Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA is non-coercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior.

In this paper, the authors discuss several aspects of seclusion and restraint, including review of CMS guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff and a review of quality improvement and risk management strategies that have been effective in decreasing its use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment of primarily acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions. [West J Emerg Med. 2012;13(1):35–40.]