Shared learning database

Type and Title of Submission


Advances in preventing injury and death during physical restraint


Following the publication of the David Bennett Inquiry (December 2003), 2gether NHS Foundation Trust commenced a programme of enhancing the clinical skills of staff involved in Rapid Tranquilisation and Physical Interventions. In undertaking this programme of training recommendations from the inquiry, public evidence from national organisations and professional journals, were utilised to develop a comprehensive training programme which identified potential and possible risk factors which need to be considered during restraint. This led us to introduce Medical Emergency Response Teams (MERT).



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG25 - Violence

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?


Description of submission


The implementation of the Medical Emergency Response Team ensures that each and every incident of restraint is attended by the Medical Emergency Response Team (MERT) Assessor, whose role is to assess, monitor and advocate for the physical wellbeing of the patient subjected to restraint. Also, an initial audit of the use of restraint has also been undertaken within the Trust.


Our key objectives were to: 1) Introduce an independent advocate for the patient's physical wellbeing whilst subjected to physical restraint. 2) To implement a robust system which ensures that a trained team will respond to any medical emergency (on site) and will be able to deliver a shock from an Automated External Defibrillator (AED) to the collapsed victim of a cardiac arrest, within the recommended guidance of 3 minutes as set by the Resuscitation Council (UK). 3) Establish a locally agreed calling criteria which could be used by staff (and this has been implemented across the local health community in Gloucestershire) should a patient's condition deteriorate, this leading to a medical emergency.


Firstly, we self assessed ourselves (as a Trust) against the NICE criteria. Then we reviewed access and the availability of Junior Doctors following the implementation of the New Deal for Doctors. We also reviewed the equipment and forms/paperwork used throughout the Trust and this was subsequently followed up with an audit trail to be used to monitor events as they occurred. The purpose of these actions was to standardise training and equipment across the Trust, to ensure that a fool proof and robust system was in place to monitor the patient condition whilst subjected to restraint and to respond to all medical and psychiatric emergencies in a clear concise manner following recognised Trust guidelines.


1) All Patients subjected to restraint are now cared for (during the actual restraint) by a fully trained workforce (trained in Basic Life Support and the safe use of an Automated External Defibrillator and emergency oxygen). 2) At each and every incident of restraint, the physical wellbeing of the patient is monitored throughout by a registered nurse, the Medical Emergency Response Team (MERT) Assessor. 3) The Medical Emergency Response Team (MERT) Assessor is an individual whose role is to independently of the restraint team. 3) We have also introduced the use of pulse oximetry during restraint and closer monitoring of the patients physical observations during the restraint process. 4) We have been able to clearly identify risk factors associated with restraint and this has been incorporated into the Trust mandatory training package. 5) Now we have the availability (on site) of the Medical Emergency Response Team (MERT) 24 hours a day, 7 days a week. 6) And finally, we have also agreed and implemented a recognised early warning calling criteria used to summon additional help if the patient's medical condition deteriorates.

Results and evaluation

To date, we have presented at the NAPICU (National Association of Psychiatric Intensive Care Units) Annual conference and other conferences. We have also submitted and have published a paper on the introduction of the Medical Emergency Response Team (MERT) in the International Journal of Psychiatric Intensive Care Volume (November 2006) 1:3 November. Recently we completed an initial audit which demonstrates the following: a) Every incident of restraint was attended by the MERT Assessor. b) We were able to identify 8 incidences of restraint where the early warning call criteria was met. In all of these incidences, restraint was stopped. c) The physical observations of the patient were recorded in virtually 100% of all psychiatric emergency incidents. d) 80% of restraints lasted less than 10 minutes. e) The BME population was not over represented in the cohort of patients subjected to restraint.

Key learning points

It is possible to introduce a system whereby, following training, a patient subjected to restraint will receive care and treatment to a higher standard, which addresses the risk issues identified by NICE in the administration of rapid tranquilisation and the use of physical restraint. We have also liaised with other providers in supporting them to develop and introduce similar systems locally. Since first introducing the MERT system of training to the Trust in January 2005, we have adapted our own model to implement similar systems to our stand alone learning disability and rehab recovery in-patient units. Also, the MERT system is soon to be rolled out to our substance misuse in-patient units and then the Trusts older persons units. So that all in-patient units throughout the Trust will then offer the same level of response following any incidents of restraint or medical emergency. For further information see Metherall A, Worthington R & Keyte A (2006) Twenty four hour medical emergency response teams in a mental health in-patient facility ? New approaches for safer restriant, Journal of Psychiatric Intensive Care Vol.1 No.3:21?29

View the supporting material

Contact Details

Name:Raili Worthington
Job Title:Lead Resuscitation Training Officer
Organisation:2gether NHS Foundation Trust
Address:Collingwood House Training and Education Centre Horton Road
Postcode:GL1 3PX
Phone:01452 891244


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This page was last updated: 26 September 2008

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.