The recent events at Chicago's Mercy Hospital bring into sharp focus the need to understand the risk factors associated with violence in the emergency department, how to prevent it from happening, when possible, and active measures ED staff can take should a violent outbreak occur. 

That's the reason we created this 3-part blog post series called Violence in the ED. 

The first part looked at the growing trend in violent incidents and outlined the associated risk factors; part two listed steps to ensure a safer work environment.

In this, the third and final installment, we discuss what we call the "art of the takedown" and outline the proper procedures to follow, and techniques to apply in managing a patient who is acutely agitated, violent, or psychotic.

Physical Restraints

The use of physical restraints, while controversial, is sometimes necessary to keep a violent episode in check.

Before applying restraints, always try verbal de-escalation first, but go ahead and prepare for physical restraint or, if deemed necessary, chemical sedation as well. Always remember that it is just as critical to safeguard the wellbeing of your staff as it is to restrain the patient.

The steps to proper physical restraint are as follows:

DOs

  • Activate the appropriate code to assemble the team;
  • Use personal protective equipment, including gloves, gowns, and facemasks;
  • Remove all objects that are potentially hazardous (i.e., pens, stethoscopes, glasses, reflex hammers, ID badges, etc.)
  • Brief the team on the indication, size of the patient, and any specific risks they may encounter; 
  • Allocate roles and state the plan of action;
  • Decide on a trigger word to use to initiate action;
  • Give the patient a final chance to comply with requests from the restraint team.

DON'Ts

  • Do not confront the patient, get into a power struggle, roll your eyes, interrupt the patient, appear frustrated, or make a promise you can’t deliver;
  • Do not attempt a restraint unless you have six trained staff ready to assist;
  • Avoid neck or torso restraint (unsafe for the patient) or hobble restraints (i.e., tying hands and legs behind back).

Proper Techniques to Restrain a Patient

Use the following techniques when left with no other option but to restrain the patient physically and/or chemically:

  • Restrain the limbs with one arm above and one arm below the knee;
  • Have one person for each limb;
  • One person with airway skills controls the head;
  • One person administers pre-prepared medications;
  • With the patient supine, apply restraints securely to each extremity;
  • Use medical grade restraints secured to the bed frame (NOT side rails);
  • Always explain to the patient what is happening.

This video, from the University of Tennessee Medical Center, vividly illustrates the proper techniques to use when restraining a patient: 

YouTube Video

Restraint Documentation

In your documentation, explain the reason for the restraint and list any alternative therapies you attempted as well as an assessment of potential injuries or complications. Also, describe your monitoring plan, thresholds for further interventions, and ongoing sedation options and a sedation chart.

Chemical Restraints

The use of chemical restraints is a staple of major importance in the ED physician’s arsenal against violence in the ED. It is important that the medication properly fit the etiology of the violence-inducing illness. Ketamine has shown to be a useful tool in non-schizophrenic patients and has the quickest onset of action. When combined with a calming medication, Ketamine can reduce the danger in a matter of a few minutes. The following table lists common medications used by illness etiology.

Chemical Restraints_Common Medications Used by Illness Etiology

Most importantly, it is pivotal that patients receiving chemical sedation get the appropriate monitoring to avoid harm from the treatment. 

Key Takeaways

ED patients who are agitated, violent, or psychotic and not only a danger to themselves but also those around them. The takedown can be a useful way to manage violent episodes when properly applied by the appropriate number of well-equipped, trained staff.

The key to violence prevention, particularly as it applies to physical or chemical restraint, is preparation. That includes proper training, having adequate supplies, and plenty of staff available to assist.

Make it an imperative that you will not physically restrain a patient without appropriate support (the six-person minimum).

Use chemical restraint when necessary but only when it's safe to do so and choose the best option possible given the patient’s disposition. Then, carefully monitor chemical sedation to ensure the patient's wellbeing.

This post was written as part of a 3-part blog post series called Violence in the ED. 
Part 1: Violence in the Emergency Department Is On the Rise, But Why?
Part 2: Violence in the Emergency Department: 7 Steps to Ensure a Safer Workplace