1. The anaesthetist, restrictive interventions & restraint teams Dr Liam Brennan Consultant Anaesthetist, Cambridge University Hospitals

2. Winterbourne View scandal (2011)
Punitive use of restraint in hospital for adults with learning disabilities; 11 staff charged with criminal offences; 6 jailed
Prompted national debate about use of restrictive interventions in all health & social care settings
DH published guidance on use of restrictive interventions (2014)
Potential implications for anaesthetic & critical care practice

3. Content Overview of restrictive interventions (RIs)
Key principles of RI practice
Legal perspectives
Physical & chemical restraint
Training implications
Restraint response teams

4. Potential need for restrictive interventions
Dementia
Perioperative
delirium
Critical care
Substance abuse
Paediatric practice
Mental health issues
Learning
disabilities

5. What is a restrictive intervention?
Deliberate acts on the part of other person(s) that restrict an individual’s movement, liberty and/or freedom to act independently in order to:
take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken; and
end or reduce significantly the danger to the person or others; and
contain or limit the person’s freedom for no longer than is necessary.

7. Restrictive interventions in children
Physical restraint should be avoided if at all possible
Always consider use of sedative premedication
If RI likely to be required ensure parents/carers are fully aware that this may be needed
Therapeutic holding by parents/care givers for induction for the young child appropriate
Tread very carefully with the Gillick competent child refusing to cooperate for elective, non-urgent procedures
Cancellation and regrouping for the older child usually wise

8. Need to learn more?
Positive Outcome and Experience Management Strategy
One day course
Strategies to ↓ child anxiety

9. Reducing the need for RIs
Use a positive behavioural support approach to understand reasons for challenging behaviour
Patient factors: mental/physical health, sensory impairment
Care environment: over/under stimulating, inflexible approach, restricted access to preferred activities, poor staff continuity
Develop a behaviour support plan to include:
Practical approaches to prevent challenging behaviour
De-escalation techniques if problems escalate e.g. distraction, diversion, disengagement
Recommended RI if crisis does occur
PBS approach just as relevant to the acute situation

10. Causes of confusion, delirium & agitation
Hypoxaemia
Shock
Sepsis
Glycaemic derangement
Substance abuse NB Alcohol withdrawal
Brain trauma/stroke/dementia/other CNS disorders
Chronic renal/hepatic/cardiac dysfunction
Anxiety/fear/stress
Under sedation
Drug reactions/interactions
General discomfort e.g. urinary retention, prolonged starvation
Advanced age is a risk factor not a cause
Environmental factors
 Noise  Inexperienced staff  Overcrowding  Lack of continuity  Lack of privacy  Staff shortages

11. Physical restraint

12. Dangers of physical restraint
13 restraint related deaths in patients detained under Mental Health Act since 1998
Asphyxia implicated in 68% of deaths
Increased risks with some co-morbidities
e.g. diabetes, epilepsy, IHD, morbid obesity
Increased dangers if physical restraint involves:
Face down positioning
Chest/abdomen/neck holds
Mouth/nose covered

13. Key principles in use of RIs
Least restrictive intervention possible
Only use RI for the shortest period of time
Must not include deliberate application of pain
RIs only used by staff trained in their safe usage
Staff safety high priority
Liaise with family/carers whenever possible
Follow local protocols

14. Key principles in use of RIs (continued)
Refer to BSP whenever possible to choose most appropriate RI
Physical restraint must not impact on ABC
Chemical restraint should use oral route whenever possible NB: co-morbidities & other medication
Vital signs must be monitored during and after RI
Post incident reviews & debrief essential
Regular audit and reporting essential

15. Chemical restraint Must be medically supervised
Consider co-morbidities & drugs (prescribed & illicit)
Resuscitation equipment available
Oral medication first line
IM second line; IV rarely used outside of critical care
Close monitoring during and after
Aim to achieve state of calm NOT unconsciousness
Lorazepam preferred in many out of theatre/ICU protocols
Potential dangers with anti-psychotics e.g. prolonged QT & arrhythmias with haloperidol

16. Legal perspectives Various key pieces of legislation are relevant:
Mental Health Act 1983
Mental Capacity Act 2005
Human Rights Act 1998
Health & Safety at Work Act 1974
Use of RIs only justified if patient lacks capacity
Using RIs in situations where patients have capacity risks accusation of assault or ‘deprivation of liberty
Use of RIs is not justified solely on the grounds that a patient makes an unwise decision
The safety of staff involved is paramount

17. Principles of the Mental Capacity Act (2005)
Understands the information (explained appropriately)
Retains the information (for long enough to decide)
Uses the information in their decision making
Communicates their decision in any way

18. Training
All staff involved in providing RIs must receive training which should be regularly updated
Current packages focus on mental health professionals
Perioperative care staff rarely receive training
DH and NICE guidance likely to recommend more widespread training
Concern that training resources will not be able to cope with potential demand

19. Training content Building therapeutic relationships
Principles of positive behavioural support
Causes of challenging behaviours
Legal framework
Risks associated with RIs
De-escalation techniques
Safe implementation of RIs
Post incident de-briefing

20. Restraint response teams
Multidisciplinary teams to provide rapid response for acutely agitated or aggressive patients with mental health issues
Some Trusts have included anaesthetists as members of these teams
RCoA with RCPsych has published guidance on anaesthetic involvement

21. RCoA/RCPsych guidance on involvement of anaesthetists in restraint teams (2014)
Anaesthetists should only act as part of a multi-disciplinary team including a psychiatrist
Trainee anaesthetists should not be routinely involved in initiating chemical restraint except in an emergency
Anaesthetists should receive appropriate training
If rapid tranquillisation is required the minimum intervention possible according to local protocols
CPR equipment & skilled assistance must be available
Post sedation management & monitoring should be in a suitable venue by appropriately trained staff
Post incident reflection & de-briefing to maximise learning

22. Summary
Public increasingly aware of the use and abuse of restrictive practices across all health & social care
Anaesthetists/intensivists face difficult situations requiring RIs in their traditional working environments and beyond
Need to increase awareness and training in all aspects of restrictive interventions to ensure safe and compassionate practice

23. Questions?