The purpose of this course is to enable the participants to understand patient and institutional factors which may necessitate the use of restraints in clinical practice. In addition, it provides alternatives that healthcare providers can explore prior to using restraints. Lastly, it gives an overview of both physical and chemical restraints used in current practices and the limitations or complications associated with the use of those specific restraints.
After the completion of this continuing education activity, the participant will be able to meet the following objectives:
Scheepmans et al. define physical restraints as any actions or devices which healthcare workers or caregivers use to restrict a patient’s freedom in any way.1 At times, it is hard for healthcare providers to define the term restraints. Sometimes administering prescribed medications can be a form of chemical restraint.
The use of restraints relies on the clinical provider's judgment of the immediate risk the patient poses to themselves, other patients, the staff working on the unit, as well as visitors to the unit. Sometimes patients will be restrained when they are at risk for elopement.2 There is an increased need for the use of restraints in both the hospital and home care setting.1
Certain conditions may make restraint use necessary when caring for patients for their own safety: impaired cognition, increased dependency, history of falls or patients at increased risk of falling and impaired mobility. Nonpatient related factors which may contribute to the use of restraints include staff skills and abilities, state legislation associated with restraint use, and staffing ratios for the hospital or facility.
Emergency room clinical providers must consider all possibilities when caring for agitated patients, including underlying psychiatric disease, alcohol abuse, drug intoxication or other life-threatening disorders, including metabolic disorders. It is imperative that clinical providers attempt to collect a detailed history from the patient and their family members. Physical examination should be targeted towards identifying the patient’s underlying cause of the agitation. Any underlying medical conditions should be addressed accordingly to obviate the need for unnecessary treatments. Examples of medical conditions which can induce agitation include hypoglycemia, drug or alcohol intoxication and head trauma.3
When taking care of agitated patients, other methods of de-escalation should be tried. Restraints should be the last resort. The use of restraints when caring for patients in the healthcare setting can have negative consequences for both the patients and clinical providers. Consequences can be physical, social and psychological.
Examples of physical consequences of restraint use include; pressure ulcers, incontinence and bruising. Social consequences include; isolation and feeling withdrawn. Psychological consequences include; depression, anger and fear. Restraint use can negatively affect family members by evoking feelings of anger, worry and guilt. Healthcare providers can also be negatively impacted by their feelings of guilt.3
Although restraint use can be lifesaving when taking care of an altered, violent or psychotic patient, there can be adverse effects associated with the use of restraints. For example, mechanical restraints can inhibit further rapport with the patient. In addition, the application of restraints can be traumatic for the patients and cause them to be more withdrawn.
State, hospital and facility policies usually govern how frequently restrained patients are evaluated. They elaborate on how often the patient’s vital signs are evaluated. They also detail rules on skin integrity, toileting, range of motion, etc. As soon as the patient is calm and quiet, the restraints can and should be removed. However, staff should continue to monitor the patient carefully for both the patient’s safety as well as that of other patients and the staff.3
The Joint Commission has stringent requirements for the use of restraints in the healthcare setting. In the hospital setting, a timed and dated physician order with frequent rechecking is required for patients in restraints, including seclusion with security watch.3
Once a patient is restrained, they require periodic and frequent evaluation to ensure that their safety is maintained while being restrained. The joint commission has a list of required assessments to be performed on patients who are restrained. According to the Joint Commission, all restraint policies must require that the restraints be removed as soon as the patient is no longer a risk to themselves or to others.3
Level of consciousness, degree of agitation, pupil examination, motor examination and sensory examination.
Heart rate, blood pressure, temperature, oxygen saturation and respiratory rate.
Focusing on motor strength in the upper and lower extremities.
Ensure that the patient has retained sensation in both the upper and lower body as well as all four extremities.
Capillary refill, distal pulses, as well as the vital signs as detailed above.
Patient comfort, skin evaluation under and around the restraints, hydration, personal hygiene and toileting needs.
De-escalation techniques which should be considered in lieu of restraint use. There are 3 phases of escalating violence as defined by Coburn and Mycyk, which are anxiety, defensiveness, and physical aggression as the last phase. These patterns of aggression are somewhat predictable, as such clinicians are encouraged to use that to their advantage in helping defuse potentially violent encounters with patients.
One simple and often underused technique is to simply ask the patient, “how can we assist you?” This allows the clinicians to engage the patient while displaying compassion. Often this is sufficient to put an agitated patient at ease. In addition, the staff should offer the patient food, drinks and help with toileting if appropriate. The goal is to treat the patient with dignity and empathy. If the patient continues to be agitated, untrained staff should immediately enlist the help of a trained staff member who can help defuse a potentially violent patient encounter. If the patient continues to be violent in spite of these measures, facility security should be called to help keep the patient, staff and other patients safe. When security does arrive, they should gather at a safe distance but within the patient’s view. Sometimes a show of force is all that is required to calm the patient, thereby making restraints unnecessary.3
Safety in caring for the elderly sometimes necessitates the use of restraints rather than instituting policies that will help restore and maintain mobility and independence as much as reasonably possible. Overall, using restraints and restricting mobility in elderly people will result in loss of function in the long run.4
There are several factors which contribute to deficiencies in safety practices when caring for elderly patients, including a lack of experience in caring for the elderly, mistaking functional decline in the elderly for a normal process of aging, and lack of access to resources.
Too often concerns about safety in elderly people are handled by limiting their mobility. However, research has shown that by maintaining and restoring functional ability among the elderly, safety concerns can be decreased. It is critical for nurses to have organizational support to assist them in developing practices that encourage nursing leaders to create practice systems which are geared towards preserving functional ability in the elderly. Leaders at the institutional level must also address organizational factors such as poor nursing staffing ratios which may indirectly contribute to safety concerns in the healthcare setting. Hospitals and other institutions are encouraged to assess for potential safety threats and address them accordingly.
Seclusion can be used in both inpatient units and specialized psychiatric units. Its use is well documented in literature. It was frequently used in the 1980s, but its use has declined significantly since then given staff shortages, specifically nursing staff shortages. In addition, most hospitals now lack adequate space to provide seclusion to all patients who need it. Seclusion remains a very effective technique for use in aggressive patients when appropriate policies and accommodations are in place.
Note that seclusion can be used in combination with other forms of restraints, including physical or chemical restraints. Patients who are placed in seclusion have to be reassessed as often as those placed in physical restraints.5
Physically restraining a patient’s limbs is the most common form of physical restraint used in clinical practice. Limb restraints can be made from different materials, including leather and cotton. In general, restraints have to be comfortable, easy to apply, easy to remove and easy to clean. Of note, leather restraints are difficult to break or tear, but they are difficult to clean if they get soiled from bodily secretions. Sometimes hard leather restraints have a difficult application and removal processes relative to soft form restraints. And that can be problematic in an acute setting when the patient is crashing. Leather limbs are usually reserved for combative and violent patients in whom the need for secure restraints is considered more important and worth the time it takes to apply or remove the restraints.3,5
Soft limb restraints are made from cotton or foam material which are intended to be used as single-use devices. They are less rigid than hard restraints and are thus easier to apply. Soft restraints are reserved for patients who are agitated but are less aggressive. Soft limb restraints are less secure than hard leather restraints.3,5
These are used as an adjunct to the 4-point restraint. It functions by restricting movement of the patient’s torso, pelvis or thighs. Fifth-point restraints are reserved for patients who continue to be a danger to themselves or others while in a 4-point restraint. It can also be used in patients whose behavior is prohibiting the medical staff from administering medically necessary care, including therapeutic interventions.3,5
Note that patients with a 5-point restraint are at increased risk of aspiration because they are unable to turn to their sides in case they start vomiting. Also, note that the 5-point restraint must be applied tight enough to prevent the risk for accidental suffocation in case the patient tries to slip under the restraint. These restraints usually require quick release locks in case of an emergency.3,5
These restraints are reserved for inpatients or patients in longer-term facilities. There are reports of associated deaths with the use of jackets or vests related to choking and suffocation.5 In general, jackets and vests are rarely used in the emergency setting. 3,5
These are characteristically used by police and law enforcement to prevent running and kicking. It is typically used in the transportation of patients. There is limited use of leg restraints in the inpatient or emergency setting.3,5
Examples of chemical restraints include medications in various classes such as benzodiazepines and antipsychotics. Sedatives can be used as a means of restraint, especially if the patient is already scheduled to be taking that medication. Chemical restraints should be used with caution because they can limit immediate psychiatric evaluation.
Benzodiazepines are commonly used as the first line medication in the management of patients who are agitated. Examples of commonly used benzodiazepines include lorazepam and diazepam. In general, sedation with a single benzodiazepine tends to be associated with undersedation, repeat dosing or oversedation requiring that the staff secure the airway.6
In the early 1990s, patient tranquilization protocols include the use of antipsychotic agents such as haloperidol and chlorpromazine. Haldol and droperidol were linked to FDA black box warnings due to the associated side effect of prolonged QT interval and potential for causing arrhythmias.6
Opiates and barbiturates are less frequently used because of the risk of respiratory depression and apnea.6 A meta-analysis published by Korczak et al. noted that patients who were sedated with benzodiazepines and antipsychotics were more likely to be sedated for longer compared to using benzodiazepines alone. Antipsychotics or benzodiazepines use alone is also associated with undersedation and repeat dosing compared to a combination of antipsychotics and benzodiazepines. Note that repeat sedation increases the risk of oversedation.6
Restraints are used to prevent patients who are agitated or violent from harming themselves, other patients or staff members. Restraints should only be used as a last resort after de-escalation techniques have failed. If patients are noted to be an immediate danger to themselves or others, they should be promptly restrained without delay.
Patients who are altered may need to be restrained to ensure that they receive life-saving medical care — for example, patients who are intubated and or patients who are sedated and require life-saving treatment.
In addition, patients who are at risk for elopement may also be restrained in very specific circumstances.
Restraints should not be used when de-escalation techniques are adequate. Restraints should not be used on fractured limbs, patients with open wounds or skin infections. Also, restraints should be used with caution in patients with impaired vascular circulation. Fifth point restraints should be avoided in patients with ostomies, feeding tubes, pelvic fractures or multiple rib fractures. Finally, patients with severe pulmonary or cardiovascular disease may not tolerate the presence of a fifth point restraint over their chest cavity as such they should be avoided.
Members of the restraint team include nurses, doctors, technicians, nurse’s assistants, physician assistants, security officers or police officers. After restraining a patient, they should be immediately searched for weapons and other harmful substances.
Restraints should be applied rapidly and safely by personnel who are trained in the application of restraints. When applying restraints in an actively violent patient, a team made up of 5 members is recommended. One team leader and one individual for each limb. Occasionally the presence of multiple team members will be enough to subdue the patient with the need to apply restraints. The team leader oversees directing the procedure of restraining the patient. The patient, as well as family members, must be provided with information about why the restraints are being applied. Also, they should always get clear instructions on the entire procedure to maintain both patient and staff safety. When the patient is restrained, offer prescribed medications if available or call a clinical provider to prescribe medications.6
You are a nurse working in the emergency department, and you are assigned to care for a patient who presented with altered mental status and agitation after being arrested for a recent fistfight outside a bar. You receive a report from another nurse at shift change who informs you that the patient has been extremely disrespectful and agitated throughout his presentation today necessitating that the physicians in the emergency department place an order for physical restraints. The previous nurse was unable to obtain a coherent past medical history from the patient, given his altered mental state. Your physical examination of the patient reveals tremors; the patient appeared to have visual and auditory hallucinations and appears to slip into varying states of consciousness. In addition, you do not smell any alcohol or other intoxicants on his breath. Upon a quick review of the chat, you recognize that the patient has had 16 prior admissions over the past two years associated with alcohol abuse or intoxication. What are your next steps?
The patient’s past medical history and your findings during the physical exams should raise the possibility of alcohol withdrawal. Early alcohol withdrawal symptoms can present as early as 6 to 8 hours after their last drink and may include mild tremors, diaphoresis, palpitations and anxiety. Later symptoms of alcohol withdrawal include auditory, visual and tactile hallucinations, marked tremors and hyperactivity. The most feared complication of alcohol withdrawal is delirium tremens, which is associated with seizures, worsened agitation and hallucinations, autonomic hyperactivity or sympathetic hyperactivity. As the nurse caring for the patient, you should inform the rest of the clinical team about your suspicions for alcohol withdrawal, and the patient should receive prompt treatment, which may eliminate the need for physical restraints.
As a healthcare professional, our responsibility and our commitment to our patients is to advocate and care for them even when they are unable to make appropriate decisions for themselves. At times ensuring a patient’s safety and the safety of others will necessitate that they are placed in restraints. If that becomes necessary, it is imperative that nurses provide compassionate care which remains compliant to state, federal and institutional recommendations on restraint use. At times, nurses will have to advocate to limit restraints use in patients who are inappropriately restraints or those who can be de-escalated with other techniques. As such, we need to remain informed about the indications, contraindications and alternatives to restraints.