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ABSTRACT Aims Methods Results Conclusions Relevance to the Clinical Practice Patient or Public Contribution Trial Registration To identify and characterise the approaches and instruments used in recent literature to measure the prevalence of restrictive care practices in adult mental health inpatient units. Additionally, it sought to summarise the reported psychometric properties, including reliability and validity of these measures.A systematic review of recent litratures was conducted using Scopus, MEDLINE, CINAHL, PsycINFO, Web of Science and Embase databases to identify studies published from 1 January 2010 to 11 October 2023. A total of 128 studies measuring the use of restrictive care practices were included. Data on measurement methods were extracted from each study and summarised to compare how consistently these practices have been measured across studies and how authors consistently reported the reliability and validity of these measurment approaches. All findings were reported following the PRISMA 2020 checklist.There were significant variations in how the prevalence of restrictive care practices was measured, and the reliability and validity of these measurements were unclear for most studies. Only 11 studies reported inter/intra‐rater reliability. Key variations were observed in data sources utilised, how and by whom the data were collected, the timing and total duration of data collection during patient admission, how and by whom data were extracted from secondary sources, measurement instruments and the reported reliability and validity of measures.Methodological inconsistencies about the measurements approaches of restricitve care practices would introduduce potential random and/or systematic biases on the reported data which may obscure the the true prevalance these practices. This hinder the ability to acurately assess the effectiveness of reduction strategies and understand the naturally occuring practices. Establishing a standardised set of reliable measures is crucial for enabling valid comparisons for the rates of restricitve car epractice use across settings and countries, which could enhance the ongoing monitoring and reduction of these practices.The absence of standardised defintions and measurement approaches for restrictive care practices challenges the global effort to reduce their use. Without reliable and common measures, clinicians and researchers often face challenges in documening RCP incidents accurately, compromising efforts to improve care quality and support a recovery‐oriented approach. Such measurment errors would mislead decission‐maker which would furhter contribute to the inconsistency the the implementation of these practices.No patient or public contribution.PROSPERO: CRD:42022335167; https://www.crd.york.ac.uk/prospero/export_details_pdf.php [ABSTRACT FROM AUTHOR]

ABSTRACT There is a global initiative to reduce the use of restrictive care practices in mental health settings. Variations in the reported rates across regions complicate the understanding of their use and tracking trends over time. However, it remains unclear whether these discrepancies reflect real differences in the implementation of these practices or are sourced from inconsistencies in incident classification and reporting methods. This study employed a co‐design approach to identify contexts that would influence the classification and reporting of restrictive care practices. The research involved 29 mental health stakeholders, including 22 professional experts from 13 countries across Europe, Africa, North America, Asia and Australasia and seven service users and family carers from Australia. Recruitment was conducted through email invitations, snowball sampling and social media outreach. Six web‐based panel meetings, each lasting 90–120 minnutes were held. These discussions focused on exploring various contexts that might lead to uncertainty among professionals when classifying and reporting actions whether or not as restrictive care practices. A final list of 23 contexts was identified and considered for the development of 81 case scenario items. Finally, all the 29 panel members selected 44 from 81 case scenarios for inclusion in an upcoming international survey to examine variations in the classification and reporting of restrictive care practices. The findings from this co‐design work emphasise the involvement of a wide range of factors and contexts in the classification and reporting of restrictive care practices that may contribute to the observed variations in the in the reported rates of these practices. The case scenarios developed in this study will support future research and serve educational purposes, illustrating real‐life situations in the mental healthcare context. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of intranasal (IN) and intramuscular (IM) administrations of azaperone (3 mg kg-1), midazolam (0. 3 mg kg-1), and ketamine (7 mg kg-1) combination (AMK) in pigs. Study design: Randomized clinical trial. Animals: sixteen adult male pigs, immunocastrated, of mixed lineage. Methods: In phase I, these animals were randomly assigned to intranasal (GIN, n = 8) and intramuscular (GIM, n = 8) groups for arterial blood sample collection at 10, 20, 30, 45, 60, and 90 min after AMK administrations for gas and electrolyte analysis. In phase II, performed 1 week after phase I, the 16 pigs were allocated to both groups (GIM, n = 16/GIN, n = 16) and submitted to the same chemical restraint (CR) protocol, with a 96-h interval between administrations. Behavioral parameters (degree of CR, muscle relaxation, loss of postural reflex, and sound stimulus response) and vital parameters (pulse rate, respiratory rate, oxygen saturation, and rectal temperature) were evaluated after recumbency (Trec) and at 5, 15, 30, 45, 60, and 90 min after administrations. In addition, the latency period and duration of CR were determined. Results: Latency to recumbency and duration of CR in GIN were shorter. CR scores did not vary between groups. Muscle relaxation was more intense in GIN at Trec. An initial tachycardia was observed, followed by a reduction in heart rate from T5 to T90 in both treatments (p < 0.05). The respiratory rate was higher at T45, T60, and T90 in GIN compared to baseline. Rectal temperature reduced in GIM from T45 onwards. PaCOt2 elevated at T90 in the GIM (p < 0.05) and there was an incidence of mild hypoxemia in 47% of the animals in the GIM. Conclusions and clinical relevance: IN administration was as effective as IM administration in promoting safe chemical restraint, with minimal changes in homeostasis, with a shorter duration and latency period. [ABSTRACT FROM AUTHOR]

Background: Restraint practice has been employed in psychiatry setting to manage patients with risk of aggression and violence. The restraint practice is also linked with the ethical, legal, and human rights of individuals and regulation has seen policies and laws on it across the globe. It is critical to assess the factors associated with restraints and its relationship with clinical variables in the Indian scenario. Materials and Methods: It was a retrospective chart review design study. It was conducted in the psychiatry department of a tertiary care hospital. The duration of the study considered from January 2024 to October 2024. We have considered purposive sampling (n = 68). We have included all patients with h/o restraints in ward stay will be included (restraint register) and excluded ward patients with no h/o any restraint and those with h/o medications given for sedation but not restraint. Results: This hospital has a 9.25% prevalence of restraint use. The main diagnoses found were alcohol use disorder presenting with delirium tremens (46.9%), mood disorder with manic or mixed episode (31.3%), schizophrenia and schizoaffective disorder (9.4%), other psychotic disorder (9.4%), and severe depression with psychotic symptom (3.1%). The main reasons for restraint were agitation/disorientation (46.9%), actual violence (46.9%), and threats of violence (6.3%). Conclusion: According to this study, receiving chemical and/or physical restraint was more frequently linked to male gender, young age, lower and middle socioeconomic status, alcohol use disorder diagnosis presenting with delirium tremens, and mood disorders presenting with mania or mixed episodes. [ABSTRACT FROM AUTHOR]

Background: The use of restraint in psychiatric inpatient settings is a contentious issue, balancing patient safety with ethical concerns. Despite India's Mental Healthcare Act of 2017, which prohibits seclusion and mandates stringent restraint regulations, restraint remains a critical intervention in managing acute behavioral crises. This study investigates the prevalence, patterns, and determinants of restraint use in a tertiary care psychiatric facility in Northern India. Materials and Methods: This hospital-based, observational, prospective study was conducted over 6 months in a 32-bedded psychiatry ward. Data were collected from ward registers, treatment charts, and patient records, documenting restraint events. Sociodemographic and clinical factors were analyzed using descriptive statistics, comparisons, and logistic regression. Results: Among 128 admissions (5,518 inpatient days), 35.1% of patients experienced restraint, yielding a restraint patient rate of 8.15 per 1000 inpatient days and an event rate of 26.1 per 1000 inpatient days. Chemical restraint was predominant (74.3% of events), followed by combined (22.9%) and physical restraint (2.8%). Restraint occurred primarily in young adults with mood and psychotic disorders, with no significant association between restraint use and sociodemographic or clinical factors. Most restraints were applied within the 1st week of admission. Conclusions: Restraint, primarily chemical, remains common in managing acute agitation and violence, especially early in hospitalization. The findings underscore the importance of balancing clinical needs with patient rights while striving for noncoercive, patient-centered psychiatric care. The findings also highlight the need for standardized reporting and continued training to minimize restraint use and promote ethical healthcare delivery. [ABSTRACT FROM AUTHOR]

Objective: Acute agitation in pediatrics is commonly encountered in hospital settings, can contribute to significant physical and psychological distress, and management is highly varied in practice. As such, the development of a standardized pharmacologic guideline is paramount. We aimed to develop a novel clinical pathway (CP) for management of acute agitation for all hospitalized pediatric patients in Canada. Methods: Healthcare professionals in Canada with expertise in treating and managing pediatric agitation formed a working group and developed a CP through conducting a literature review, engaging key partners, and obtaining interdisciplinary consensus (iterative real-time discussions with content experts). Once developed, the preliminary CP was presented to additional internal and external partners via multiple grand rounds and a webinar; feedback from participants guided final CP revisions. Results: The working group created a pediatric inpatient CP to guide pharmacologic management of agitation and serve as an easy-to-use clinical and educational resource with three complementary sections including: 1) a treatment algorithm, 2) a quick reference medication chart, and 3) two supporting documents, which provide a general overview of non-pharmacologic strategies prior to CP implementation and an illustrative scenario to accompany the medication chart to ensure effective utilization. Conclusions: This is the first CP to standardize pharmacological treatment and management of acute agitation in children in inpatient settings in Canada. Although further research is warranted to assess implementation and support process improvement, the CP can be adapted by individual institutions to assist in prompt pharmacological management of pediatric agitation to potentially improve outcomes for patients, families, and healthcare professionals. [ABSTRACT FROM AUTHOR]

ObjectiveTo compare the efficacy of intranasal (IN) and intramuscular (IM) administrations of azaperone (3 mg kg−1), midazolam (0. 3 mg kg−1), and ketamine (7 mg kg−1) combination (AMK) in pigs. Study design: Randomized clinical trial. Animals: sixteen adult male pigs, immunocastrated, of mixed lineage.MethodsIn phase I, these animals were randomly assigned to intranasal (GIN, n = 8) and intramuscular (GIM, n = 8) groups for arterial blood sample collection at 10, 20, 30, 45, 60, and 90 min after AMK administrations for gas and electrolyte analysis. In phase II, performed 1 week after phase I, the 16 pigs were allocated to both groups (GIM, n = 16/GIN, n = 16) and submitted to the same chemical restraint (CR) protocol, with a 96-h interval between administrations. Behavioral parameters (degree of CR, muscle relaxation, loss of postural reflex, and sound stimulus response) and vital parameters (pulse rate, respiratory rate, oxygen saturation, and rectal temperature) were evaluated after recumbency (Trec) and at 5, 15, 30, 45, 60, and 90 min after administrations. In addition, the latency period and duration of CR were determined.ResultsLatency to recumbency and duration of CR in GIN were shorter. CR scores did not vary between groups. Muscle relaxation was more intense in GIN at Trec. An initial tachycardia was observed, followed by a reduction in heart rate from T5 to T90 in both treatments (p < 0.05). The respiratory rate was higher at T45, T60, and T90 in GIN compared to baseline. Rectal temperature reduced in GIM from T45 onwards. PaCO2t elevated at T90 in the GIM (p < 0.05) and there was an incidence of mild hypoxemia in 47% of the animals in the GIM.Conclusions and clinical relevanceIN administration was as effective as IM administration in promoting safe chemical restraint, with minimal changes in homeostasis, with a shorter duration and latency period.

Aim: This study aimed to evaluate the knowledge, attitudes, and skills of intensive care nurses regarding physical and chemical restraint. Material and Methods: It is a descriptive cross-sectional study conducted with 108 nurses working in a training and research hospital between March and April 2021. The data of the study were collected using the "Nurse Identification Form", "Level of Knowledge, Attitude, and Practices for Using Physical Restraint Scale for Nurses" and "Sedation Practice Scale". Results: It was found that the mean knowledge score was 7.96±2.73, the mean attitude score was 32.31±5.97 and the mean practice score was 36.86±4.55. The mean score of "Beliefs and Attitudes Regarding Sedation Practices" was 4.09±0.72, the mean score of "External Factors in Sedation Management" was 3.07±0.96, and the mean score of "Sedation Management Practices" was 3.89±0.60. Conclusion: It was determined that the average scores of intensive care nurses on the Sedation Practice Scale and the Level of Knowledge, Attitude, and Practices for Using Physical Restraint Scale for Nurses were high. [ABSTRACT FROM AUTHOR]

Psychiatrists prescribe the psychotropic medication that is used to manage behaviors of concern (BOC) in people with intellectual disability (ID) (i.e., chemical restraint), and their attitudes and perceptions towards this treatment are important topics for study. 133 Queensland psychiatrists and psychiatry trainees completed a survey on attitudes and perceptions of ID and psychotropic medication. Exploratory cluster analysis was performed on 14 Likert items from this survey to detect groupings within the data. Cluster analysis indicated the existence of two distinct clusters. While both groups were willing to be involved in the treatment of adults with ID, Cluster 1 held attitudes that showed inconsistencies with human rights principles and with international guidelines regarding psychotropic medication use for BOC. Our study highlights that the attitudes and perceptions of a significant subgroup of psychiatrists may contribute to the overprescribing of psychotropics for BOC. [ABSTRACT FROM AUTHOR]

Abstract Background The prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care. Methods Publicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken. Results Four key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family’s fight for liberty. Triangulation across the data and academic literature supports the findings. Conclusion Our findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a “first resort” care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers.

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision‐making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision‐making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision‐making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision‐making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice. [ABSTRACT FROM AUTHOR]

Background: Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use. Methods: This was a retrospective study of patients ages 8–17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital‐level factors associated with treatment with IV/IM chemical restraint medications. Results: Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13–17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48–1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64–1.74), disruptive disorders (AOR 1.61, 95% CI 1.53–1.69), suicide/self‐injury (AOR 1.3, 95% CI 1.26–1.34), substance use (AOR 1.24, 95% CI 1.20–1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17–1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26–1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40–1.47). Conclusions: We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment. [ABSTRACT FROM AUTHOR]

Background: The prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care. Methods: Publicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken. Results: Four key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family's fight for liberty. Triangulation across the data and academic literature supports the findings. Conclusion: Our findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a "first resort" care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers. [ABSTRACT FROM AUTHOR]

Background: Adults with intellectual disability are at higher risk of being administered psychotropic medications. The UK‐developed SPECTROM (Short‐term PsychoEducation for Carers To Reduce Over Medication of people with intellectual disabilities) training programme educates disability support workers on psychotropic medications and alternatives to these medications. Method: Interviews were conducted with 10 participants who took part in the pilot SPECTROM training programme to elicit their views on the programme and its appropriateness in an Australian context. Results: The key theme was 'Need for a psychotropic medication practice framework'. Four sub‐themes were Broad satisfaction with the SPECTROM training programme; Disability support workers acknowledging the limitations of their scope of practice; Empowering training through prescriptive and reflective methods and; Need for future mentoring from Multi‐Disciplinary Team members in the application of new knowledge. Conclusions: Participants felt that whilst they could improve their knowledge and attitudes surrounding psychotropic medication administration for behaviours of concern through SPECTROM training, a national practice framework is needed to execute its goals at scale. [ABSTRACT FROM AUTHOR]

Complaints reflect a person's or family's experience within the aged care system and provide important insight into community expectations and consumer priorities. Crucially, when aggregated, complaints data can serve to indicate problematic trends in care provision. Our objective was to characterize the areas of medication management most frequently complained about in Australian residential aged care services from 1 July 2019 to 30 June 2020. A total of 1134 complaint issues specifically referenced medication use. Using content analysis, with a dedicated coding framework, we found that 45% of these complaints related to medicine administration processes. Three categories received nearly two thirds of all complaints: (1) not receiving medication at the right time; (2) inadequate medication management systems; and (3) chemical restraint. Half of the complaints described an indication for use. These were, in order of frequency: 'pain management', 'sedation', and 'infectious disease/infection control'. Only 13% of medication-related complaints referred to a specific pharmacological agent. Opioids were the most common medication class referred to in the complaint dataset, followed by psychotropics and insulin. When compared to complaint data composition overall, a higher proportion of anonymous complaints were made about medication use. Residents were significantly less likely to lodge complaints about medication management, probably due to limited engagement in this part of clinical care provision. [ABSTRACT FROM AUTHOR]

Practical relevance: The '2022 AAFP/ISFM Cat Friendly Veterinary Interaction Guidelines: Approach and Handling Techniques' (hereafter the 'Cat Friendly Veterinary Interaction Guidelines') support veterinary professionals with feline interactions and handling to reduce the impact of fear and other protective (negative) emotions, in so doing enhancing feline welfare and In implementing these Guidelines, team satisfaction and cat caregiver confidence in the veterinary team will increase as the result of efficient examinations, better experience, more reliable diagnostic testing and improved feline wellbeing. Veterinary professionals will learn the importance of understanding and appropriately responding to the current emotional state of the cat and tailoring each visit to the individual. Clinical challenges: Cats have evolved with emotions and behaviors that are necessary for their survival as both a predator and prey species. A clinical setting and the required examinations and procedures to meet their physical health needs can result in behavioral responses to protective emotions. Cat friendly interactions require understanding, interpreting and appropriately responding to cats' emotional states and giving them a perceived sense of control while performing the required assessment. Evidence base: These Guidelines have been created by a Task Force of experts convened by the American Association of Feline Practitioners and the International Society of Feline Medicine, based on an extensive literature review and, where evidence is lacking, the authors' experience. Endorsements: These Guidelines have been endorsed by a number of groups and organizations, as detailed on page 1127 and at catvets.com/interactions and icatcare.org/cat-friendly-guidelines. [ABSTRACT FROM AUTHOR]

Chemical restraint research is growing with multiple healthcare disciplines increasing focused on understanding uses, harms of restraint and restraint reduction in inpatient mental health settings. Despite increased restraint research relatively little is known about nurses' experiences of administering chemical restraint. The research question guiding this study was: what are mental health nurses' experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? The purpose of the research was to understand direct care nurses' first-hand experiences in use of chemical restraint interventions. Eight adult acute inpatient mental health nurses were interviewed using hermeneutic phenomenological method. The aim of this paper to discuss three themes that emerged in the research which clearly highlight the complex ethical issues and education needs of mental health nurses who use chemical restraint: working within constraints, making medication choices, and transitioning from novice to expert. Research findings indicated a need for further focus on medication best practice, policy development and nurse education. These exploratory research findings can be used to both inform and challenge dominant inpatient mental health practice to guide nurses, health care leaders, and policy makers by increasing understanding of the complex ethical decision-making required for use of chemical restraint interventions. Education strategies can be developed from the findings which highlight integral ways that nurses make meaning in their administering of chemical restraint, and their accompanied insights into the complex clinical and ethical decision-making aspects involved in nursing care. • The reasearch question was: what are mental health nurses' experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? • Three themes that emerged were: (1) working within constraints, (2) making medication choices, and (3) transitioning from novice to expert. • This exploratory research provides insights into the complex clinical and ethical decision-making involved in mental health nurses' use of chemical restraint interventions. • Findings can be used to develop standard policy, practice and education strategies that consider ways nurses make meaning of chemical restraint use. [ABSTRACT FROM AUTHOR]

Background: There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients. Methods: We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study. Results: The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers. Conclusion: The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints. [ABSTRACT FROM AUTHOR]

To determine the effective dosage of the combination tiletamine–zolazepam–ketamine–xylazine (TKX), with or without methadone, in dogs. Prospective, randomized, experimental study. A total of 29 dogs. Dogs were randomly administered TKX (group TKX, n = 13) or combined with 0.3 mg kg–1 of methadone (group TKXM, n = 16) intramuscularly. The TKX solution contained tiletamine (50 mg mL–1), zolazepam (50 mg mL–1), ketamine (80 mg mL–1) and xylazine (20 mg mL–1). The effective dosages for immobility in 50% and 95% of the population (ED 50 and ED 95) were estimated using the up-and-down method. Approximately 20 minutes after drug administration, a skin incision was performed and the response was judged as positive or negative if the dogs moved or did not move, respectively. The TKX volume for the subsequent dog in the same group was increased or decreased by 0.005 mL kg–1 if the response of the previous dog was positive or negative, respectively. Heart and respiratory rates, and sedation/anesthesia scores (range 0–21) were recorded before and 15 minutes after drug administration. Estimated ED 50 and ED 95 (95% confidence intervals) were: TKX, 0.025 (0.020–0.029) and 0.026 (0.010–0.042) mL kg–1; TKXM, 0.022 (0.018–0.025) and 0.033 (0.017–0.049) mL kg–1. Median (interquartile range) scores for sedation/anesthesia were 17 (16–18) and 17 (15–20), and times until lateral recumbency were 5 (4–6) and 6 (4–10) minutes in TKX and TKXM, respectively (p > 0.05). In both groups heart and respiratory rates decreased, but values remained acceptable for anesthetized dogs. The results provide a guide for volumes of TKX and TKXM in dogs requiring restraint for minimally invasive procedures. Inclusion of methadone in the TKX combination did not influence ED 50. [ABSTRACT FROM AUTHOR]

Aggressive and violent behaviours often lead to the use of coercive interventions in health and forensic institutions. Restraint minimization is now a legal or governmental requirement in most jurisdictions. While physical restraint and seclusion are relatively well-understood, chemical restraint remains problematic to define and measure. The aim of this review is to explore the international understandings of chemical restraint and to formulate an operational definition to support the development of quality indicators and care standards. This review was the first step prior to a realist synthesis to clarify the scope of chemical restraint intervention. PRISMA extension for Scoping Review was used. A keyword-based literature review (2006–2020, French and English) was conducted in health and social science databases. Chemical restraint or sedation of behavioural symptoms involves an emergency (STAT), as needed (PRN), regular or continuous medication with sedative properties, administered with the intention of preventing or controlling harmful behaviours or behaviours that interfere with diagnostic or therapeutic interventions, AND/OR administered to avoid physical restraint or seclusion; AND/OR without the person's consent. This first operational definition of chemical restraint could support the development of quality indicators in addition to allowing initiatives to improve health outcomes, safety and promote person-centred care. • Elimination of chemical restraint has been stated as a global priority. • No operational definition of chemical restraint or valid quality indicator exist. • Defining chemical restraint requires uncovering the intentions of the provider in charge of the administration. • This definition can support measurement, security and quality improvement. [ABSTRACT FROM AUTHOR]

With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices. [ABSTRACT FROM AUTHOR]

Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6–36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2−0.8)), although no dose differences were found for droperidol. 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness. [ABSTRACT FROM AUTHOR]

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

Introduction: The incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED.Methods: Adult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of >50 mmHg, a change of 10% above or below baseline, or a loss of waveform for >15 seconds. Hypoxia was defined as a SpO2 of 15 seconds.Results: We enrolled 59 patients, and excluded 9 because of >35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42-69%); the median number of events was 2 (range 1-6).  Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29-55%); the median number of events was 2 (range 1-5). Nineteen (19/21) (90%, 95% CI 71-97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56-91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68-98%) and specificity 69% (95% CI: 49-84%).  Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24  had a concurrent psychiatric history.  None of these patients had a major adverse event.Conclusion:  About half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians. [West J Emerg Med. 2014;15(4):430-437.]

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CH emical R estraints av O idance ME thodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn. [ABSTRACT FROM AUTHOR]

While there is a growing body of research available on general restraint intervention in acute adult psychiatric settings, relatively little is known about nurses’ experiences of administering chemical restraint. The research question explored in this study was: what are mental health nurses’ experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? Through this Canadian study understanding of direct care nurses’ first-hand experiences of the use of chemical restraint interventions was sought. Eight adult acute inpatient mental health nurses were interviewed using hermeneutic phenomenological method. Two major themes that emerged from data analysis are explored to illuminate the existing tension between therapeutic, person-centred care and coercive control to maintain safety: taking control to maintain safety and working within constraints. Integral ways that nurses make meaning from administering chemical restraint were found, as well as some of the complex clinical and ethical decision-making aspects involved in psychiatric nursing care. Implications for practice, education, and policy are discussed. Research findings indicated a need for further focus on medication best practice, policy development and nurse education. These exploratory research findings can be used to both inform and challenge dominant inpatient mental health practice to guide nurses, health care leaders, and policy makers by increased understanding of the complex ethical decision making required for use of chemical restraint interventions.

BackgroundPhysical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting.MethodsA systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied.DiscussionThis review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research.Systematic Review RegistrationPROSPERO registration number: CRD42019116186.

INTRODUCTION: This study was conducted to evaluate the knowledge of manager service/ICU nurses about physical and chemical restraint practices. METHODS: In this study, a descriptive phenomenological method was used based on the concept of "restraint". The concept of restraint was considered as physical restraint and chemical restraint. The study was conducted with general service/ıntensive care units manager nurses at a Research Hospital. The analysis of the data was done in 4 steps using Giorgi's (1997a; 2000b) phenomenological method analysis. RESULTS: The average age of the manager nurses was 32,57 +- 6,36 and the average of the total working years was 9,73 +- 6,18. According to the expressions of the manager nurses, two hours, benefit, patient safety, fastening, doctor-nurse, verbal and written permission, speaking and helping themes were appeared. DISCUSSION AND CONCLUSION: In this study, it was determined that manager nurses stated that they used restraints by reasons such as not harming the patient, benefiting, patient safety. It should not be forgotten that despite the fact that the restraint procedure is for the benefit of the patient, this procedure restricts the patient's freedom and has complications that may reach to death.

The study evaluated the combination of ketamine, dexmedetomidine, and meperidine for vasectomy in golden‐headed lion tamarins. Lidocaine infiltration was required for intraoperative analgesia and atipamezole was used at the end of the procedure. The protocol promoted satisfactory sedation and analgesia with a short recovery time in tamarins. [ABSTRACT FROM AUTHOR]

Practical relevance: Procedural sedation and analgesia (PSA) describes the process of depressing a patient's conscious state to perform unpleasant, minimally invasive procedures, and is part of the daily routine in feline medicine. Maintaining cardiopulmonary stability is critical while peforming PSA. Clinical challenges: Decision-making with respect to drug choice and dosage regimen, taking into consideration the cat's health status, behavior, any concomitant diseases and the need for analgesia, represents an everyday challenge in feline practice. While PSA is commonly perceived to be an uneventful procedure, complications may arise, especially when cats that were meant to be sedated are actually anesthetized. Aims: This clinical article reviews key aspects of PSA in cats while exploring the literature and discussing complications and risk factors. Recommendations are given for patient assessment and preparation, clinical monitoring and fasting protocols, and there is discussion of how PSA protocols may change blood results and diagnostic tests. An overview of, and rationale for, building a PSA protocol, and the advantages and disadvantages of different classes of sedatives and anesthetics, is presented in a clinical context. Finally, injectable drug protocols are reported, supported by an evidence-based approach and clinical experience. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on the subject?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted.Chemical restraint involves the use of medication. What the paper adds to existing knowledge?: This is the first paper to systematically review the prevalence of the use of chemical restraint.The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide.Consumers who are restrained are also likely to receive chemical restraint.The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. What are the implications for practice?: Implications of practice include the need to report adverse events post‐chemical restraint as these can deleteriously affect a person's physical health.Identification of and staff education about first‐line management techniques before chemical restraint is administered are significant to reduce its use. Introduction: Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim: This systematic review aimed to synthesize the international prevalence of chemical restraint for non‐consenting adults. Method: PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer‐reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results: Forty‐eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice: This is the first known comprehensive meta‐view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement: There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non‐consenting adults. This meta‐view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use. [ABSTRACT FROM AUTHOR]

Background: The use of chemical restraints (CRs) in health care facilities is a complex intervention that raises questions about its effectiveness and whether it is safe and patient oriented. Purpose: This review aims to gather nursing quality standards for the use of CR through an innovative method of knowledge synthesis, the realist review, to support the development of a quality evaluation tool. Methods: A realist review method was chosen. Results: An operational definition of chemical restraint is proposed, a concept seen as synonymous with the management of behavioral symptoms by pharmacological agents with sedative proprieties. Twenty-eight quality standards were identified and presented in a theoretical model. Conclusions: These quality standards will allow the evaluation of practices from a nursing perspective for the use of CR in health care settings. [ABSTRACT FROM AUTHOR]

Background: Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non‐consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. Aims: To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. Methods: This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. Results: This review identified 311 relevant primary studies (21 RCTs; 46 non‐controlled experimental or prospective observational studies; 77 cross‐sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross‐country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). Discussion A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non‐consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non‐chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research. [ABSTRACT FROM AUTHOR]

Background: Psychotropic medication is widely prescribed to treat mental illness. However, it is controversial when used as a chemical restraint (CR) to manage challenging behaviours (CBs) of adults with intellectual disability (ID). CR has potentially negative consequences and affects human rights.Method: Qualitative research conducted between 2014 and 2015 explored the views of 'guardian' decision makers appointed under unique Queensland legislation oversighting the use of CR.Results: Findings included (1) negative conceptualization of CR, (2) concerning relationships with prescribers and disability sector staff, (3) challenges to information seeking about people with ID prescribed CR and (4) problematic implementation of positive behaviour support plans.Conclusion: According to guardians, CR may be used in lieu of community supports, and prescribers sometimes diagnose mental illness to avoid CR legislative requirements. Guardians, prescribers and professionals would benefit from training that addresses the intersection between physical and mental health, CB and CR. [ABSTRACT FROM AUTHOR]

In Quebec, control measures – isolation, restraints and chemical substances – have been the subject of a legislative framework since 1998. However, since that date, chemical substances have been at the heart of a debate on their legal status, between therapy and control. In 2015, the Ministry of Health and Social Services published a revised Reference Framework that is supposed to establish guidelines for chemical substances used for control purposes. A review of this framework, however, reveals several inconsistencies, continuing an indeterminacy about their status. On the one hand, the consent exception does not correspond to the Quebec legal framework for care, suggesting that it is indeed a control measure. On the other hand, the reserved acts are the same whether the chemical substances are used for control or for therapeutic purposes, suggesting that it is in fact a therapeutic measure. [ABSTRACT FROM AUTHOR]

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base. [ABSTRACT FROM AUTHOR]

Objective: Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria.Design: Observational prospective longitudinal study.Setting: Single nursing home in Las Palmas de Gran Canaria, Spain.Participants: 288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia.Intervention: Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription.Measurements: Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107).Results: For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005).Conclusions: Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries. [ABSTRACT FROM AUTHOR]

Background: Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting. Methods: A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied. Discussion: This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research. Systematic Review Registration: PROSPERO registration number: CRD42019116186. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to describe the sedative and some physiological effects of tiletamine–zolazepam following buccal administration (BA) in cats. Methods: Seven healthy spayed European shorthair cats (three males, four females) were studied twice in this randomized, blinded, crossover study. Each cat received two doses of tiletamine–zolazepam by BA: the low-dose (LD) group consisted of 5 mg/kg of each drug, and the high-dose (HD) group consisted of 7.5 mg/kg of each. Baseline systolic blood pressure (SAP), heart rate (HR), respiratory rate (RR) and a sedation score were recorded prior to administration of each treatment. The same variables plus the percentage of hemoglobin saturated with oxygen as measured by pulse oximetry (SpO2) were recorded at predefined intervals for the next 2 h. Results: All cats completed the study. No retching or vomiting were observed. Hypersalivation was observed in 0/7 and 3/7 for LD and HD groups, respectively (P = 0.2). There were significant changes in scores over time for posture, response to clippers and response to manual restraint for both groups, without differences between groups. RR, HR and SAP changed significantly over time. SAP and RR were significantly lower for the HD than for the LD group. No values for hemoglobin saturation <95% were observed. Conclusions and relevance: BA of tiletamine–zolazepam at the doses studied here is a simple and effective method for chemical restraint in cats, where the LD group had a lower impact on SAP and RR than the HD group. [ABSTRACT FROM AUTHOR]

Blue poison dart frogs (Dendrobates tinctorius azureus) are commonly maintained in zoological institutions and are becoming popular in the pet trade industry. Sedation or light anesthesia is required for safe and effective handling of this species. In this study, the sedative effects of subcutaneously administered alfaxalone–midazolam–dexmedetomidine (AMD) (20, 40, 5 mg/kg, respectively) and ketamine–midazolam–dexmedetomidine (KMD) (100, 40, 5 mg/kg, respectively) were compared in a prospective, randomized, blinded, crossover study in juvenile blue poison dart frogs (n = 10). Both protocols were partially reversed 45 min after administration of either protocol with subcutaneously administered flumazenil (0.05 mg/kg) and atipamezole (50 mg/kg). Heart rate, pulmonic respiratory rate, various reflexes, and behavioral parameters were monitored after drug administration. Both protocols resulted in rapid loss of righting reflex [median (range): AMD, 5 min (5–5 min); KMD, 5 min (5–10 min)]. Time to complete recovery was similar with both protocols (mean ± SD: AMD, 97.5 ± 11.4 min; KMD, 96.5 ± 25.4 min). The AMD protocol resulted in pulmonic respiratory depression, whereas no significant difference in heart rate was found between the two protocols. All frogs were observed eating within 24 hr of chemical restraint. Gastric prolapses occurred in four frogs (AMD 3, KMD 1) that were easily reduced with a cotton-tip application. No other adverse reactions were observed. The results of this study provide two different subcutaneous chemical restraint protocols in juvenile blue poison dart frogs. [ABSTRACT FROM AUTHOR]

Reducing and/or eliminating the use of coercive measures in psychiatric services is a priority worldwide. Chemical restraint is one such measure, yet to date has been poorly defined and poorly investigated. The aim of this study was to examine chemical restraint use in 12 adult acute inpatient psychiatric units in Adelaide, South Australia. Methods involved the analysis of all reported chemical restraint events occurring over a 12‐month period analysed using a descriptive quantitative design. There were 166 chemical restraint events involving 110 consumers. The highest prevalence rate in an individual unit was 28.78 events per 1000 occupied bed days, with the lowest being 0.12 events per 1000 occupied bed days. More males (n = 69, 57.5%) were involved in chemical restraint than females. Schizophrenia, schizotypal, and delusional disorders were the predominant diagnoses among consumers who were chemically restrained. The most events occurred during three time blocks: 14.00–14.59 pm, 16.00–16.59 pm, and 21.00–21.59 pm. The two most common medications used were olanzapine and clonazepam. The study presents a general picture of the practice of chemical restraint in Adelaide and identifies areas of concern in relation to the need for monitoring of side effects and completion of systematic processes of documentation regarding chemical restraint events. Findings highlight the need for sustained focus on reducing the need for chemical restraint and exploring less restrictive measures with those most likely to receive medication against their will. [ABSTRACT FROM AUTHOR]

To evaluate if intramuscular (IM) lidocaine potentiates the sedative effects of alfaxalone and results in cardiopulmonary changes in sedated bearded dragons. Prospective experimental crossover study. A group of eight adult bearded dragons (Pogona vitticeps) weighing 334 ± 46 g. Animals were administered alfaxalone (10 mg kg−1 subcutaneously) and 15 minutes later either lidocaine 2% (4 mg kg−1) or 0.9% sodium chloride (0.2 mL kg−1) was administered IM in the thoracic limb. The treatments were randomized and separated by 7 days. Sedation was scored based on body position, eye closure, jaw tone, swallowing, pick up response, righting reflex and pelvic limb withdrawal reflex. Heart rate (HR) and respiratory rate (f R) were recorded every 5 minutes until recovery from sedation. Lidocaine had no significant effect on duration or depth of alfaxalone sedation. HR increased significantly for <10 minutes following lidocaine administration by a median (interquartile range) of 33% (28–37%; p = 0.024). No clinically significant effects on f R occurred following lidocaine injection. Administration of lidocaine 2% (4 mg kg−1) IM did not potentiate alfaxalone sedation but resulted in a transient clinically relevant increase in HR. [ABSTRACT FROM AUTHOR]

This article argues that there exist unnecessary gaps in the regulation of the use of physical, mechanical and chemical restraints in mental health and aged care settings. While the use of these forms of restraint may be rationalised on the basis of preventing harm to self or others, there are adverse consequences that necessitate the minimisation, if not elimination, of their use. The overuse of mechanical and chemical restraints at the Oakden Older Persons Mental Health Service in South Australia led to several scathing inquiries. This article looks at the lessons learned and suggests a multidimensional, consistent approach is overdue. [ABSTRACT FROM AUTHOR]

Intranasal anesthesia in birds is considered a safe, simple and efficient technique. The aim of this study was compare the anesthetic effects of midazolam (5 mg.kg-1) with racemic (R) or S+ (S) ketamine (15 mg.kg-1), administered intranasally (IN) or intramuscularly (IM) in budgerigars (Melopsittacus undulatus). Eight budgerigars were used in a crossover design with four treatments: INR, INS, IMR and IMS. Onset time, dorsal recumbency time duration, total anesthesia time, total recovery time, sedation degree and recovery quality were evaluated. Significant differences were observed in onset time between INS (40.25±10.55 sec) and IMR (74.32±21.77 sec); between administration vials for dorsal recumbency time, INS (23.93±7.51 min) and INR (28.68±16.13 min), which were different from IMS (60.08 ± 27.37 min) and IMR (74.3±21 min). In total anesthesia time, INS (45.48±17.94 min) and INR (39.24±15.62 min) were different from IMS (75.84±20.20 min) and IMR (20.73±79.4 min). The total recovery time was significantly higher in INS (21.55±18.43 min) compared to IMR (5.1±3.56 min). The results of this study indicated that both administration vials can be used for short time non-invasive procedures and the intranasal vial is preferable for fast procedures.

The article focuses on use of chemical restraint remains controversial with different understandings of what it is and its role in the care of acutely unwell psychiatric consumers. It mentions unique and separate issues relating to the use of chemical restraint in people with a disability, older people in residential care settings and children and adolescents with mental health problems. It also mentions use of psychotropic medication to control severe agitation, or violent behaviours.

Bilateral corneal opacity was observed in a free ranging adult male wild water buffalo (Bubalus arnee). The opacity had severely affected its vision, forcing the animal to depend on the sense of hearing and smell. The animal was chemically immobilized to facilitate a thorough examination. Both eyes were washed with normal saline and then subjected to fluorescein test (using fluorescein strips) to rule out the presence of any point of ulceration on the corneal surface. Conjunctively ceftriaxone, prednisolone and Placentrex (placental extract) were injected in both the eyes. The animal became more active after a week of this line of treatment and was able to roam freely with restored vision by the 22nd day of treatment. [ABSTRACT FROM AUTHOR]

This report describes weekly repeated anesthesia in a 7-yr-old, 1,030 kg, female Eastern black rhinoceros (Diceros bicornis michaeli), that was immobilized six times using a combination of 2 mg etorphine (0.002 mg/kg), 5 mg medetomidine (0.005 mg/kg), 25 mg midazolam (0.024 mg/kg), and 300 mg ketamine (0.29 mg/kg) delivered intramuscularly (IM) via remote dart to facilitate long-term medical care of a bilateral, obstructive Actinomyces sp. rhinitis. The drug combination described in this study resulted in reliable, rapid recumbency of the animal within 2–8 min after initial administration via dart and produced deep anesthesia for 34–78 min without supplemental anesthetic administration. Antagonist drugs (100 mg naltrexone [0.1 mg/kg] and 25 mg atipamezole [0.024 mg/kg] IM) produced reliable and uneventful recoveries in all the procedures. During each anesthetic procedure, the animal was intubated and provided intermittent positive pressure ventilation with a megavertebrate demand ventilator. Tachycardia and hypoxia noted after induction resolved after positive pressure ventilation with oxygen. This report provides useful information on a novel anesthetic protocol used repeatedly for intensive medical management in a black rhinoceros. [ABSTRACT FROM AUTHOR]