Restraint Use: Evidence Based Practice

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 ((Scheepmans et al., 2017). 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, and visitors to the unit. Sometimes patients will be restrained when at risk for elopement (Marian, n.d.). There is an increased need for using restraints in hospital and home care settings (Scheepmans et al., 2017).

Certain conditions may make restraint use necessary when caring for patients for their safety: impaired cognition, increased dependency, history of falls or patients at increased risk of falling and impaired mobility. Nonpatient-related factors contributing 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. Clinical providers must attempt to collect a detailed history from the patient and their family members. Physical examination should target 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 that can induce agitation include hypoglycemia, drug or alcohol intoxication, and head trauma (Boyce et al., 2016).

Other methods of de-escalation should be tried when caring for agitated patients. Restraints should be the last resort. Using restraints when caring for patients in healthcare can negatively affect 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 Social consequences include; isolation and feeling withdrawn.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 (Boyce et al., 2016).

Although restraint use can be life-saving 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. The restraints can and should be removed as soon as the patient is calm and quiet. However, staff should continue to monitor the patient carefully for both the patient's safety and that of other patients and the staff (Boyce et al., 2016).

The Joint Commission has stringent requirements for using 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 a security watch (Boyce et al., 2016).

Once a patient is restrained, they require periodic and frequent evaluation to ensure that their safety is maintained while restrained. The joint commission has a list of required assessments for restrained patients. 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 others (Boyce et al., 2016).

De-escalation techniques should be considered instead of restraint use. There are 3 phases of escalating violence as defined by Coburn and Mycyk: 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 asking the patient, "how can we assist you?" This question 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 and 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 despite 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 required to calm the patient, thereby making restraints unnecessary (Boyce et al., 2016).

Safety in caring for the elderly sometimes necessitates using restraints rather than instituting policies that will help restore and maintain mobility and independence as reasonably possible. Overall, using restraints and restricting mobility in elderly people will result in loss of function in the long run (Dahlke et al., 2019).

Several factors 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 safety concerns can be decreased by maintaining and restoring functional ability among the elderly. Nurses must have organizational support to assist them in developing practices that encourage nursing leaders to create practice systems 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.

Restraints prevent agitated or violent patients from harming themselves, other patients or staff members. Restraints should only be used as a last resort after de-escalation techniques have failed. Patients who are noted to be an immediate danger to themselves or others should be promptly restrained without delay.

Patients who are altered may need to be restrained to ensure they receive life-saving medical care — for example, intubated patients and sedated patients requiring life-saving treatment.

In addition, patients 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 cautiously 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 on an actively violent patient, a team 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 and 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 patient and staff safety. When the patient is restrained, offer prescribed medications or call a clinical provider to prescribe medications (Korczak et al., 2016).

• Increased agitation: Increased agitation can further inhibit rapport building with the patient, as discussed above (Boyce et al., 2016).
• Local skin breakdown: Physically restricting the patient can prevent them from repositioning themselves, thereby increasing their risk of developing pressure ulcers.
• Vascular compromise: If restraints are applied too tight, there is an increased risk of vascular compromise to a limb.
• Respiratory restrictions: Patients with moderate to severe respiratory disease are at risk for respiratory compromise if they are physically or chemically restrained. For example, a patient with severe obstructive lung disease is at increased risk of respiratory failure if they are in a vest restraint or receive benzodiazepines as a form of chemical restraint.
• Cardiovascular compromise: Patients with severe congestive heart failure who cannot lay flat may be at increased risk of cardiovascular and eventually respiratory compromise if physically restrained and forced to lay flat.

You are an emergency department nurse 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 emergency department physician places an order for physical restraints. The previous nurse could not 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 associated with alcohol abuse or intoxication over the past two years. 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, associated with seizures, worsened agitation and hallucinations, autonomic hyperactivity, of sympathetic hyperactivity. As the nurse caring for the patient, you should inform the rest of the clinical team about your suspicions of alcohol withdrawal, and the patient should receive prompt treatment, which may eliminate the need for physical restraints.

As healthcare professionals, our responsibility and commitment to our patients is to advocate and care for them even when they cannot make appropriate decisions. At times ensuring a patient's safety and the safety of others will necessitate that they are placed in restraints. If that becomes necessary, nurses must provide compassionate care which remains compliant with 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.

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