agitation in the pediatric emergency department.

PURPOSE OF REVIEW: The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED. RECENT FINDINGS: Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time. SUMMARY: Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department.

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.

Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial.

BACKGROUND: Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion. METHODS: This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model. RESULTS: 97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017). CONCLUSIONS: Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.

Use of physical restraints and its associated risk factors in the aged care facilities: A multicentre cross-sectional study.

AIMS AND OBJECTIVES: To investigate the use of physical restraints in aged care facilities(ACFs)and analyse its associated risk factors. BACKGROUND: Physical restraints have been widely used in ACFs worldwide, but they can cause physical and mental harm to older people. It is important to regulate the use of physical restraint. DESIGN: A cross-sectional observational and correlational multicentre study. METHODS: By convenience sampling method, we selected eight ACFs in four representative regions of Hunan province, China, for this study. The ACF-related information was obtained by interviewing the managers and reviewing records. We conducted investigation and observation on the elderly in the ACFs to understand the use of physical restraints at three different times: 9:30-11:30, 16:00-18:00 and 19:30-21:30 on a working day. The STROBE checklist was followed for this cross-sectional study. RESULTS: This study found that the utilisation rate of physical restraints was 23.2%. The critical risk factors affecting the use of physical restrains include the following: (1) the ratio of nursing staff to the elderly residents; (2)whether there is a dementia care unit at the facility; (3) the number of elderly residents in each room; (4) the elderly residents' age, degree of education, marital status, care dependence and cognitive impairment; (5) whether the elderly has suffered from a stroke or senile dementia; (6) whether the elderly carries medical catheters. CONCLUSION: There is a lack of standardisation in the use of physical restraints in ACFs of central China. Chinese ACFs should develop guidelines and reduction measures to standardise the use of physical restraints, basing on the key factors affecting the use of physical restraints. RELEVANCE TO CLINICAL PRACTICE: The use of physical restraints in ACFs is threatening the safety of the elderly residents. Understanding the implementation of physical restraint in ACFs can provide reference for reducing the use of physical restraint.

Restraint use in residents with dementia living in residential aged care facilities: A scoping review.

AIMS AND OBJECTIVES: To provide an overview of restraint use in residents with dementia in the context of residential aged care facilities. BACKGROUND: Restraints are commonly used in people with dementia living in residential aged care facilities to manage behaviours and reduce injuries, but the concept of restraint use in people with dementia remains ambiguous, and current practices to reduce restraint use in long-term care residents with dementia remain unclear. DESIGN: A scoping review using the methodological frameworks of Arskey and O'Malley and colleagues. METHODS: Nine databases (CINAHL, MEDLINE, EMBASE, PubMed, Scopus, Web of Science, OVID, Cochrane Central Register of Controlled Trials and ProQuest) were searched from 2005 to 20 May 2019. Articles were included if they were written in English, peer-reviewed and used any research method that described restraint use in residents with dementia living in residential care settings. The PRISMA-ScR checklist was used. RESULTS: From 1,585 articles, 23 met the inclusion criteria. There is a lack of a clear definition of restraint use, and the prevalence of restraint use varied from 30.7% to 64.8% depending on the different operational concepts. People with dementia were at a higher risk for restraint use, and the decision-making process for restraint use was largely ignored in the literature. The effect of staff educational interventions to reduce restraint use was inconsistent due to varying delivery duration and content. CONCLUSIONS: The prevalence of restraint use in people with dementia living in residential care settings remains high alongside the absence of a clear definition of restraint use. More research about the decision-making process involved in using restraint and development of effective interventions are needed. RELEVANCE TO CLINICAL PRACTICE: Better education about the decision-making regarding staff, conditions of residents and organisations for restraint use is needed to improve the care for people with dementia living in care settings.

PET neuroimaging reveals upregulation of dopamine D2 receptor contributes to amygdaloid dysfunction in rat acute restraint stress model.

Acute stress relates to high prevalence of anxiety, depression or even sudden death. Although dopaminergic system in amygdala-medial prefrontal cortex (mPFC) circuit is hyper-responsive to stress-induced anxiety, the mechanisms that control anxiety still remains unanswered. Here, the acute restraint stress model(ARS) was established to develop anxiety-like behavior. The D2-dopamine receptor (D2R) availability in amygdala and mPFC was assessed using [18F]-fallypride positron emission tomography(PET) and immunohistochemical assay. We revealed that ARS paradigm was successfully established, as evidenced by elevated plus-maze test(EPM) and increased corticosterone release. Moreover, PET imaging displayed elevated D2R availability in the amygdala and mPFC in ARS as compared to that in the naives. PET imaging combined with immunohistochemical assay confirmed that amygdaloid D2R was significantly implicated in stress-induced anxiety. Our findings delivered valuable insights into neuromechanism of amygdaloid D2R underlying stress-induced anxiety and might have important implications for developing therapeutics for anxiety by targeting amygdaloid D2R.

Decline in Physical Restraint Use Following Implementation of Institutional Guidelines.

OBJECTIVE: To investigate the strategies implemented at our institution to reduce medical restraint use. BACKGROUND: Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients. METHODS: The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation. RESULTS: The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark. CONCLUSIONS: This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

Experience with a "Feed and Swaddle" program in infants up to six months of age.

BACKGROUND: Feed and swaddle is a technique in which an infant is fed and allowed to fall asleep to facilitate diagnostic imaging. This study reviews our experience and diagnostic success in premature and term infants up to 6 months old undergoing brain magnetic resonance imaging (MRI) using a feed and swaddle technique and with comparable patients imaged under anesthesia. METHODS: We reviewed the charts of all infants ≤6 months who underwent brain MRI at our institution between 1 January 2013 and 31 March 2016. We recorded and analyzed demographic information, scan indication, scan length, prematurity status, anesthetic technique if used, complications, and diagnostic success or failure. RESULTS: One hundred and sixty-four term infants underwent brain MRI using a feed and swaddle technique. The success rate in term infants <90 days was 91.1% (113/124) versus 95.0% (38/40) in infants ≥90 days and ≤181 days old. Fifty-three premature infants underwent feed and swaddle for brain MRI with a diagnostic success rate of 92.5% (49/53). No complications were noted in any feed and swaddle patients. Those who received anesthesia had a diagnostic success rate of 100% (70/70) but experienced complications including hypoxemia, 14.3% (10/70); hypothermia, 18.9% (10/53); bradycardia, 10.1% (7/69); and hypotension, 4.2% (3/70). CONCLUSION: Given the high rate of success and absence of complications with feed and swaddle in children ≤6 months for brain MRI and the presence of anesthesia-related complications, most infants should undergo a trial of feed and swaddle prior to undergoing brain MRI with anesthesia.

Effects of spinal immobilization at 20° on end-tidal carbon dioxide.

OBJECTIVE: The aim was to determine the effect on end-tidal carbon dioxide (ETCO2) of spinal immobilization (SI) at a conventional 0° angle and to investigate the usefulness of immobilization at a 20° angle for preventing possible hypoventilation. METHODS: The study included 80 healthy volunteers, randomly divided into two groups. Spinal backboards and cervical collars were applied in Group 1 using a 0° angle and in Group 2 using a 20° angle, with the head up. SI was continued for 1 h, and ETCO2 values were measured at the 0th, 30th and 60th minute. RESULTS: There were no significant differences between the groups in 0th and 30th minute ETCO2. However, after 60th minute, results showed a statistically significant increase in ETCO2 in Group 1 (35.5 mmHg [IQR 25-75:35-38]) compared to Group 2 (34 mmHg [IQR 25-75:33-36]) (p < 0.001). During SI, there was a statistically significant increase in ETCO2 in Group 1 (35 mmHg [IQR 25-75:34-36], 35.5 mmHg [IQR 25-75:34-37] and 36 mmHg [IQR 25-75:35-38] respectively at the 0th, 30th and 60th minute after SI) (p < 0.001) and no change in Group 2. Also, we found statistically significant differences between ΔETCO2 levels in Groups 1 and 2 at all 3 time intervals. CONCLUSION: Conventional SI with an angle of 0° led to an increase in ETCO2 while subjects immobilization at a 20° angle maintained their initial ETCO2 values. Immobilization at 20° may prevent decompensation in patients who have thoracic trauma or lung diseases or those who are elderly, pregnant, or obese.

Exploring head and neck cancer patients' experiences with radiation therapy immobilisation masks: A qualitative study.

OBJECTIVE: Head and neck cancer (HNC) patients commonly undergo radiation therapy requiring immobilisation by a mask. Some find the mask distressing, and this can disrupt treatment sessions. This study aimed to explore the patient experience of immobilisation masks in the Australian and New Zealand (ANZ) context, to guide possible intervention. METHODS: Semi-structured interviews were conducted with HNC patients who had completed radiation therapy, recruited via hospitals and social media. Interviews continued until data saturation; then, three further interviews were conducted for member-checking purposes. Qualitative methodology with thematic analysis was used to identify themes in the data. RESULTS: Twenty HNC survivors participated in interviews, and seven themes were identified: information received by participants, potential predictors of mask anxiety, participant reactions to the mask, trajectories of mask anxiety, supportive behaviour and communication of health professionals, coping with the mask, and thoughts and feelings about the mask. CONCLUSIONS: Participant experiences of the immobilisation mask were diverse. The findings fit with Lazarus and Folkman's (Stress, appraisal, and coping. New York, NY: Springer Pub. Co) transactional model of stress and coping, as participants appeared to make cognitive appraisals of the mask and their coping abilities throughout treatment, resulting in varied levels of mask-related distress. Complex intervention is recommended to reduce mask anxiety in HNC patients across ANZ.

The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-Behavioral Intervention Package.

BACKGROUND: Invasive interventions can produce fear, anxiety, and pain in children. This may negatively affect the children's treatment and care. AIM: This study was conducted to determine the effects of procedural restraint (PR) and cognitive-behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age. DESIGN: Quasi-experimental study. SETTINGS: The study was conducted in the pediatric blood collection service of the hospital in Turkey between October 1, 2015, and April 1, 2016. PARTICIPANTS/SUBJECTS: The population of the study consisted of children admitted to the blood collection service during the study period who met the inclusion criteria. METHODS: The children included in the study were divided into two groups. Group 1 (n = 31) received PR in accordance with routine clinical practice. Group 2 (n = 30) received the CBIP. The data were collected by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-FACES) Pain Rating Scale. RESULTS: The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of 8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-FACES pain scores of the groups (p < .05). CONCLUSIONS: The results of this study showed that the children in the CBIP group had a lower pain level during venipuncture compared to those restrained for the procedure.

Interventions to reduce physical restraints in general hospital settings: A scoping review of components and characteristics.

AIMS AND OBJECTIVES: To describe the characteristics of interventions for reducing physical restraints in general hospital settings. BACKGROUND: Physical restraints, such as bedrails and belts in beds and chairs, are commonly used in general hospital settings. However, there is no clear evidence on their effectiveness but some evidence on potential risks for harm. DESIGN: Scoping review. METHODS: We conducted a systematic database search (MEDLINE via PubMed, CINAHL, Cochrane Library; March 2020) and snowballing techniques. We included both interventional studies and quality improvement projects conducted in general hospital settings and published in English or German language. Two reviewers independently performed the study selection and data extraction. The Scoping Reviews (PRISMA-ScR) Checklist was used. RESULTS: We included 31 articles (published between 1989 and 2018), 15 quality improvement projects and 16 intervention studies. Only five studies used a controlled design. Most studies and quality improvement projects investigated multicomponent interventions including education (predominantly for nursing staff) and additional components (e.g. case conferences). Three studies examined simple educational programmes without additional components. CONCLUSIONS: A large number of multicomponent interventions for preventing and reducing physical restraints in general hospital settings have been developed. The interventions differed widely regarding the components, contents and settings. Well-designed evaluation studies investigating the effects of such interventions are lacking. RELEVANCE TO CLINICAL PRACTICE: Multicomponent educational interventions might be one approach to change clinical practice, but only insufficient information is available about potential effects of these approaches.

Mediating the interface between voluntariness and coercion: A qualitative study of learning disability nurses' work in medical examinations of people with intellectual disability.

AIMS AND OBJECTIVES: To gain knowledge of prevention and use of restraints in provision of medical care to people with intellectual disability. To this end, we explore how learning disability nurses in community services support the individual through medical examinations when facing resistance. BACKGROUND: Despite increased focus on limiting restraints, there is a lack of knowledge of how restraints are prevented and used in the delivery of physical health care to people with intellectual disability. DESIGN: We used an ethnographic comparative case design (n = 6). METHODS: The study was carried out in Norway. The analysis is based on data from semi-structured interviews, participant observation and document studies, in addition to health sociological perspectives on how to support individuals to make their body available for medical examination and intervention. The SRQR checklist was used. RESULTS: Learning disability nurses strove to ensure that examinations were carried out on the individual's terms, supporting the individual in three phases: preparing for the examination, facilitating the examination and, when facing resistance, intervening to ensure safe and compassionate completion of the examination. CONCLUSIONS: Supporting the person was a precarious process where professionals had to balance considerations of voluntariness and coercion, progress and breakdown, safety and risk of injury, and dignity and violation. Through their support, learning disability nurses helped to constitute the "resistant" individual as "a cooperative patient," whose body could be examined within the knowledge and methods of medicine, but who could also be safeguarded as a human being through the strain of undergoing examination. RELEVANCE TO CLINICAL PRACTICE: The article sheds light on how restraints are used in the medical examination and treatment of people with intellectual disabilities and demonstrates the significance of professional support workers' contributions, both in facilitating safe and efficient medical care and in ensuring the least restrictive and most compassionate care possible.

Seclusion, restraint, and involuntary medication in Finnish psychiatric care: a register study with root-level data.

Purpose: Despite potentially harmful effects, seclusion, restraint, and involuntary medication continue to be frequently applied in psychiatric care. These restrictive measures are often examined by means of registers, but homogeneous practices in the measurement and description seem to be missing. This nationwide register study aimed to examine the use of seclusion, mechanical and physical restraint, and involuntary medication in Finland.Material and methods: Root-level register data concerning the year 2017 were collected directly from 140 inpatient psychiatric wards within 21 organizations. The data were analyzed statistically.Results: In 2017, the most used restrictive measure in Finnish psychiatric wards was seclusion (4006 episodes), followed by involuntary medication (2187 episodes), mechanical restraint (2113 episodes) and physical restraint (1064 events). Similarly, the duration of seclusion episodes was longer than the duration of restraint episodes. Remarkable variation between wards in the use of seclusion, restraint and involuntary medication was observable. A negative binomial regression model (NB2) was used to analyze the associations between the use of restrictive measures and regional variables concerning demography, health, substance abuse, and socio-economic status, but reliable interpretations were impossible to generate.Conclusion: This study provides detailed and unique data on the use of seclusion, restraint and involuntary medication in Finland. Compared to previous national-level data, this study highlights the importance of collecting root-level data. Future research should use registries and describe the associations between the use of restrictive measures and ward-level factors, patient-level characteristics, and societal factors.

Potential benefit of a thoracic squeeze technique in two newborn calves delivered by caesarean section.

Case History: Two calves delivered following elective caesarean section showed behaviour typical of neonatal maladjustment syndrome described in foals, i.e., indifference to environmental stimuli, lack of affinity for the dam, failure to find the udder, refusal to suck, aimless wandering or motionless standing. Calves were subjected to a clinical examination immediate after delivery and there were no signs of defects, illness, pain, dehydration, hypoxia, acidaemia or other causes for the unresponsive behaviour.Clinical Findings and Treatment: Both calves were subjected to the thoracic squeeze technique, one at 6 hours and the other at 20 hours after delivery. A soft rope was looped around the thorax and gentle pressure was applied to the free end of the rope, squeezing the calf's chest for 20 minutes. Both calves exhibited a sleep-like state manifested by closed eyes, no body movements, slow breathing and a decrease in heart rate, for the entire squeezing period. When the rope was removed the calves woke up immediately, rose and walked towards the dam. When led to the dam's udder, the weaker calf began to suck. Both were reported, by the stockperson, to follow the dam and suck normally the following day.Clinical Relevance: Provided all other disease processes are excluded, very young calves that exhibit indifference to environmental stimuli and lack of affinity for the dam may be good candidates for application of the thoracic squeeze technique that has been demonstrated to have clinical efficacy in foals with neonatal maladjustment syndrome.

Emerging technologies for the prevention and management of diabetic foot ulcers.

Diabetic foot ulcers (DFUs) are one of the most serious complications of diabetes mellitus (DM). Although research has improved understanding of DFU etiology, an effective clinical prevention and management of DFUs remains undetermined. Knowledge of recent technologies may enable clinicians and researchers to provide appropriate interventions to prevent and treat DFUs. This paper discusses how diabetes causes peripheral neuropathy and peripheral arterial diseases, which contribute to increased risk of DFUs. Then, emerging technologies that could be used to quantify risks of DFUs are discussed, including laser Doppler flowmetry for assessing plantar tissue viability, infrared thermography for early detection of plantar tissue inflammation, plantar pressure and pressure gradient system for identification of specific site at risk for DFUs, and ultrasound indentation tests (elastography) to quantify plantar tissue mechanical property. This paper also reviews how physical activity reduces risks of DFUs and how technology promotes adherence of physical activity. The clinician should encourage people with DM to exercise (brisk walking) at least 150 min per week and assess their exercise log along with the blood glucose log for providing individualized exercise prescription. Last, rehabilitation interventions such as off-loading devices, thermotherapy and electrotherapy are discussed. Although the exact etiology of DFUs is unclear, the emerging technologies discussed in this paper would enable clinicians to closely monitor the change of risk of DFUs and provide timely intervention. An integrated approach using all these emerging technologies should be promoted and may lead to a better outcome of preventing and managing DFUs.

Choosing an optimal headrest for preventing postoperative alopecia - A manikin study.

BACKGROUND: Postoperative alopecia is a rare complication after surgery. The etiology is thought to be pressure-induced hair follicles ischemia caused by prolonged immobilized head. Headrest is always used as head positioner during operation. The contact pressure between the head and headrest is believed to be related to the development of postoperative alopecia. The aim of this study was to find a headrest with the minimum contact pressure. METHODS: Five different materials headrests - folded sheet, foam donut, gel donut, natural latex, and memory foam were examined. The contact pressures between the manikin's head and tested headrests were continuously recorded for 4 h using CONFORMat System sensor. The average and peak pressures over the contact area were measured at 15 min, 30 min, 45 min, 1 h, 2 h, 3 h, and 4 h. A generalized estimating equations (GEEs) analysis and one way repeated measures ANOVA were used to assess the data. RESULTS: The memory foam headrest showed the lowest average and peak contact pressures over the contact area (p < 0.05), and the natural latex headrest, gel donut headrest, foam donut headrest, and folded sheet headrest revealed increase of the contact pressures in order. The peak contact pressure of the gel donut headrest at 4 h was significantly higher than that of at 15 min (p = 0.032) and 30 min (p = 0.037). CONCLUSION: Of the five headrests we examined, the memory foam headrest is suggested to be the best choice for surgical patients because of its lowest contact pressure.

Predicting mechanical restraint of psychiatric inpatients by applying machine learning on electronic health data.

OBJECTIVE: Mechanical restraint (MR) is used to prevent patients from harming themselves or others during inpatient treatment. The objective of this study was to investigate whether incident MR occurring in the first 3 days following admission could be predicted based on analysis of electronic health data available after the first hour of admission. METHODS: The dataset consisted of clinical notes from electronic health records from the Central Denmark Region and data from the Danish Health Registers from patients admitted to a psychiatric department in the period from 2011 to 2015. Supervised machine learning algorithms were trained on a randomly selected subset of the data and validated using an independent test dataset. RESULTS: A total of 5050 patients with 8869 admissions were included in the study. One hundred patients were mechanically restrained in the period between one hour and 3 days after the admission. A Random Forest algorithm predicted MR with an area under the curve of 0.87 (95% CI 0.79-0.93). At 94% specificity, the sensitivity was 56%. Among the ten strongest predictors, nine were derived from the clinical notes. CONCLUSIONS: These findings open for the development of an early warning system that may guide interventions to reduce the use of MR.

Physical Restraint Use in Adult Patients Presenting to a General Emergency Department.

STUDY OBJECTIVE: The prevalence of agitation among emergency department (ED) patients is increasing. Physical restraints are routinely used to prevent self-harm and to protect staff, but are associated with serious safety risks. To date, characterization of physical restraint use in the emergency setting has been limited. We thus aim to describe restraint patterns in the general ED to guide future investigation in the management of behavioral disorders. METHODS: We conducted a cross-sectional study of adult patients presenting to 5 adult EDs within a large regional health system for 2013 to 2015, and with a physical restraint order during their visit. We undertook descriptive analyses and cluster analysis to determine unique meaningful groups within our sample. RESULTS: In 956,153 total ED visits, 4,661 patients (0.5%) had associated restraint orders, representing 3,739 unique patients. The median age was 47 years (interquartile range 32 to 59 years), 66.7% of patients were men, 61.9% had a psychiatric history, and 91.1% arrived by ambulance. For chief complaints, 33.7% were alcohol or drug use, 45.4% medical, 12.3% psychiatric, and 8.5% trauma. Cluster analysis identified 2 distinct cohorts. A younger, predominantly male population presented with alcohol or drug use, whereas an older group arrived with medical complaints. CONCLUSION: Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED. Further characterization of causal links and safer practices to manage agitation for these vulnerable populations are needed.

Factors associated with pasung (physical restraint and confinement) of schizophrenia patients in Bogor regency, West Java Province, Indonesia 2017.

BACKGROUND: Schizophrenia is a chronic mental disorder affecting more than 21 million worldwide. In Indonesia, 14.3% of households have a patient with a mental disorder, and the majority of these are in rural areas. Family members in Indonesia use repressive social measures like pasung (physical restraint and confinement) for these patients. A study was conducted with the objective to determine the factors associated with pasung among patients with schizophrenia in Bogor Regency, West Java Province, Indonesia 2017. METHODS: A case-control study was conducted in Bogor Regency from May-June 2017. A case subject was defined as a patient with schizophrenia who was ever subjected to pasung and a control subject was defined as a patient with schizophrenia residing in the same geographical area and never subjected to pasung. Multi-stage sampling was used to select case and control subjects from the registered reports of the Health Service of Bogor Regency (2012-16) in 34 sub districts and 59 health centers. Multivariate logistic regression was used to identify the factors associated with pasung. Attributable and population attributable risks (AR, PAR) for pasung were calculated. RESULTS: A total of 114 case and 136 control subjects were studied. Patient's aggressive or violent behavior (AdjOR: 4.49, 95%CI: 2.52-8.0), unemployment (AdjOR: 2.74, 95%CI: 1.09-6.9) and informal employment (AdjOR: 2.5, 95%CI: 1.1-5.84) in the family and negative attitude of the family towards the patient (AdjOR: 2.52, 95%CI: 1.43-4.43) were associated with pasung. Patient's aggressive or violent behavior (PAR = 44.3%) and unemployment in the family (PAR = 49.3%) were the predominant factors of pasung. CONCLUSIONS: Patient's aggressive or violent behavior, negative attitude of the family towards the patient and unemployment in the family were associated with pasung. We recommend health education and encouraging family members to shift patients with schizophrenia exhibiting aggressive or violent behavior to a mental health facility. Strengthening of basic mental health services and involving family members while treating patients with schizophrenia to develop positive attitudes could be considered. Creating employment opportunities and a social support system for treated patients with schizophrenia and family members could further avert pasung.