EMERGENCY MEDICINE PRACTICE
A N E V I D E N C E - B A S E D A P P R O A C H TO E M E R G E N C Y M E D I C I N E
The Violent Patient: Clinical
Management, Use Of Physical
And Chemical Restraints,
And Medicolegal Concerns
Volume 1, Number 6
Louise W. Kao, MD
Methodist Hospital Emergency Medicine Residency,
Gregory P. Moore, MD
Associate Clinical Professor, Indiana University
School of Medicine; Attending Physician, Emergency
Medicine Residency, Methodist Hospital,
Andy Jagoda, MD, FACEP
Associate Professor of Emergency Medicine, Mount
Sinai School of Medicine, New York, NY.
Robert D. Pelicata, DO, MSc
Philadelphia College of Osteopathic Medicine,
Upon completing this article, you should be able to:
1. describe the epidemiology of violent behavior
in the ED.
2. list common organic etiologies associated
3. list common psychiatric diagnoses associated
4. describe de-escalation techniques.
5. describe important factors in successful
implementation of physical and
6. list indications and contraindications for
physical and chemical restraints.
7. discuss medicolegal concerns regarding
consent, duty, and third-party responsibility.
Date of original release: November 1, 1999.
Date of most recent review: October 29, 1999.
See “Physician CME Information” on back page.
Lecture Slide Show Framework for teaching by Dr/Adv Navin Naidoo
ADMINISTRATIVE PATHWAY: Refusal of consent in a Violent Patient.
CLINICAL PATHWAY: Management of the Violent Patient
CLINICAL PATHWAY: Diagnostic Testing of the Violent Patient
LECTURE FRAMEWORK FOR TEACHING- FREE TO USE FOR EDUCATION
Ice and the GP surgery: 4 Hrs Interactive
Emergency Department Management
Acute agitation is a common psychiatric emergency, manifesting in at least 10-25% of emergency psychiatric presentations and is frequently seen in all acute mental health settings and Emergency Departments. These presentations are associated with a high risk of harm to the patient and to others. Non-pharmacological interventions may not be successful or effective in a safe timeframe. Pharmacological agents, particularly Benzodiazepines and anti-psychotic agents, either alone or in combination are frequently used to treat acute agitation syndromes to minimise the risk of injury and to stabilise the clinical course. A practitioner has a duty of care to the affected patient to prevent them harming themselves, as well as a duty of care to others to prevent them being harmed by an aggressive, volatile patient.
Chemical Restraints- medication given primarily to control a person’s behaviour, not to treat a mental illness or physical condition.
Some medications that are used to reduce symptoms of physical conditions or medically identified major mental illnesses have side effects. This may include sedating the person to whom they are given.
The appropriate use of medications which have such side effects to reduce or manage symptoms of diagnosed anxiety, depression or psychosis is not chemical restraint.
Similarly, the prescription of medications to control the disordered behaviour of a person with an underlying medical condition such as a delirium or dementia is not chemical restraint.
Rather, chemical restraint occurs when medication is intentionally given to exert control over a patient’s movements or behaviour.
Chemical restraint may involve the administration of higher than usual doses of a person’s regular medication; or the administration of psychotropic medication (alone or in combination, whether given orally or by intramuscular or intravenous routes) to a person who does not have a diagnosed mental illness.
Whether or not the giving of medication constitutes chemical restraint will effectively depend on why the medical practitioner in question is giving the particular patient the medication that is being given, at the relevant time. Clinical factors which may be taken into account in determining this include:
The nature of the patient’s condition and whether the medication is being given to address symptoms of the patient’s condition, or for another reason. Whether or not the patient has been diagnosed with a mental illness and the nature of medication that would usually be given to address symptoms of the illness that has been diagnosed, may be of relevance, and
Whether the medication is given as the last step in a series of escalating interventions which have been tried without success or with limited success. 
The general intent and objectives of good clinical practice is the provision of treatment and care in the least restrictive setting in a manner consistent with the clinical needs of the patient and the safety and welfare of all persons involved with the patient.
While chemical restraint can provide safety and containment at a time when this is needed to protect involuntary patients, staff and others, it can also be a source of distress not only for the patient but also for support persons, representatives, other patients, staff and visitors.
Wherever possible, alternative, less restrictive ways of managing a patient’s behaviour should be used, and the use of chemical restraint minimised. This can be achieved through the adoption of a prevention and early intervention framework.
Prevention and early intervention practices rely on reducing the risk factors for aggression or violence as well as enhancing the protective factors that promote a safe, secure, understanding and accepting environment.
Mental health care and the environment in which it is delivered are intended to optimise the safety and wellbeing of patients. Prevention and early intervention activities are aimed at improving the overall experience of patients and include, for example, strategies aimed at building connectedness, inclusion and a sense of acceptance.
Appropriate prevention and early intervention strategies can assist to reduce the circumstances in which the need to chemically restrain a patient arise.
There is a greater chance of avoiding the need to use restrictive interventions when inpatient care involves patients, their representatives and support persons.
It should not be assumed that patients, or their representatives or support persons will be aware that the person may be chemically restrained while an involuntary inpatient in an approved hospital or approved assessment centre.
On admission of a person to an approved hospital or approved assessment centre, every effort should be made to provide information about restraint practices, particularly where the person has a history of, or potential for, aggression, or where there are concerns related to the safety of others. In practice
Staff should listen to concerns expressed by patients, and by their representatives and support persons about the use of chemical restraint and should provide information which may address concerns, and answers to any questions asked, whenever needed.
While it is appropriate to provide information to representatives and support persons in this way care should be taken to ensure that information which is specific to the patient and their restraint is provided to others only when the patient consents.
Right to privacy, safety and bodily integrity
Duty of care to patient and others
Care planning that takes into consideration individual patient needs, preferences and experiences of which interventions are most effective should occur in relation to restraint for all patients.
Restraint care planning should consider the patient’s primary diagnosis and involve an assessment of the patient’s clinical needs, treatment objectives and outcomes, management of any underlying conditions, appropriate communication with the patient about what behaviours are unacceptable, and incorporate the development of a written restraint management or safety plan for the issues identified. The plan should in particular address individual patient, staff and environmental triggers.
In circumstances where chemical restraint is likely to be necessary, planning should also consider the individual’s safety and care needs while being restrained, particularly for patients who are assessed as likely to present with acutely disturbed or aggressive behaviours, for those who require repeated episodes of restraint or where there is considered to be a need to restrain a patient who is extremely disturbed immediately after the patient’s arrival at an approved assessment centre or approved hospital.
Care planning should also involve:
• Identifying mental and physical health problems and risks, and how they are to be managed
• Determining the frequency and nature of clinical observations required to be performed. This may include physical (respiration, pallor or cyanosis, posture, level of consciousness, motor activity, blood pressure and pulse) and mental state (pattern and content of speech, thought content, mood, affect, concentration, attention and level of motor activity) observations
• Identifying the time and frequency of medical examinations required to be performed
• Identifying the patient’s bedding and clothing needs and how these are to be met
• Identifying the patent’s need to have access to communication or physical aids while being restrained and an indication of how these needs are to be managed
• Identifying the patient’s hygiene and toileting needs and making arrangements for these to be met
• Identifying the patient’s dietary needs and arranging for these to be met. At a minimum this should involve fluid being offered to the patient at least every two hours and food being offered at least every four hours, except overnight when this may not be desirable. It may be
appropriate for the patient to be supplied with a plastic cup and container of water. A fluid balance chart should be commenced for a patient who is likely to experience the effects of chemical restraint for more than four hours
• Establishing when the care plan itself should be reviewed.
Where chemical restraint involves medication being given in large doses or the giving of medication which is likely to be in effect some hours later, it is good clinical practice to obtain a second opinion or hold a case conference to review the patient’s management as soon as practicable.
Right to bodily integrity
Health Authorities Expectations
A patient for whom chemical restraint is considered to be necessary should be thoroughly medically assessed. This should occur either prior to, or as soon as possible after, a patient is chemically restrained.
Medical Fraternities Expectations
Particular emphasis should be placed on seeking a history of the presentation from the patient and their support persons, as well as other relevant/significant people. This should include information about the possible ingestion of alcohol, illicit drugs, over-the-counter medication and prescription medication that may have been ingested as overdose, deliberate or accidental. Information on medication prescribed should also be obtained.
The assessment should be as thorough as the circumstances allow and should include an assessment of the risk to the patient from deliberate or accidental self-harm.
Patients who repeatedly behave in a manner that threatens themselves or others and whose symptoms fail to respond to a full range of clinical interventions pose particular clinical challenges. Careful consideration and management may be required.
A thorough review of the patient’s history, treatments attempted and their duration, and doses of medication administered and the patient’s responses to these should be undertaken by the treating team, and may be the subject of a case conference. A second opinion external to the treating team may also be sought.
A restraint management or safety plan that is developed for the patient should describe the behaviour in question; should identify, wherever possible, the precipitating and exacerbating factors; and should suggest a graded series of responses. The plan should include strategies aimed at reducing the behaviour and the need for such restrictive interventions.
Advance Safety Plans for Chemical Restraint
For those who are at high risk of chemical restraint or who have been chemically restrained in the past, a collaborative advance safety plan for chemical restraint may be useful.
This should address patient concerns and vulnerabilities. For example, a patient with a history of a specific form of assault may become agitated where physical restraint that reminds them of this assault, is used. In other instances a patient may prefer oral rather than intramuscular medication when severely distressed.
Security staff involved in restraint procedures should be under the direct authority and supervision of the senior registered nurse on duty or medical practitioner present, at all stages of a patient’s restraint.
Any concerns about the individual practices of staff involved in these procedures should be escalated to a senior manager.
The patient’s written consent to the medication proposed to be given should be obtained, prior to it being administered. This should be accompanied by a written statement from the patient’s treating medical practitioner or a senior nurse on duty confirming the patient’s capacity to provide consent to the medication.
The principles outlined in this Guideline should be applied to the extent that they are relevant, to the giving of acute sedation to a patient with consent.
Should the behaviour of a voluntary patient meet the criteria for being chemically restrained, consideration should be given to whether the patient meets the assessment or treatment criteria with steps taken to obtaining an Assessment Order or Treatment Order if this is the case.
Once the decision has been made to use chemical restraint, careful assessment of the patient’s safety needs is essential, together with clinical monitoring, support and review.
Clinical Observation Requirements
Given the need for continuous observation of a patient who has been chemically restrained, a monitoring nurse must be stationed to sit with and clinically observe the patient who has been chemically restrained. This should involve:
Monitoring the patient’s vital signs including details of the patient’s pulse, respiration, blood pressure, posture, muscle tone, level of consciousness and comfort level, and
Mental status observation including the patient’s pattern and content of speech, attention, level of motor activity and orientation.
Particular emphasis should be placed on seeking the patient’s history at the first examination. This should include information about the possible ingestion of alcohol or illicit drugs, and of deliberate or accidental overdose of prescribed medications, and any history of suicide attempts by the patient, and involve:
• A review of the patient’s physical and mental health status, and
• An assessment of the adverse effects of medication, and
• A reassessment of the medication prescribed, and
• An assessment of the risk to the patient from deliberate or accidental self-harm, and
• An assessment of the potential or likely need for repeat application of chemical restraint.
Occasionally a patient whose mental state and reasoning is profoundly impaired by their illness is admitted to an inpatient unit. Patients in this state may be unable or unwilling to give coherent responses to questions and/or are aggressively opposed to being physically examined. While this makes adequate assessment difficult, as thorough an assessment of the patient as is possible should take place before any medication is administered.
Staff must be alert to the possibility that the patient who appears to be asleep may actually be unconscious. Where a patient appears to be asleep while under the effects of chemical restraint, clinical staff should be alert to and assess the level of consciousness and respirations of the patient to exclude the possibility of an altered level of consciousness or respiratory distress.
Communication with the Treating Team
A senior member of the treating team should be informed of a patient’s chemical restraint as soon as is reasonably practicable in order to inform ongoing management decisions associated with the patient.
Clear systems and processes should be in place to communicate to relevant clinical staff across successive shifts. In particular, details regarding the reasons for the use of chemical restraint, the current plan and previous treatments provided should be clearly communicated at handover points and be available in the clinical record. The clinical record should contain up-to-date documentation such as risk assessments, restraint management or safety plans, observation charts, medical reviews and communication with other parties - for example, support persons.
Post-Restraint Patient Support
Although chemical restraint may be used for sound clinical reasons, it is a potentially traumatic intervention that requires sensitivity and skill in its management.
Once the patient is settled and willing to discuss the incident leading to chemical restraint, the patient’s understanding and experience of the incident should be explored and the reasons restraint was used and other interventions deemed ineffective or inappropriate explained to the patient.
The patient should be allowed to discuss their experience of being chemically restrained and of any restraint reviews conducted.
Staff must be aware that the purpose of a post-restraint discussion with the patient is to provide an opportunity for the individual’s experience of the episode to be discussed. Attempts by staff to justify the decision to restrain may be counterproductive.
The patient should be given a choice as to who they would like to discuss their experience with, wherever possible.
Consideration should be given to the sensitive reintegration of the patient into the general inpatient population because patients might consider chemical restraint as embarrassing or humiliating.
Clinical staff members also need to be aware of how the patient and others in the inpatient unit are affected by the use of chemical restraint. Staff should offer information on chemical restraint to visitors and to other people (including other patients) who have witnessed the application of chemical restraint.
Documentation and Review
Following the cessation of a chemical restraint episode, a formal chemical restraint review meeting should occur as soon as possible. This should involve at least the unit manager, senior registered nurses and consultant psychiatrist.
Wherever possible, the patient and his or her carers and family members should be encouraged to participate in the relevant parts of the review process.
The aim of the review meeting is to:
• Review the chemical restraint episode including the lead up to the application of chemical restraint
• Identify preventative strategies trialled and the reasons for failure
• Review compliance with the Act
• Review system-wide management issues that may need addressing to prevent further chemical restraint episodes
• Consider what else might have been done to prevent or minimise the disturbed behaviour
• Update clinical risk assessments relating to the patient and the patient’s care plan.
Any systemic issues identified in the formal review are to be forwarded to the relevant safety and quality improvement committee for attention.
(1) Except if authorised under any other law, an involuntary patient who is not a forensic patient may be placed under restraint if, and only if –
(a) the patient is in an approved assessment centre or approved hospital; and
(b) the restraint is authorised as being necessary for a prescribed reason by –
(i) in the case of chemical or mechanical restraint, the CCP; or
(ii) in the case of physical restraint where the patient is a child, the CCP; or
(iii) in the case of physical restraint where the patient is not a child, the CCP, a medical practitioner or an approved nurse; and
(c) the person authorising the restraint is satisfied that it is a reasonable intervention in the circumstances; and
(d) the restraint lasts for no longer than authorised under this section; and
(e) the means of restraint employed in the specific case is, in the case of a mechanical restraint, approved in advance by the CCP; and
(f) the restraint is managed in accordance with any relevant CCP standing orders or clinical guidelines.
(2) If an involuntary patient who is not a forensic patient is placed under restraint under this section –
(a) the patient must be clinically observed by a member of the approved hospital's nursing staff at intervals not exceeding 15 minutes or at such different intervals as CCP standing orders may mandate; and
(b) the patient must be examined by a medical practitioner or approved nurse at intervals not exceeding 4 hours to see if the restraint should continue or be terminated; and
(c) the patient must also be examined by an approved medical practitioner at intervals, each of not more than 12 hours; and
(d) the restraint must not be applied beyond 7 hours unless –
(i) the patient has been examined by a medical practitioner within those 7 hours; and
(ii) the extension is authorised by the CCP within those 7 hours; and
(iii) if applicable, each subsequent extension (regardless of duration) is also authorised in advance by the CCP; and
(e) the CCP may impose conditions on any extension authorised under paragraph (d); and
(f) the CCP, on authorising an initial extension of the restraint, must stipulate the maximum timeframe for its continuance; and
(g) the patient must be provided with –
(i) suitable clean clothing and bedding; and
(ii) adequate sustenance; and
(iii) adequate toilet and sanitary arrangements; and
(iv) adequate ventilation and light; and
(v) a means of summoning aid; and
(h) the administration of any prescribed medications to the patient must not be unreasonably denied or delayed; and
(i) the patient must not be deprived of physical aids except as may be strictly necessary for the patient's safety or the preservation of those physical aids for the patient's future use; and
(a) the patient must not be deprived of any communication aid that the patient uses in communicating on a daily basis, except as may be strictly necessary for the patient’s safety or the preservation of the communication aid for the patient’s future use; and
(j) regardless of authorisation, the restraint must not be maintained to the obvious detriment of the patient's mental or physical health.
(3) Nothing in this section is to be taken as conferring any kind of authority for a patient to be placed under restraint as a means of punishment or for reasons of administrative or staff convenience.
(4) However, nothing in this section applies to or prevents the emergency short-term physical restraint of a patient, subject to and in accordance with relevant CCP standing orders or clinical guidelines, so as to –
(a) prevent the patient from harming himself or herself or others; or
(b) prevent the patient from damaging, or interfering with the operation of, a facility or any equipment; or
(c) break up a dispute or affray involving the patient; or
(d) ensure, if he or she is uncooperative, the patient's movement to or attendance at any place for a lawful purpose.
(5)Notwithstanding the discretionary nature of the power under section 152(1), the CCP must ensure that standing orders are issued for this section.
(6)In this section–
prescribed reason, for placing a patient under restraint, means –
(a) to facilitate the patient's treatment; or
(b) to ensure the patient's health or safety; or
(c) to ensure the safety of other persons; or
(d) to effect the patient's transfer to another facility, whether in this State or elsewhere.
Note 1: The restraint of an involuntary patient is reviewable by the Tribunal – see Division 2 of Part 3 of Chapter 3.
Note 2: The CCP has power to intervene in such circumstances – see section 147.
58. Records, &c.
(1) This section applies if an involuntary patient who is not a forensic patient is placed in seclusion or under restraint under this Part.
(2) The person who authorises the seclusion or restraint is to –
(a) make an appropriate record of the matter; and
(a) give a copy of the record to the patient, together with a statement of rights in a CCP approved form; and
(b) give a copy of the record to the CCP and the Tribunal; and
(c) place a copy of the record on the patient's clinical record.
(3) The CCP or Tribunal, by notice, may require the treating medical practitioner to provide further information about the matter within a required time and the treating medical practitioner is to comply with that requirement.
1. The mental health service delivery principles are as follows:
(a) to respect, observe and promote the inherent rights, liberty, dignity, autonomy and self-respect of persons with mental illness;
(b) to interfere with or restrict the rights of persons with mental illness in the least restrictive way and to the least extent consistent with the protection of those persons, the protection of the public and the proper delivery of the relevant service;
(c) to provide a service that is comprehensive, accessible, inclusive, equitable and free from stigma;
(d) to be sensitive and responsive to individual needs (whether as to culture, language, age, religion, gender or other factors);
(e) to emphasise and value promotion, prevention and early detection and intervention;
(f) to seek to bring about the best therapeutic outcomes and promote patient recovery;
(g) to provide services that are consistent with patient treatment plans;
(h) to recognise the difficulty, importance and value of the role played by families, and support persons, of persons with mental illness;
(i) to recognise, observe and promote the rights, welfare and safety of the children and other dependants of persons with mental illness;
(j) to promote the ability of persons with mental illness to make their own choices;
(k) to involve persons receiving services, and where appropriate their families and support persons, in decision-making;
(l) to recognise families, and support persons, of persons with mental illness as partners, with mental health service providers, in the provision of their treatment and care to the extent that this is appropriate and consistent with their own wishes;
(m) to respect the wishes of persons receiving services, and the wishes of their families and support persons, to the maximum extent consistent with the health and safety of those persons and the safety of others;
(n) to promote and enable persons with mental illness to live, work and participate in their own community;
(o) to operate so as to raise community awareness and understanding of mental illness and to foster community-wide respect for the inherent rights, liberty, dignity, autonomy and self-respect of persons with mental illness;
(p) to be accountable;
(q) to recognise and be responsive to national and international clinical, technical and human rights trends, developments and advances.
Australian Case Law Applicable currently
Consequences For Practitioners
Sanctity of the Law
“Hearsay” and how it applies in Law
Indemnification and the lack thereof
1) Understand the effect acute intoxications have on emergency departments and GP surgeries.
2) Understand the legal implications involved in the management of acute intoxications
3) Understand the consequences for practitioners in the management of acute intoxications.
Interface between Medicine and the law: 2 Hrs Interactive
Patient Complaints- Administrative Authority- AHPRA
Breach of Confidentiality
Assault- Lack of Consent
LEARNING OUTCOMES SUMMARIZED
1) Identify the areas where medicine and the law interface.
2) Understand how complaints are managed and the role of various quasi-judicial bodies in such management.
3) Understand the various sanctions that can be applied against doctors through conduct in practice.
4) Understand the ambit and implications of making a statutory notification against a fellow practitioner.
5) Understand the processes and procedures of a coronial inquest
6) Understand the differences between civil litigation and criminal sanction.
7) Understand the impact that complaints have on a doctors insurability and career.
Conflicting duties 1 Hr Interactive
Duty of care vs Right to Bodily Integrity
1) Understand the concept of duty of care and its applicability to a doctors practice.
2) Understand the fundamental right to bodily integrity and how such is protected by law.
3) Understand how the practice of medicine can conflict with the right to bodily integrity
4) Understand how consent applies as a legal defence
Protecting the Practitioner 2 Hrs Interactive
Value of civil suit
Negligent follow up
Causation of loss
Proximity of Damage
1) Understand the concept of emergency situation and the protections it affords practitioners.
2) Understand the concept of consent and how it applies as a defence in law
3) Understand how and when witnesses can be called in defence.
4) Understand the economics of civil litigation and how this impacts on practitioners.
5) Understand how damages are assessed and awarded in civil litigation.
6) Understand how error and negligence is determined in civil litigation.
7) Understand the concepts of causation and proximity of damage in the quantification of claims.
 Chief Civil Psychiatrist Clinical Guideline 10 Tasmania 2014