Background: Chemical restraints are parenteral medications used to limit patient movement or behavior rather than treat an underlying condition. Risks include oversedation, respiratory compromise, and loss of patient trust. Regulatory standards require their use only for imminent risk after less restrictive measures have failed, with strict monitoring and timely discontinuation. However, real-world practice patterns remain poorly characterized. This study retrospectively evaluated pharmacologic chemical restraint practices in adult patients, including medication selection, dosing patterns, and ordering services, to identify variability and inform development of a standardized institutional order set aligned with patient safety and regulatory standards.
Methods: A retrospective chart review was performed on patients at least 18 years of age who received at least one dose of a medication classified as a chemical restraint between March 1 and August 31, 2025 at Northside Hospital. Eligible episodes involved injectable haloperidol, ziprasidone, olanzapine, ketamine, lorazepam, diazepam, or midazolam ordered for indications such as aggressive or combative behavior, agitation/anxiety, agitation or severe/refractory agitation, psychosis, hallucinations, or chemical restraint. Patients receiving procedural sedation or anesthesia for non‑restraint purposes were excluded. The primary objective was to evaluate the pharmacological treatments used for chemical restraint. Secondary objectives included average dose used per agent and route, use of multiple restraint agents, ordering service, location of administration, and indication.
Results: The retrospective review included 45 eligible patients with violent agitation (agitation scale 3) who received parenteral chemical restraint medications. Haloperidol was the most frequently administered chemical restraint (N = 32; 37%), followed by lorazepam and ziprasidone (N = 20; 23% each), olanzapine (N = 6; 7%), ketamine (N = 5; 6%), and midazolam (N = 3; 4%). Diazepam was not utilized. Mean doses by agent and route were as follows: haloperidol, 3.99 mg intramuscularly (IM) and 2.41 mg intravenously (IV) (N = 70); ketamine, 0.67 mg/kg mg IM and 1 mg/kg IV (N = 5); lorazepam, 1.32 mg IM and 1.17 mg IV (N = 38); and midazolam, 2 mg IM and 3.67 mg IV (N = 6). Olanzapine and ziprasidone were administered exclusively via the IM route, with mean doses of 6.11mg (N = 9) and 10.66 mg (N = 38). The most frequently documented indications were agitation (N = 24; 56%) and agitation/anxiety (N = 17; 38%), while severe or refractory agitation (N = 2; 4%) and aggressive or threatening behavior (N = 1; 2%) were less common, with no other indications documented.
Most chemical restraints were ordered by Internal Medicine Services (62.2%), followed by the Emergency Department (33.3%) and the Intensive Care Unit (4.4%), with the ordering service corresponding to location of administration. Use of multiple chemical restraint agents per episode occurred in 35 cases (77.8%).
Conclusions: This study identified variability in chemical restraint utilization, dosing, route of administration, episode duration, indications, and documentation among adult hospitalized patients at Northside Hospital. Antipsychotics and benzodiazepines were most commonly used, with haloperidol administered most frequently. 77.8% of patients received multiple agents per episode, suggesting lower initial dosing strategies and the absence of a chemical restraint episode duration. These findings demonstrate the need for a standardized order set and highlight opportunities to enhance consistency in chemical restraint practices and clinical documentation. In response, an Adult Chemical Restraint Order Set was developed that includes four-hour chemical restraint episode, maximum 24-hour dosing recommendations, and age- and obstetric-specific recommendations to support appropriate agent selection and dosing. Required nursing assessments of vital signs and behavioral status were aligned with Joint Commission standards, with additional safety measures including integrated Behavioral Health consultation and electrocardiogram monitoring. This standardized framework aims to improve consistency, safety, monitoring, and documentation of chemical restraint use while promoting patient-centered care across hospital services.
