On October 4 and 5, the Helen Hayes Hospital Traumatic Brain Injury Service will be hosting its second symposium on managing trauma, restoring function and re-entry into the community. One hour of this conference will discuss “managing agitation and aggression in a restraint free environment,” to be presented by this author along with the Nurse Manager of the TBI Unit. Before discussing the relevance and importance of this subject, I want to share a story from my past that speaks directly to the topic.
Thirty-two years ago, I was working as a mental health worker on an acute psychiatric inpatient unit. One Saturday afternoon, a man admitted the previous night, who was intoxicated on a mix of drugs and alcohol including cocaine and PCP as well as others, had picked up a couch that usually took three or four of us mental health workers to move. Holding it over his head, he was running towards the double glass doors in the back of the unit, planning to use it as a battering ram to escape from the hospital. Thankfully, he began to list to one side and the weight tipped him and the couch over.
He then used some chairs and tables to barricade himself in a corner and began to break off the legs of the chairs and was trying to sharpen the ends of the legs on the cinder block walls. There were three of us mental health workers on the unit that day and the nurses told us to bring the patient up to the seclusion room from the back of the unit where he was barricaded.
Seeing the strength and violence of the patient, the nurses agreed to call the Sheriff’s Office and shortly, seven very large deputies, wearing tall hats that made them look even larger and more intimidating, arrived on the unit. With our “back-ups” in place, we three mental health workers along with the seven Sheriff’s deputies walked together to confront the patient. He saw us coming. I could see him scanning the group. He stood up, dropped the chair leg he was sharpening and said, “so, where do you want me to go?”
Despite the humor of the above story, the issue of using physical restraints to control agitation or aggression in any patient is no laughing matter. Physical restraints have contributed to physical injuries and death, as well as to emotional trauma to patients and their loved ones. There are many techniques and strategies that can be learned that in essentially all situations can obviate the need for physical restraint. Helen Hayes Hospital became a physical restraint free organization over 15 years ago, long before the Joint Commission on the Accreditation of Hospitals and the National Patient Safety Goals for Hospitals made the use of restraints an issue in hospitals and nursing homes. There are many good reasons for not using physical restraints, but the decision to practice in a restraint free environment creates a number of issues. When treating patients with brain injury, agitation and aggression are to be expected in some percentage of patients, though not all. On the macro level, the institution and the unit must be committed to a safety first philosophy in which the safety of the patients and of the staff is paramount. The institution must be committed to adequate staffing when agitation or aggression necessitates one to one or even two to one supervision.
There must also be a commitment to provide on-going education to staff members in assessment of factors contributing to the agitation or aggression, skills and techniques for calming and soothing, for de-stressing the environment, for standing and walking safely with an ambulatory patient, for using voice and body language to de-escalate an agitated patient and many other management strategies. Staff must be well versed in the use of medications that can be helpful in an acute crisis as well as in managing a more chronic irritability and agitation. Distraction, keeping busy, having recreational opportunities available are additional tools to be used for managing unwanted behaviors. Staff must be given sufficient training and education such that they are comfortable in the face of agitation and aggression and able to not present their fear to the patient. It is important that patients’ feel that staff are competent and in control and not afraid as these characteristics help the patient feel safe and less agitated.
There is actually much more to talk about but I think it best that you come to the symposium and hear the talk in person. We look forward to seeing you in October!
Bruce Lowenstein, PsyD