Once the decision to restrain a patient is made, appropriate personnel must be assembled. At least four to five people with a single team leader should be present. On the command of this leader, the procedure is carried out without undue force or harm to the patient or staff. Soft restraints should never be used on a truly violent patient, and once the patient is restrained the devices should not be removed except under the order of the treating physician, with the assent of the other health care providers, and with security personnel present. It is important that one explain the reason for restraint to the patient. Once restrained, the patient should not be abandoned.
Strict protocols for the use of restraints should be available in every emergency department. They should incorporate input not only from emergency department staff but from security, law enforcement, hospital legal departments, and, if possible, psychiatric services in order to present a consistent, lawful approach to the use of restraints. Once the protocol is developed, in-service meetings should be arranged to familiarize and train all emergency department personnel in the use of restraints.
Medicolegal issues are part of any restraining procedure. It is law that the minimal use of force be used to hold a violent patient. 8 The presence of security may be the only restraint needed. Anytime a person is placed in restraints, the medical chart should reflect the reason the patient was restrained. The chart should state clearly that a direct physician order is required to remove a restraint. No patient for whom restraints are needed should be allowed to leave the emergency department against medical advice. If necessary, contacting hospital legal authorities may be helpful. In general, restraining a patient against his or her will is preferable to facing the legal issues that arise when patients harm themselves or someone else in the emergency department and the threat of violence was clearly evident.
Restraining also allows the patient to be searched for weapons or drugs, although that is never the primary motivation. Searching can often be accomplished by simply asking the patient to allow such a search or by deferring to security personnel. The best search is done by undressing the patient. Emergency department staff should not attempt to take weapons from a patient without assistance; if weapons are obtained, they should never be returned, despite the patient's insistence.
Those who come to the emergency department in restraints should be left in restraints. Yet law enforcement officials often bring patients in handcuffs to the emergency department only to give them a summons and release them once treatment has begun. No person should be released from law enforcement personnel in the emergency department. If initial plans were to release the patients (the perpetrators), they should not have been brought to the emergency department, especially those refusing any type of care. Law enforcement officers should not be allowed to leave a patient unattended in the emergency department if physical restraint was needed earlier. Furthermore, prisoners in the emergency department should never be released from restraints; many an escape has taken place from a hospital setting.
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