The use of restraint for pediatric psychiatric patients in emergency departments

Objective: To identify current practice and staff education regarding the use of restraint in emergency departments for children undergoing psychiatric evaluations and to compare restraint practice and education in emergency medicine residencies (EMRs) and pediatric emergency medicine fellowships (PEMFs). Methods: A self-administered survey regarding staff and resident education and the use of restraint for emergency pediatric patients undergoing psychiatric evaluation was mailed to the directors of EMRs and PEMFs. Main outcome measures included frequency of restraint use, staff trained in restraint use, favored positions for physical restraint, and agents regularly used for chemical restraint. Results: Forty-one percent (48/118) of EMRs and 66% (33/50) of PEMFs completed the survey. The great majority of both EMRs and PEMFs report use of physical and chemical restraint in 5% or less of pediatric psychiatric patients. Forty of 47 EMRs and 29 of 32 PEMFs have formal policies on physical restraint use. Far fewer programs have formal policies for chemical restraint (13/33 EMRs and 5/28 PEMFs). A large percentage of both EMRs and PEMFs do not teach their trainees about the application of restraints (EMR = 52%, PEMF = 82%) or the appropriate situations in which to use restraint (EMR = 35%, PEMF = 64%). However, EMRs were more likely than PEMFs to teach about both appropriate restraint application and appropriate situations for their use (RR = 2.6, 1.2-5.8 and RR = 1.8, 1.1-2.9, respectively). The supine position was the position favored by both groups for physical restraint. Therapeutic holding was infrequently used, mostly for younger children. Seventy-two percent of EMRs and 85% of PEMFs used chemical restraint in children. Benzodiazepines and butyrophenones were the most commonly used agents. However, butyrophenones were often misclassified as phenothiazines by both EMRs and PEMFs. Conclusion: Restraint, both physical and chemical, is a widely, but uncommonly used, intervention for pediatric psychiatric patients in emergency departments. Many EMRs and PEMFs do not teach residents about restraint.