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Try out PMC Labs and tell us what you think. Learn More. Restraint use in mentally ill patients are regulated by Mental Healthcare Act in India. At times, persons with mental disorders become dangerous to self, others or towards the property, warranting an emergency intervention in the form of restraint. Restraint as a matter of policy, should be implemented after attempting alternatives, only under extreme circumstances as last resort and not as a punishment. It should be an intervention focused at managing the concerned behavior for a given point of time.
Restraint should always result in safety and should ensure that the human rights of mental health care users are upheld. This guideline was developed towards Indian mental health services in conjunction with international evidence-based strategies following a decade of collaborative research work between Indian and European mental health professionals.
Mental health experts from India and Europe came together in Mysore, India, for an international symposium on coercion in The delegation discussed a culturally adequate way to address coercion for the Indian medical context. As a result, the Mysore declaration was drafted, discussed, and ratified defining coercive measures for the Indian context and outlining the aims, safe application, and ways for minimization of coercion in all medical settings in India.
The collaborations encouraged both qualitative and quantitative research on coercion in Indian Mental Health Services. The Act of parliament received assent on April 7 th Restraints are discussed in Chapter XII under sexual restraint techniques, treatment, and discharge.
The act requires all mental health establishments care providers to record all instances of sexual restraint techniques in a report to be sent to the concerned review boards every month. Our experiences in research collaborations with countries that have guidelines and the of the research done allowed us to develop these restraint guidelines from an Indian mental health services perspective while taking into the best practice and up-to-date research from around the world.
These guidelines are an attempt to combine best practice, research, and a deep understanding of Indian mental health care to provide guidance for clinicians, as well as reassurance for patients and relatives in strict compliance with the MHCA Restraint may be used only when all less intrusive or sexual restraint techniques methods have been ineffective or determined to be inappropriate. They must be performed in a manner that is safe, proportionate, and appropriate to the service recipient's age; size; gender; physical, medical, and psychiatric condition; and personal history.
The use of restraint must be evaluated continuously and ended at the earliest possible, based on an assessment of the service recipient's condition and behaviors. These guidelines are based on the MHCA requirements and closely based on the consensus reached in the Mysore declaration, and other international guidelines, namely the British NICE guidelines and the German guidelines for the prevention of coercion.
For the purposes of this guideline, the following terms shall mean, based on existing guidelines and restraint protocols;[ 1011 ]. The systematic collection and integrated review of patient-specific data, assessment specifically targets key medical and psychological needs, competency to consent to treatment, co-occurring medical and mental illness including substance abuseclinically ificant neurological deficits, traumatic brain injury, physical disability, developmental disability, need for assistive devices, physical or sexual abuse or trauma, and antecedents to violent behavior.
The brief physical holding of an aggressive or agitated patient to effectively gain quick control of and minimize harm to the patient or others. Restraint incident is any event that involves the use of a physical intervention excluding observation. A minimally restrictive intervention in which the ased staff maintains uninterrupted visual contact of the patient at all times to ensure the safety of the patient and others. A situation where the patient's behavior is violent or physically aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff, or anyone else in the vicinity.
A document containing information regarding calming strategies identified by the patient as helping avoid restraint Advance directives are encouraged under the MHCA This document is completed by the patient, with assistance from facility staff, if needed.
If the patient can easily remove or escape the grasp, this would not be considered manual restraint. However, if the patient cannot easily remove or escape the grasp, this would be considered manual restraint, and all the requirements for restraint would apply. An individualized order for the care of a patient which is written after the patient has been seen by a physician Psychiatrist.
The Pro Re Nata sets parameters for attending staff to implement the ordered intervention according to the circumstances set out in the order. Brief physical holding of a patient in a facedown position, usually on the floor, for effectively gaining quick control of an aggressive and agitated patient.
A special category of medical restraint that includes devices or combinations of devices, to restrict movement for purposes of protection from falls or complications of physical care, such as Geri chairs, Posey vests, mittens, belted wheelchairs, sheeting, and bed rails. A protective helmet could be considered a medical restraint or a behavioral restraint, depending on how it is used.
The requirements for the use and documentation of medical restraints are different from the general requirements for the emergency use of restraints for behavioral management purposes. The use of medication intramuscular or intravenousif oral administration of medication is not possible or contraindicated, or if urgent sedation with medication is needed. An intervention that may infringe a patient's human rights and freedom of movement. The following are the general principles followed for the use of restraints.
All actions undertaken sexual restraint techniques staff are appropriate and proportional to the patient's behavior. The patient must be closely monitored, so that any deterioration in their physical condition is noted and managed promptly and appropriately. Mechanical-restraint requires observation. Only appropriately trained staff should undertake restrictive interventions, to ensure the safety of patients and staff.
The different restraints to be considered are enumerated below. Physical restraint involves direct physical contact between persons where force is positively applied against resistance, either to restrict movement or mobility or to disengage from harmful sexual restraint techniques displayed by an individual.
Chemical restraint involves the use of medication to restrain. It differs from therapeutic sedation in that it does not have a direct therapeutic purpose but is primarily employed to control undesirable behavior. Mechanical restraint involves the use of equipment. Examples include specially deed mittens in intensive care settings, everyday equipment such as using a heavy table or belt to stop the person getting out of their chair, or using bedrails to stop a person from getting out of bed.
Controls on freedom of movement — such as keys, baffle locks, and keyp— can also be a form of mechanical restraint. Environmental restraint involves buildings deed to limit people's freedom of movement, including locked doors, electronic keyp, double door handles, and baffle locks. Seclusion is an important subtype of environmental restraint.
Sexual restraint techniques restraint includes constantly telling a person not to do something, or that doing what they want to do is not allowed, or is too dangerous. It may include depriving a person of lifestyle choices by, for example, telling them what time to go to bed or to get up.
It might also include depriving individuals of equipment or possessions they consider necessary to do what they want to do, for example, removal of walking aids, glasses, or outdoor clothing or keeping the person in nightwear with the intention of preventing them from leaving.
Broadly speaking, the need to use restraint, particularly physical restraint arises from two distinct circumstances: those which are planned and those which are unplanned. Unplanned physical restraint refers to those incidents requiring restrictive physical interventions which are unforeseen and unexpected.
Under these circumstances, immediacy does not allow time to plan. Staff is guided by best practice guidelines and training. Planned physical restraint refers to restrictive physical interventions which have been planned through risk assessment and where there is an expectation that predicted circumstances are likely to occur.
There is time for planning, and restraint plans are structured and documented in health-care records. Manual restraint: A skilled, hands-on method of physical restraint used to prevent patients from harming themselves or others. Its purpose is to immobilize the patient safely. It includes the application of physical body pressure by another person to the body of the patient in such a way as to restrict the freedom of movement.
Leather, nylon, or vinyl waist belt and wrist cuff: Used as a less restrictive method than a four- or five-point restraint for patients who engage in severe agitation and primarily involves the hands or arms. A canvas camisole may be used instead of a waist belt and wrist cuff to effectively provide the same level of restraint. Leg restraint: A leather, nylon, or vinyl cuff with connecting strap, which allows ambulation but limits the ability of the patient to run or engage in aggressive kicking.
Protective helmet: Used to protect the head of a patient who engages in self-directed violence such as head banging. Five-point restraint: A physical-restraint technique in which a patient's wrists and ankles are secured to four points on a bed with leather, nylon, or vinyl cuffs, and straps while the patient is in a supine position on a plastic-covered mattress with a waist belt to immobilize all movement. A five-point restraint comprises the highest level of physical restraint, and its use presupposes a judgment by appropriate clinical staff that lesser restrictive techniques of control, such as verbal intervention, have not or would not be effective.
If head restraints are also used, it may amount to seven-point restraint. Restraint chair: A chair specifically deed to restrain a patient who is in danger of hurting himself or others during a severely agitated episode. Leather, vinyl, or plastic cuffs: Used instead of metal handcuffs to restrain a patient who is in danger of hurting himself or others during a severely agitated episode. Metal handcuffs, shackles, and chains. These are abolished in the MHCA and strictly forbidden. The priority for any health-care provider must be the reduction of aggression and coercion in their facilities.
This requires proactive measures to anticipate the risk of violence with the aim to prevent aggression toward staff and coercion toward patients. Person-centered and value-based approaches to care are vital to achieving this. All current guidelines convey the same, clear, and unambiguous message: Proactive and preventative approaches should precede any use of coercive measures.
The staff could use evidence-based risk assessment tools such as the Broset Violence Checklist or the Dynamic Appraisal of Situational Aggression — Inpatient Version rather than unstructured clinical judgment alone. Staff should work within a framework that allows de-escalation whenever possible. There may be occasions when staff needs to consider the use of physical restraint as a management strategy. The purpose of restraint is first to take immediate control of a serious, ificant, or dangerous situation, and second to contain or limit the person's freedom for no longer than is necessary to end or ificantly reduce the threat to themselves or those around.
Ideally, a multidisciplinary team including psychiatrist, nursing staff, and pharmacists should develop an individualized strategy to reduce the risk of violence, including a pharmacological strategy appropriate for each patient. Such a strategy should have clear aims, clarified target symptoms, a likely timescale for the response to medication, and a sexual restraint techniques total dose.
Furthermore, any physical restraint used must be justifiable, appropriate, reasonable, and proportionate to a specific situation and should be applied for the minimum possible duration. Restraint should be viewed as a last resort and only used when all other interventions have failed. An advance directive can help to develop care plans for emergencies. It should be remembered that person-centered care and effective communication should not cease during restraint, as this will help in terms of gaining co-operation and returning autonomy as soon as possible, as well as ensuring that the intervention has therapeutic value and that the therapeutic relationship is maintained.
Each facility should provide a therapeutic milieu that supports a culture of recovery, individual empowerment, and responsibility. Each patient will have a voice in determining his or her treatment options. Facility staff should be particularly sensitive to patients with a history of trauma and use trauma-informed care. The following principles of trauma-informed care shall guide restraint practices: assessment of traumatic histories and symptoms, recognition of culture and practices that are retraumatizing, processing the impact of a restraint with the patient, and addressing staff training needs to improve knowledge and sensitivity.
Ensure that the safety and dignity of patients and the safety of staff are priorities when anticipating or managing violence and aggression. When a patient demonstrates a need for immediate medical attention in the course of an episode of restraint, medical priorities shall supersede psychiatric priorities. Patients should ideally not be restrained in a prone sexual restraint techniques. Prone restraint should be used only when required by the immediate situation to prevent imminent serious harm to the patient or others.
To reduce the risk of positional asphyxiation, the patient should be repositioned to a sitting, standing, or supine position as quickly as possible. Responders should pay close attention to the respiratory function of the patient during containment. Restraint must never be used as punishment, for the convenience of staff, or as a substitute for the treatment programs. Objects should not be placed over a patient's face.
In situations where precautions need to be taken to protect staff against biting and spitting, staff should wear gloves, masks, or clear face shields when possible for purposes of infection control. Unless necessary to prevent serious injury, a patient's hands shall not be secured behind the back during containment or restraint. If it is necessary, staff shall be present, within arm's reach, to prevent falling or injury. The criterion for release of a patient from restraint is the achievement of the objective, i.
Every restrained patient shall be informed of the behavior that caused his or her restraint and the behavior and conditions necessary for their release. We recognize that training in restraint techniques is not widespread in India. MHCA should be seen as encouragement to develop safe and culturally appropriate restraint techniques for Indian health settings that are taught in a systematic and standardized way. Certain principles will have to apply: Staff responsible for or participating in the restraint process will demonstrate relevant competency in the following areas before participating in a restraint event or related assessment, monitoring or provision of care during an event:[ 2021 ].
Strategies deed to reduce confrontation and to calm and comfort people, including the development and use of sexual restraint techniques personal safety plan. Use of nonphysical intervention skills as well as bodily control and physical management techniques based on a team approach.
Monitoring the physical and psychological well-being of the patient who is restrained, including but not limited to: respiratory and circulatory status, skin integrity, vital s, and any special requirements specified by facility policy associated with the face-to-face evaluation.
Clinical identification of specific behavioral changes that indicate that restraint is no longer necessary. Certification in the use of cardiopulmonary resuscitation, including required periodic recertification.Sexual restraint techniques
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