Psychiatric confinement is the use of restraints to detain a person in need of care and further evaluation.
The purpose of restraint and confinement are crucial since they have a medico legal implication. The primary purpose for such intervention is typically an urgent or emergent condition that could cause danger to the affected person or others, or cause severe disability to the extent whereby the affected person is unable to care for himself or herself.
Clinicians utilizing this form of patient and public safety should perform a comprehensive mental status examination and document the findings. This approach can potentially provide clear records establishing the specific presenting problems and symptoms that can lead to ambiguities and potential legal action.
Confinement with restraints can be categorized as urgent or emergent. Emergent causes can include patients exhibiting abnormal vital signs (breathing, pulse rate, temperature, blood pressure), threatening or violent behavior, and those who present with signs and symptoms of alcohol or illicit drug intoxication. Urgent use of confinement is indicated in patients showing suicidal thoughts, extreme anxiety, homicidal or violent tendencies, or a danger to self or the public at large.
Those categorized as emergent should be prepared for further testing that can include blood chemistry and psychological assessment and evaluation. Initially the patient is restrained with four point leather restraints (both arms and both legs) and placed in a quiet room with a sitter. For those with urgent needs, restraint is initiated and initial management is directed to assess for an underlying medical cause and address psychological needs.
Further assessment, testing, and evaluation is necessary for a definitive diagnosis and devising an appropriate treatment plan.
A deficiency in record-keeping can lead to legal problems. The criteria and specifications for confinement should be clearly indicated. Meticulous clinical examination and documentation is essential for a definitive diagnosis. Persons who are confined due to substance abuse problems may have legal issues. As of 2001 there is proposed legislation concerning the misuse of restraints for psychiatric inpatients, which in the past has been responsible for numerous wrongful deaths. There are currently no federal laws that regulate the use of inpatient restraints nor any requirements for reporting injuries or death.
Rosen, Peter. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis: Mosby-Year Books, Inc, 1998.
Reeves, R., et al. "Medicolegal Errors in the ED Related to the Involuntary Confinement of Psychiatric Patients." American Journal of Emergency Medicine (Nov. 1998).
Laith Farid Gulli, MD
Keith Tatarelli, JD