Service use by Asian Americans: In Reply

LETTERS Letters from readers are welcome. They will be published at the edi- tor’s discretion as space permits and will be subject to editing. They should not exceed 500 words with no more than three authors and five references and should in- clude the writer’s telephone num- ber and e-mail address. Letters re- lated to material published in Psy- chiatric Services, which will be sent to the authors for possible re- ply, should be sent to Howard H. Goldman, M.D., Ph.D., Editor, Psychiatric Services, American Psychiatric Association, 1000 Wil- son Boulevard, Suite 1825, MS#4 1906, Arlington, Virginia 22209- 3901; fax, 703-907-1095; e-mail, psjournal@psych. org. Letters re- porting the results of research should be submitted online for peer review (http://appi.manu scriptcentral.com). Us e o f P u l s e O x i m e t r y D u r i n g R e s t r a i n t E p i s o d e s To the Editor: I read with interest the special section in the September issue on the use of seclusion and re- straint in psychiatric treatment set- tings. Physical restraint—the holding of an individual by staff to contain dangerous behavior—is used at many different levels of care, from hospitals and residential facilities to group homes and schools, especially with children and adolescents (1,2). Unpublished data for 1995 to 2004 from the Joint Commission on Ac- creditation of Healthcare Organiza- tions (JCAHO) indicate that among 3,000 sentinel events that involved se- vere injury or death, 115 restraint-re- lated fatalities occurred. Fourteen percent of the restraint-related deaths involved “take-down and hold” maneuvers. Death resulted from as- phyxia because of inability to expand the chest or from obstruction of the airway, usually with a face towel to prevent spitting or biting (personal communication, Croteau R, 2005). A JCAHO study of 20 restraint-related deaths found that chest compression PSYCHIATRIC SERVICES had limited the patients’ air exchange, which led to inadequate oxygenation (3). Similar problems have been not- ed for sitting restraints, such as the basket hold. Currently, when a person is re- strained, adequacy of oxygenation is assessed through pulse, blood pres- sure, and respiration measurements, which are confounded by anxiety and anger. Pulse oximetry is a noninvasive direct measure of oxygenation that has been used in medical facilities to measure the oxygen saturation of he- moglobin. Portable oximeters are ac- curate and reliable (4). To determine the usefulness of pulse oximetry during restraint pro- cedures, baseline pulse oximetry readings were obtained for all pa- tients at our residential treatment fa- cility, which has an average daily cen- sus of 84. The residents were given information by a licensed practical nurse about the use of pulse oximetry readings to decrease the possibility of suffocation during restraint. Resi- dents included male and female ado- lescents aged 12 to 18 years who had psychiatric and behavior problems and who lived in seven separate units in the facility. Oxygen saturation was measured during 31 physical restraint episodes (12 patients) over 70 days (March 10 to May 19, 2005) by using a probe from a portable oximeter that was clipped to a finger or toe (2) by li- censed practical nurses. The oximeter used was the 503 DX model from Criticare Systems Mini SPO2T. In seven of the restraint episodes, the patients were prone; in the remain- der, the patients were in standing po- sitions. The mean±SD duration of an individual episode was 9±6 minutes. Baseline oxygen saturation read- ings were 96 percent or greater; read- ings during restraint episodes were 95 percent or greater. No incidents of respiratory distress were noted either by the staff or by the residents during restraint. Oximetry was well accepted by staff and patients. In fact, we found that placing the finger probe on the adolescent’s hand and asking him or her to turn on the oximeter, if ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10 interested, sometimes distracted everyone involved, diffused tension, and ended the restraint. It will be necessary to see how oximetry performs under conditions of impaired oxygenation. There is concern that it might give an inaccu- rate reading during acute dyspnea, making repeat readings and clinical correlation essential (4). In addition, in one study when volunteer staff of a mental health facility were restrained in either a prone or a supine position and then directed to exercise, those subjected to prone restraint showed prolonged pulse recovery after exer- cise, which may suggest a link with sudden death during prone restraint (5). Although the oximetry measures for the volunteers did not show ab- normalities, measurements during clinical situations could help clarify any role that oxygenation plays in pulse abnormalities. Our investigations suggest that oximetry in medical settings, such as hospitals, and nonmedical settings, such as group homes, may be a viable, cost-effective tool that could protect persons who are subjected to physical restraint from respiratory embarrass- ment, suffocation, and death. Kim James Masters, M.D. Deborah Wandless, L.P.N. Dr. Masters is affiliated with the psychiatry department at Pines Residential Treatment Center, Midlands Campus, in West Colum- bia, South Carolina, and Charleston Cam- pus. Ms. Wandless is director of nursing at New Hope Treatment Center in Rock Hill, South Carolina. References 1. Mohr WK, Petti TA, Mohr BD: Adverse ef- fects associated with physical restraint. Canadian Journal of Psychiatry 48:330– 2. American Academy of Child and Adoles- cent Psychiatry: Practice parameter on the prevention and management of aggressive behavior in psychiatric institutions with special reference to seclusion and restraint. Journal of the American Academy of Child and Adolescent Psychiatry 41:(suppl 2): 4s–25s, 2002 3. Sentinel Alert 8. Oakbrook Terrace, Ill, Joint Commission on Accreditation of Healthcare Organizations, 1998 4. Reeves RR, Ladner ME: Screening for de- creased oxygen saturation during medical

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