Anaesthetists and Restraint

Joanna David14/4/2015

• Section 6(4) of the Mental Capacity Act states that someone is using restraint if they:

– use force – or threaten to use force – to make someone do something that they are resisting, or

– restrict a person’s freedom of movement, whether they are resisting or not

Types of Restraint

• Physical

• Mechanical

• Chemical

• Psychological

• The authority to restrain a client is allowed if the following conditions are satisfied:

– the patient lacks capacity in relation to the matter in question

– the member of staff reasonably believes that it is necessary to restrain in order to prevent harm to the client

– Requiring treatment by legal order (e.g. MHA 1983 amended 2007)

– Requiring life saving or urgent treatment

– Needing to be maintained in secure settings

Practical Application

• This guidance ONLY applies to patients who would otherwise not have been sedated or intubated for medical or surgical reasons and exclude patients with:

– With low or fluctuating GCS– With head trauma– Who need airway protection– Who need ventilatory support– etc

• Therefore restraint may be considered in the following circumstances, where the patient is:

– Displaying behaviour that is putting themselves at risk of harm

– Displaying behaviour that is putting others at a risk of harm

Position statement on the involvement of anaesthetists in restraint teams

Royal College of PsychiatristsRoyal College of Anaesthetists

17/1/2014

This policy guides the use of anaesthetists as part of a response team to provide:

• physical, • mechanical and/or• pharmacological restraint of acutely agitated or aggressive patients with

mental health issues outside of the operating theatre/intensive care environment.

• Following consultation with The Royal College of Psychiatrists, the College would wish to emphasise the following principles relating to the involvement of anaesthetists in these difficult scenarios:

• Anaesthetists should only act as part of a multidisciplinary response team incorporating mental health care professionals including a psychiatrist Trainee

• Anaesthetists should not routinely be involved in initiating pharmacological restraint - referred to as ‘rapid tranquillisation’

• If the urgency of the clinical situation dictates they must only act within their competence and, whenever possible, after consultation with a consultant anaesthetist

• Anaesthetists should receive appropriate locally delivered training to safely fulfill their role as part of the response team

• When rapid tranquillisation is deemed appropriate the minimum intervention possible should be used as guided by the local protocol

• Equipment for ventilatory support and the full range of resuscitation equipment must be immediately available along with trained assistance for the anaesthetist

• Careful consideration must be given to post sedation management including:– the venue for recovery of the patient,– adequacy of monitoring and – availability of nursing care with appropriate airway

management skills

• Organisations should ensure that there are processes in place for post incident reflection and de-briefing to ensure that individual and team learning is maximised

• The College does not support under any circumstances the use of rapid tranquillisation to manage violence or aggression in visitors or other individuals on hospital premises.

AAGBI Position Statementon Hospital Restraint Poilicies

16/09/2013

• Such restraints should only be employed under the strict control of written policies that have been developed, agreed and implemented after:– clinical, legal, and managerial input, and which

must take account of relevant legislation such as the Mental Capacity Act 2005 and the Adults with Incapacity Act (Scotland) 2000.

• Council of the AAGBI does not believe that trainees in anaesthesia should be involved in pharmacological restraint:

– except in extraordinary circumstances and

– after consultation with a consultant anaesthetist,

– should refer any requests for pharmacological restraint to a supervising consultant anaesthetist.

QUESTIONS?

SUMMARY

• Intubation is not always the answer

– Asses the patient yourself

– Be familiar with and follow your local guideline

– Get your consultant involved early

– If there is disparity in assessment, get the consultants to assess and decide if there is time

– Consider alternatives for sedation as in the above protocol if indicated

Let common sense prevail

• Regain control of the situation

• Ensure the patient is safe