Published in the, Sentinel Event Alert paper of the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Issue Eight, November 18, 1998
Since the Joint Commission began tracking sentinel events two years ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 20 cases related to deaths of patients who were being physically restrained. For each of the events reviewed, a root cause analysis was completed. Most of the events occurred in psychiatric hospitals (12), followed by general hospitals (6) and long term care facilities (2).
In 40 percent of the cases, the cause of death was asphyxiation. The remainder of the cases were caused by strangulation, cardiac arrest or fire.
In 40 percent of the cases, the cause of death was asphyxiation. Asphyxiation was related to factors such as putting excessive weight on the back of the patient in a prone position; placing a towel or sheet over the patient's head to protect against spitting or biting; or obstructing the airway when pulling the patient's arms across the neck area.
The remainder of the cases were caused by strangulation, cardiac arrest or fire. All of the strangulation deaths were of geriatric patients who were placed in vest restraints. In half of those cases, the patients died when they slipped between unprotected split side rails. All of the deaths by fire were of male patients who were attempting to smoke or were using a cigarette lighter to burn off the restraints.
Two-point, four-point or five-point restraints were used on extremities in 40 percent of the cases related to restraint deaths. A therapeutic hold was used in 30 percent of the cases, a restraint vest was used in 20 percent, and a waist restraint was used in 10 percent.
Joint Commission analysis identified the following factors that may contribute to an increased risk of deaths. These include:
The organizations that experienced the restraint deaths identified the following areas of root causes:
The Joint Commission and organizations that experienced restraint deaths offered the following suggestions for preventing and reducing restraint deaths. The Joint Commission believes that these strategies help to reduce risk, and it plans to investigate them more fully in the future.
Jack Zusman, M.D., a psychiatrist who teaches at the Florida Mental Health Institute of the University of South Florida in Tampa, says a facility can have alternatives to restraints. For example, it can create special rooms open to patients such as a quiet area for patients who are feeling upset or a room with punching bags or treadmills where patients can work off energy without threatening others.
Zusman, a Joint Commission surveyor, recommends that psychiatric hospitals or psychiatric units of general hospitals train staff in de-escalation. This involves using interpersonal skills to calm and relax patients in a difficult situation involving conflict or potential conflict. "All front-line staff should be trained in de-escalation and the application of restraints," he says. "Supervisors also should be trained in team leadership in dealing with these situations."