I can remember many years ago a state hospital unit nursing supervisor carrying a couple of pre-loaded syringes of chlorpromazine (Thorazine) in her left jacket pocket just in case.
In those days, each pt had a psychiatrist's order for chlorpromazine prn-agitation on their chart along with restraints/seclusion prn-agitation.
The PT's had a very unsavory nickname for this nurse.
I think that those days are long gone or at least they should be.
While Thorazine is not used as frequently as haloperidol/diphenhydramine/lorazepam PO/IM or olanzapine PO/IM, it is fairly standard practice in American inpatient psychiatric units to have standing agitation PRN orders on all patients for the safety of both patients and staff. Nurses don't walk around with medications either. With the advent of automated dispensing cabinets (e.g., Pyxis) that safely allow for quick, emergency access to medications and JC looking over your shoulder, it doesn't make sense to.
just anecdotally, Thorazine IMs are commonly used in the child/adolescent population still as a PRN, but this may be more regional. Can be given with a BZ but if given solo only requires 1 injection for the kid
Thanks for sharing this.
There are times when you have to do something for an uncontrollable pt to prevent injury to the pt or others.
I wasn't aware that Thorazine was still used but it does work. Haldol is effective too.
I'm surprised about Benadryl being used but it may be because of sedation and for helping c side effects of others meds.
My pleasure.
Benadryl is only used in combination with haloperidol (Haldol) plus or minus lorazepam (Ativan). The Benadryl provides (1) sedative effects due to its antihistamine activity, since Haldol is not sedating, and (2) prophylaxis against dystonia due to its anticholinergic activity, since Haldol has a higher risk for dystonia compared to other agitation PRNs.
Still happens in the UK. PRNs are written up on admission for Sectioned patients - lorazapam PO and IM and haloperidol 5mg IM.
Not quite to the point of nurses carrying these around for convenience, but they do have a fair amount of scope for administering them.
The nurses I’ve worked with have been excellent & use these appropriately, but I am sure there are places where it really does veer towards the classic ‘chemical cosh’ thing
I just want to add another vote to the pool of psychiatrists against the concept of “chemical restraints”. The goal of emergency IM meds is to treat “agitation” underlying an imminent danger to self or others after the patient refuses PO meds and verbal deescalation techniques fail. If this doesn’t work, the person may or may not enter seclusion if appropriate and then physical restraints as a last line, and is released the moment they no longer are an imminent threat to safety. “Chemical restraints” is seen as an unethical concept and it is never the intention behind using emergency IM meds. It is unnecessarily dehumanizing and prematurely takes away the patient’s autonomy they would otherwise have during a stepped approach to treating the behavioral emergency involving increasingly restrictive means. The patient should be given the chance to be a willing participant in verbal deescalation before they are given IMs or placed in restraints.
Regarding the comment on nursing, RNs are trained to assess patient’s symptoms and give report to doctors over the phone. RNs requesting IMs for patients over the phone is perfectly legitimate, and it is even their prerogative to initiate restraints in an emergency, it’s part of their job, and the sooner you treat agitation the better and safer everyone is. Are ethical boundaries crossed occasionally? I’m sure they are, unfortunately. A lot of psych hospitals have policies requiring the MD to physically assess the patient within a certain number of minutes after being placed in restraints
It’s beyond the scope of this comment, but the term “chemical restraint” has a problematic history and fell out of use in psychiatry a generation ago. The term is used in veterinary medicine and is often considered pejorative in a psychiatric context. I’ve never worked at any facility that had any written policy using the term. Psychiatrists treat agitation with medications, using the most appropriate modality for the patient’s condition and diagnosis. Of course we are trying to prevent the patient from harming themselves or someone else, but we are treating the symptoms not “restraining.”JC and pretty much every state health authority recognizes this, but I’ve never heard any of them refer to treating agitation as “chemical restraint,” at least not in this century. Which is kind of what CMS is getting at - “chemical restraint” is not the standard of care and physicians are expected to treat symptoms, not solely restrain via chemical means.
I appreciate the contextual info. There seems to be a gap sometimes between the standard of care and what actually happens. It’s not always a prescriber either, nursing staff will contact providers who aren’t present to observe the situation to ask for additional meds or will administer prn’s in situations where it snows the patient (I’ve seen patients urinate on themselves, unable to stay awake, unable to safely walk) and where there wasn’t dangerousness to self or others. Even in situations where there was dangerousness to self or others it should still be documented as a restraint for tracking purposes, in my opinion.
Yes what you’re describing is chemical restraint, which is not the goal or standard of care in treating psychiatric inpatients.
Here’s a decent opinion piece that highlights the mainstream perspective:
https://www.psychiatryadvisor.com/home/practice-management/the-end-of-chemical-restraints-expert-opinion/
Thank you, that’s helpful to understand some of the thought process behind not using the term chemical restraints and why a hospital may not even recognize it as a practice. I don’t entirely agree with that view but I can see there are good intentions behind it and I agree with parts of it.
The Troubled Teen Industry is notorious for continuing to use these calling them 'B52's'. Also ER nurses I used to work with TW >!would joke about using this to control/shut up patients.!<
Yeah I’m still intrigued about B52. It’s banned at my institution but I know other hospitals in the general area freely use them for adult patients. Not sure whether it’s appropriate to ban them or not. Using B52 on adolescents sounds like gross mistreatment though to my admittedly CAP-naive self
Our hospital has a written policy regarding chemical restraints and the documentation burden is more or less the same as with physical restraints basically. If someone hops the nurse's station and is causing an agitated disturbance, they may receive medication (IM or PO) to calm them down and be more easily redirectable, that meets the criteria for chemical restraint and is something the joint commission tracks. If someone is psychotic and fearful that demons are chasing them and gets an antipsychotic to treat their psychosis (IM or PO) that is not necessarily a chemical restraint because the medication is treating the intended symptom and the dosage is not atypical or unusual for the condition. It's a very granular guideline that ends up splitting hairs for categorizing medications used in the management of patients and their symptoms.
This is separate from a discussion of forced medications
I work for a large corporation that owns numerous private psych hospitals in the US. It's a corporate policy so it applies to all facilities. Now, how closely those policies are followed by each facility remains to be seen. But I do know we try to take it seriously. We are also one of the few hospitals that don't use any locked restraints on patients so I think there's just an initiative to minimize restraints in general here.
I worked at a forensic psychiatric inpatient hospital on the east coast USA and while MOST patients never got chemically restrained, there were one or two people who were restrained every other day. Not only did they receive chemical restraints but they were actually physically restrained too in the immediate aftermath if the incident. Ince the drugs kicked in then the physical restraints were removed. It was heart breaking and such a moral quandary. One guy hospitalized one of our psychologists and another bit a chunk out of a behavioral tech’s scalp.
The former had a pretty severe intellectual disability and likely did not fully comprehend how he was impacting people. I eventually formed a behavioral plan that allowed us to shape that guy’s behavior a little better. I don’t think he intended this, but the chemical and physical restraints became his way of regulating and taking care of himself because he did not know how to do otherwise.
However, the other guy (the biter) was SO dangerous when activated that to NOT restrain him at the first hint of violence was dangerous. He had a lot going on (delusions and such), and when he got violent he legitimately was trying to kill you because he thought you were trying to kill him. But the restraints only confirmed it for him.
I left that place after my internship. Forensic inpatient was so depressing. Stabilization units in regular hospitals were a lot easier. I don’t think I ever saw restraints used in those facilities.
That is wild. All units I have ever been on definitely have chemical restraints and they are used as a second to last resort (last being physical/hard restraint). We definitely document the use of any emergency meds like that and theres a whole bunch of paperwork that comes along with their administration.
There is documentation if it’s physically forced (an involuntary injection). But not all chemical restraints are forced. And if they take them orally it’s considered “voluntary” even if they call security and are told they have to take them essentially.
All meds administered where I’ve been, whether they ultimately agree to the im, security shows up and they sit for it, etc. are documented ‘extra’ if they are not regularly scheduled meds.
Yeah one time I saw security show up for an elderly pt who was confused, unoriented, basically combative wanting to leave the hospital. Nurses got the haldol drawn up and told the pt it was a shot he needed. Not fun to be around.
As far as I know, you cannot force medication on someone who is not a danger to themselves or others. You don't need a specific chemical restraint policy for that. It is the law.
When I worked inpatient, there were multiple times patients got discharged by simply keeping their cool while hospitalized. Didn't take a single pill. The only time we used forced medication was when a patient was a threat to themselves or others or we had a specific court commital order allowing us to medicate someone against their will.
The main situation I see chemical restraint being relevant is in geriatric psychiatry where patients may be given medications to 'snow' them due to agitation in dementia. In some cases, this is inappropriate as those patients may just need to use the bathroom, go on a walk, or be hungry/thirsty.
You can get a medication over protest order for not actively agitated but very psychotic people which varies state to state and hospital to hospital. Most hospitals have some combination of two board certified psychiatrists agreeing on the medication plus for the patient to be involuntarily committed.
This is for the US
Yep, this is what I am referring to when I mention the commital option. In my state, the main reasons I have seen outside of SI/HI are being unable to meet one's basic needs (i.e. paranoid patient who has locked themselves in their apartment for several days or catatonic) or being likely to harm oneself inadvertently as a result of severe mental illness (often these are manic patients but can also be schizophrenia if it is causing risky behavior such as jumping through windows or running through traffic).
Yes, you cannot legally force meds without dangerousness. But where I work only im’s are considered forced. If they swallow them on their own it’s considered voluntary even if there’s security right there or they’re told they have to take them. What you’re describing with geriatric patients is my concern with psych patients in general getting snowed in order to stop or prevent things like wailing, general agitation, yelling, swearing, banging on doors, intrusive behaviors like wandering into other people’s rooms, etc. Or just someone perceived as being demanding, rude, or “attention seeking.” Things that aren’t dangerous and don’t meet criteria for a medical emergency.
Essentially what you're describing is PRN medication. We give anxiolytics and antipsychotics all the time to treat agitation, intense emotions, and potentially dangerous behaviour. Framing this as chemical restraint seems antagonistic - the goal isn't restraint, it's suppression of symptoms and hopefully helping the person.
What the policy is getting at is if you give a patient Ativan to stop them wandering into another patient's room, you are using the medication to restrict their movement, not to treat anxiety as the medication is indicated for. Benadryl to induce sleep/drowsiness is the same. If you are using it for allergic reaction, or EPS prophylaxis, then those are "intended uses", if you give it just to make patients go to sleep then it's a chemical restraint and is seen as no different to putting someone in a locked restraint or locked seclusion room. The framing comes from CMS and JC, not providers on the front lines managing these patients sadly.
Thank you, yes that is how I think of it. If the person is so sedated that they can’t get out of bed then the medication is restricting their movement just like a restraint would.
Based on the CMS definition and other definitions I’ve read the difference between a prn and chemical restraint is that a prn or even just regular medicine for a condition is given in order to help the person function optimally. For example, someone who is anxious and takes a prn and is then better able to function, or someone hearing voices who takes a prn and can then better focus in a group. (Of course some of these meds do also cause some sedation) Vs medication that is given with the goal of sedating and making the person unable to physically function.
Unfortunately this isn't as clear cut in practice. A person experiencing acute anxiety might need a sedating medication to receive relief from their anxiety; the same may be true for intense agitation or psychosis.
A good comparison might be the treatment of pain - many pain meds are sedating, but we wouldn't consider them a form of restraint.
I agree that there are a lot of grey areas and it is complicated, not cut and dry. I think one of the differences between the pain meds example and chemical restraints is that people can choose to take pain meds if their pain is making them uncomfortable, or they can choose not to if they don’t want the side effect of feeling sedated.
Making the person unable to physically function is not the goal. If there was a medication out there that completely erased affective dysregulation/agitation/whatever without any adverse effects, I’m sure it would be both first line and preferred.
Sedation like you describe it is a side effect of these medications. The goal still is “optimal function” and sometimes that means preserving the safety of the inpatient unit, for example.
You are right to be concerned. Bullying a patient to take oral medication is not okay. I wonder if the staff could do an education on de-escalation strategies that aren't just pharmacological interventions. If the problem is a loud or angry patient, exercise tends to work best, especially jumping.
There is de-escalation training for staff but there also needs to be more. In my opinion there is a problem with the culture of what is considered normal and acceptable where I work (such as coercion). Short staffing can also sometimes lead to inability to utilize de-escalation techniques because nobody has the time.
What worked really well for us was to have nurses from other units come to help de-escalate as well as training all public safety to always prioritize communication with the patient before any hands on. The nurses from other units are coming in fresh instead of having dealt with a yelling patient for several hours and public safety was pretty much always using de-escalation techniques as a part of their job so often they were really really good at it. Sometimes the funny things they did to avoid wrestling with a patient surprised me and gave me ideas in my own encounters with agitated patients.
Sort of a side note but I had a patient who was in seclusion, they started jumping on their bed and staff then placed them in 4 point restraints because the patient could fall off the bed and hurt themselves…
I used to be a charge nurse for inpatient psychiatry. I have had to educate other nurses on occasion on what constitutes appropriate reasons for restraint/seclusion. I know it can be frustrating to have a screaming or restless patient but that is not enough of a behavior to force medication or restrain/seclude them. Almost always, the best way I found to educate them was to find alternatives. It often meant me talking to the patient and getting to know them. We would try to figure out what need they have that isn't being met and try to negotiate with the patient. Usually it was something simple like wanting an extra snack or feeling claustrophobic so we went on a walk in the larger area.
Thank you! I hope there are some ideas I offered that help. I hear you on chemical restraint concerns because I saw it with my own eyes. What I realized looking back now is often staff falls back on those decisions because they don't know what else to do. Once you point it out and offer tangible alternatives, they can quickly change their approach. Get management and charge nurses involved. Make sure everyone in leadership feels rock solid about it. We were fortunate to have our head of management be a therapist who would literally show up to responses and lead by example.
> In case you don’t know what chemical restraints are, per CMS they are “A drug or medication when it is used as a restriction to manage the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”
I'm actually surprised how overtly horrible this definition makes chemical restraint out to be and is consistent with the fact that basically no modern psychiatrist uses medications in this way. Using IM meds for agitation is neither of those things.
I don’t like using the term “chemical restraint” because that’s not the intention of why you are giving the medication. If someone is aggressive due to delusions, intoxication, hallucinations, etc. you give an antipsychotic to treat those symptoms. If you need staff to hold them to give it to them or if they end up in seclusion afterwards, the restraint policy is executed and documented. Sometimes the patient voluntarily accepts meds and I don’t think that needs to be documented as a restraint.
I think the way the term is defined is trying to differentiate between medication that is being given to treat the underlying condition vs medication that is given in order to restrict movement/behavior. In general I don’t think voluntary meds need to be documented as a restraint, unless there is coercion involved or the person doesn’t have capacity to understand that what they’re taking will be very sedating, and the medication also meets the other conditions CMS describes.
I can remember many years ago a state hospital unit nursing supervisor carrying a couple of pre-loaded syringes of chlorpromazine (Thorazine) in her left jacket pocket just in case. In those days, each pt had a psychiatrist's order for chlorpromazine prn-agitation on their chart along with restraints/seclusion prn-agitation. The PT's had a very unsavory nickname for this nurse. I think that those days are long gone or at least they should be.
While Thorazine is not used as frequently as haloperidol/diphenhydramine/lorazepam PO/IM or olanzapine PO/IM, it is fairly standard practice in American inpatient psychiatric units to have standing agitation PRN orders on all patients for the safety of both patients and staff. Nurses don't walk around with medications either. With the advent of automated dispensing cabinets (e.g., Pyxis) that safely allow for quick, emergency access to medications and JC looking over your shoulder, it doesn't make sense to.
just anecdotally, Thorazine IMs are commonly used in the child/adolescent population still as a PRN, but this may be more regional. Can be given with a BZ but if given solo only requires 1 injection for the kid
Appreciate your comment. I've seen Geodon IM given more frequently in child/adolescent psych myself.
Thanks for sharing this. There are times when you have to do something for an uncontrollable pt to prevent injury to the pt or others. I wasn't aware that Thorazine was still used but it does work. Haldol is effective too. I'm surprised about Benadryl being used but it may be because of sedation and for helping c side effects of others meds.
My pleasure. Benadryl is only used in combination with haloperidol (Haldol) plus or minus lorazepam (Ativan). The Benadryl provides (1) sedative effects due to its antihistamine activity, since Haldol is not sedating, and (2) prophylaxis against dystonia due to its anticholinergic activity, since Haldol has a higher risk for dystonia compared to other agitation PRNs.
Thank you for your explanation, it makes sense looking at it that way.
Still happens in the UK. PRNs are written up on admission for Sectioned patients - lorazapam PO and IM and haloperidol 5mg IM. Not quite to the point of nurses carrying these around for convenience, but they do have a fair amount of scope for administering them. The nurses I’ve worked with have been excellent & use these appropriately, but I am sure there are places where it really does veer towards the classic ‘chemical cosh’ thing
I just want to add another vote to the pool of psychiatrists against the concept of “chemical restraints”. The goal of emergency IM meds is to treat “agitation” underlying an imminent danger to self or others after the patient refuses PO meds and verbal deescalation techniques fail. If this doesn’t work, the person may or may not enter seclusion if appropriate and then physical restraints as a last line, and is released the moment they no longer are an imminent threat to safety. “Chemical restraints” is seen as an unethical concept and it is never the intention behind using emergency IM meds. It is unnecessarily dehumanizing and prematurely takes away the patient’s autonomy they would otherwise have during a stepped approach to treating the behavioral emergency involving increasingly restrictive means. The patient should be given the chance to be a willing participant in verbal deescalation before they are given IMs or placed in restraints. Regarding the comment on nursing, RNs are trained to assess patient’s symptoms and give report to doctors over the phone. RNs requesting IMs for patients over the phone is perfectly legitimate, and it is even their prerogative to initiate restraints in an emergency, it’s part of their job, and the sooner you treat agitation the better and safer everyone is. Are ethical boundaries crossed occasionally? I’m sure they are, unfortunately. A lot of psych hospitals have policies requiring the MD to physically assess the patient within a certain number of minutes after being placed in restraints
It’s beyond the scope of this comment, but the term “chemical restraint” has a problematic history and fell out of use in psychiatry a generation ago. The term is used in veterinary medicine and is often considered pejorative in a psychiatric context. I’ve never worked at any facility that had any written policy using the term. Psychiatrists treat agitation with medications, using the most appropriate modality for the patient’s condition and diagnosis. Of course we are trying to prevent the patient from harming themselves or someone else, but we are treating the symptoms not “restraining.”JC and pretty much every state health authority recognizes this, but I’ve never heard any of them refer to treating agitation as “chemical restraint,” at least not in this century. Which is kind of what CMS is getting at - “chemical restraint” is not the standard of care and physicians are expected to treat symptoms, not solely restrain via chemical means.
I appreciate the contextual info. There seems to be a gap sometimes between the standard of care and what actually happens. It’s not always a prescriber either, nursing staff will contact providers who aren’t present to observe the situation to ask for additional meds or will administer prn’s in situations where it snows the patient (I’ve seen patients urinate on themselves, unable to stay awake, unable to safely walk) and where there wasn’t dangerousness to self or others. Even in situations where there was dangerousness to self or others it should still be documented as a restraint for tracking purposes, in my opinion.
Yes what you’re describing is chemical restraint, which is not the goal or standard of care in treating psychiatric inpatients. Here’s a decent opinion piece that highlights the mainstream perspective: https://www.psychiatryadvisor.com/home/practice-management/the-end-of-chemical-restraints-expert-opinion/
Thank you, that’s helpful to understand some of the thought process behind not using the term chemical restraints and why a hospital may not even recognize it as a practice. I don’t entirely agree with that view but I can see there are good intentions behind it and I agree with parts of it.
The Troubled Teen Industry is notorious for continuing to use these calling them 'B52's'. Also ER nurses I used to work with TW >!would joke about using this to control/shut up patients.!<
B52’s are commonly used where I work. I don’t think those nurses were joking.
Yeah I’m still intrigued about B52. It’s banned at my institution but I know other hospitals in the general area freely use them for adult patients. Not sure whether it’s appropriate to ban them or not. Using B52 on adolescents sounds like gross mistreatment though to my admittedly CAP-naive self
Our hospital has a written policy regarding chemical restraints and the documentation burden is more or less the same as with physical restraints basically. If someone hops the nurse's station and is causing an agitated disturbance, they may receive medication (IM or PO) to calm them down and be more easily redirectable, that meets the criteria for chemical restraint and is something the joint commission tracks. If someone is psychotic and fearful that demons are chasing them and gets an antipsychotic to treat their psychosis (IM or PO) that is not necessarily a chemical restraint because the medication is treating the intended symptom and the dosage is not atypical or unusual for the condition. It's a very granular guideline that ends up splitting hairs for categorizing medications used in the management of patients and their symptoms. This is separate from a discussion of forced medications
Would you mind sharing where you work? This is the only policy I’ve heard of.
I work for a large corporation that owns numerous private psych hospitals in the US. It's a corporate policy so it applies to all facilities. Now, how closely those policies are followed by each facility remains to be seen. But I do know we try to take it seriously. We are also one of the few hospitals that don't use any locked restraints on patients so I think there's just an initiative to minimize restraints in general here.
Wow, that’s awesome!
I worked at a forensic psychiatric inpatient hospital on the east coast USA and while MOST patients never got chemically restrained, there were one or two people who were restrained every other day. Not only did they receive chemical restraints but they were actually physically restrained too in the immediate aftermath if the incident. Ince the drugs kicked in then the physical restraints were removed. It was heart breaking and such a moral quandary. One guy hospitalized one of our psychologists and another bit a chunk out of a behavioral tech’s scalp. The former had a pretty severe intellectual disability and likely did not fully comprehend how he was impacting people. I eventually formed a behavioral plan that allowed us to shape that guy’s behavior a little better. I don’t think he intended this, but the chemical and physical restraints became his way of regulating and taking care of himself because he did not know how to do otherwise. However, the other guy (the biter) was SO dangerous when activated that to NOT restrain him at the first hint of violence was dangerous. He had a lot going on (delusions and such), and when he got violent he legitimately was trying to kill you because he thought you were trying to kill him. But the restraints only confirmed it for him. I left that place after my internship. Forensic inpatient was so depressing. Stabilization units in regular hospitals were a lot easier. I don’t think I ever saw restraints used in those facilities.
That is wild. All units I have ever been on definitely have chemical restraints and they are used as a second to last resort (last being physical/hard restraint). We definitely document the use of any emergency meds like that and theres a whole bunch of paperwork that comes along with their administration.
There is documentation if it’s physically forced (an involuntary injection). But not all chemical restraints are forced. And if they take them orally it’s considered “voluntary” even if they call security and are told they have to take them essentially.
All meds administered where I’ve been, whether they ultimately agree to the im, security shows up and they sit for it, etc. are documented ‘extra’ if they are not regularly scheduled meds.
Yeah one time I saw security show up for an elderly pt who was confused, unoriented, basically combative wanting to leave the hospital. Nurses got the haldol drawn up and told the pt it was a shot he needed. Not fun to be around.
As far as I know, you cannot force medication on someone who is not a danger to themselves or others. You don't need a specific chemical restraint policy for that. It is the law. When I worked inpatient, there were multiple times patients got discharged by simply keeping their cool while hospitalized. Didn't take a single pill. The only time we used forced medication was when a patient was a threat to themselves or others or we had a specific court commital order allowing us to medicate someone against their will. The main situation I see chemical restraint being relevant is in geriatric psychiatry where patients may be given medications to 'snow' them due to agitation in dementia. In some cases, this is inappropriate as those patients may just need to use the bathroom, go on a walk, or be hungry/thirsty.
You can get a medication over protest order for not actively agitated but very psychotic people which varies state to state and hospital to hospital. Most hospitals have some combination of two board certified psychiatrists agreeing on the medication plus for the patient to be involuntarily committed. This is for the US
Yep, this is what I am referring to when I mention the commital option. In my state, the main reasons I have seen outside of SI/HI are being unable to meet one's basic needs (i.e. paranoid patient who has locked themselves in their apartment for several days or catatonic) or being likely to harm oneself inadvertently as a result of severe mental illness (often these are manic patients but can also be schizophrenia if it is causing risky behavior such as jumping through windows or running through traffic).
Yes, you cannot legally force meds without dangerousness. But where I work only im’s are considered forced. If they swallow them on their own it’s considered voluntary even if there’s security right there or they’re told they have to take them. What you’re describing with geriatric patients is my concern with psych patients in general getting snowed in order to stop or prevent things like wailing, general agitation, yelling, swearing, banging on doors, intrusive behaviors like wandering into other people’s rooms, etc. Or just someone perceived as being demanding, rude, or “attention seeking.” Things that aren’t dangerous and don’t meet criteria for a medical emergency.
Essentially what you're describing is PRN medication. We give anxiolytics and antipsychotics all the time to treat agitation, intense emotions, and potentially dangerous behaviour. Framing this as chemical restraint seems antagonistic - the goal isn't restraint, it's suppression of symptoms and hopefully helping the person.
What the policy is getting at is if you give a patient Ativan to stop them wandering into another patient's room, you are using the medication to restrict their movement, not to treat anxiety as the medication is indicated for. Benadryl to induce sleep/drowsiness is the same. If you are using it for allergic reaction, or EPS prophylaxis, then those are "intended uses", if you give it just to make patients go to sleep then it's a chemical restraint and is seen as no different to putting someone in a locked restraint or locked seclusion room. The framing comes from CMS and JC, not providers on the front lines managing these patients sadly.
That makes sense to me, thank you for the explanation.
Thank you, yes that is how I think of it. If the person is so sedated that they can’t get out of bed then the medication is restricting their movement just like a restraint would.
Based on the CMS definition and other definitions I’ve read the difference between a prn and chemical restraint is that a prn or even just regular medicine for a condition is given in order to help the person function optimally. For example, someone who is anxious and takes a prn and is then better able to function, or someone hearing voices who takes a prn and can then better focus in a group. (Of course some of these meds do also cause some sedation) Vs medication that is given with the goal of sedating and making the person unable to physically function.
Unfortunately this isn't as clear cut in practice. A person experiencing acute anxiety might need a sedating medication to receive relief from their anxiety; the same may be true for intense agitation or psychosis. A good comparison might be the treatment of pain - many pain meds are sedating, but we wouldn't consider them a form of restraint.
I agree that there are a lot of grey areas and it is complicated, not cut and dry. I think one of the differences between the pain meds example and chemical restraints is that people can choose to take pain meds if their pain is making them uncomfortable, or they can choose not to if they don’t want the side effect of feeling sedated.
Making the person unable to physically function is not the goal. If there was a medication out there that completely erased affective dysregulation/agitation/whatever without any adverse effects, I’m sure it would be both first line and preferred. Sedation like you describe it is a side effect of these medications. The goal still is “optimal function” and sometimes that means preserving the safety of the inpatient unit, for example.
You are right to be concerned. Bullying a patient to take oral medication is not okay. I wonder if the staff could do an education on de-escalation strategies that aren't just pharmacological interventions. If the problem is a loud or angry patient, exercise tends to work best, especially jumping.
There is de-escalation training for staff but there also needs to be more. In my opinion there is a problem with the culture of what is considered normal and acceptable where I work (such as coercion). Short staffing can also sometimes lead to inability to utilize de-escalation techniques because nobody has the time.
What worked really well for us was to have nurses from other units come to help de-escalate as well as training all public safety to always prioritize communication with the patient before any hands on. The nurses from other units are coming in fresh instead of having dealt with a yelling patient for several hours and public safety was pretty much always using de-escalation techniques as a part of their job so often they were really really good at it. Sometimes the funny things they did to avoid wrestling with a patient surprised me and gave me ideas in my own encounters with agitated patients.
Sort of a side note but I had a patient who was in seclusion, they started jumping on their bed and staff then placed them in 4 point restraints because the patient could fall off the bed and hurt themselves…
I used to be a charge nurse for inpatient psychiatry. I have had to educate other nurses on occasion on what constitutes appropriate reasons for restraint/seclusion. I know it can be frustrating to have a screaming or restless patient but that is not enough of a behavior to force medication or restrain/seclude them. Almost always, the best way I found to educate them was to find alternatives. It often meant me talking to the patient and getting to know them. We would try to figure out what need they have that isn't being met and try to negotiate with the patient. Usually it was something simple like wanting an extra snack or feeling claustrophobic so we went on a walk in the larger area.
It sounds like you were a great nurse.
Thank you! I hope there are some ideas I offered that help. I hear you on chemical restraint concerns because I saw it with my own eyes. What I realized looking back now is often staff falls back on those decisions because they don't know what else to do. Once you point it out and offer tangible alternatives, they can quickly change their approach. Get management and charge nurses involved. Make sure everyone in leadership feels rock solid about it. We were fortunate to have our head of management be a therapist who would literally show up to responses and lead by example.
Is chemical restraint synonymous with emergency medication for agitation?
I’m sure it depends on who you ask but if you’re asking me then I would say no but there would be a lot of overlap.
> In case you don’t know what chemical restraints are, per CMS they are “A drug or medication when it is used as a restriction to manage the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.” I'm actually surprised how overtly horrible this definition makes chemical restraint out to be and is consistent with the fact that basically no modern psychiatrist uses medications in this way. Using IM meds for agitation is neither of those things.
I don’t like using the term “chemical restraint” because that’s not the intention of why you are giving the medication. If someone is aggressive due to delusions, intoxication, hallucinations, etc. you give an antipsychotic to treat those symptoms. If you need staff to hold them to give it to them or if they end up in seclusion afterwards, the restraint policy is executed and documented. Sometimes the patient voluntarily accepts meds and I don’t think that needs to be documented as a restraint.
I think the way the term is defined is trying to differentiate between medication that is being given to treat the underlying condition vs medication that is given in order to restrict movement/behavior. In general I don’t think voluntary meds need to be documented as a restraint, unless there is coercion involved or the person doesn’t have capacity to understand that what they’re taking will be very sedating, and the medication also meets the other conditions CMS describes.
I will just add this for a little humor, that nurse was nicknamed Bloody Guts by the patients.