Jacob Theresa, Sahu Geetanjali, Frankel Violina, Homel Peter, Berman Bonnie, McAfee Scot
Department of Psychiatry, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY, 11219, USA.
Psychiatr Q. 2016 Mar;87(1):31-48. doi: 10.1007/s11126-015-9353-7.
Restraint use in psychiatry has been a topic of clinical and ethical debate for years. As much as the medical community desires to attain the goal of a restraint-free environment, there are not many alternatives available when it comes to protecting the safety of violent patients and those around them. Our objective was to examine patterns of restraint use and analyze the factors leading to its use in adult psychiatric inpatient units. We conducted a retrospective review of restraint orders from January 2007 to December 2012, for inpatient units at a community mental health hospital, examining-unit, patient gender, number and duration of restraint episodes, time of day, and whether medications and/or verbal redirection were used. For the 6-year period studied, a total of 1753 restraint order-sheets were filed for 455 patients. Mixed-model regression found significant differences in duration of restraint episodes depending on: patient gender, unit, medication use, verbal redirection and AM/PM shifts. These differences were consistent over time with no significant interactions with years and remained significant when included together in an overall multivariate model. We elucidate variable patterns of restraint utilization correlating with elements such as patient gender, time of day and staff shift, medication use, and attempts at verbally redirecting the patient. Besides providing much needed data on the intricate dynamics influencing restraint use, we suggest steps to implement hospital-wide restraint-reduction initiatives including cultural changes related to restraint usage, enhanced staff-training in conflict de-escalation techniques and personalized treatment plans for foreseeable restraint episodes.
多年来，精神病学中约束措施的使用一直是临床和伦理辩论的话题。尽管医学界渴望实现无约束环境的目标，但在保护暴力患者及其周围人员的安全方面，可用的替代方法并不多。我们的目标是研究约束措施的使用模式，并分析导致其在成人精神科住院病房使用的因素。我们对一家社区精神卫生医院住院病房2007年1月至2012年12月期间的约束令进行了回顾性审查，审查内容包括病房、患者性别、约束发作的次数和持续时间、一天中的时间，以及是否使用了药物和/或言语引导。在研究的6年期间，共为455名患者提交了1753份约束令记录。混合模型回归发现，约束发作的持续时间存在显著差异，具体取决于：患者性别、病房、药物使用、言语引导以及上午/下午班次。这些差异随时间保持一致，与年份无显著交互作用，并且在纳入总体多变量模型时仍然显著。我们阐明了与患者性别、一天中的时间、工作人员班次、药物使用以及言语引导患者的尝试等因素相关的约束使用的可变模式。除了提供关于影响约束使用的复杂动态的急需数据外，我们还建议采取措施实施全院范围内的减少约束倡议，包括与约束使用相关的文化变革、加强工作人员在冲突降级技术方面的培训以及针对可预见的约束发作制定个性化治疗计划。
