Course Contents

	Purpose/Goals    Objectives    Acute Medical and Surgical (Non-psychiatric)      Restraints    Behavioral Health Care Restraint and      Seclusion    Consequences of Restraint Use    Interventions and Alternatives to Restraints    Least-Restrictive Device    Delirium    External Agencies    References    Click any section in the index above to browse to the corresponding course section

Purpose/Goals

The purpose of this course is to update the healthcare professional on current guidelines and procedures for restraint use.

Objectives

After completing this course, the learner will be able to:

 Restraint is the direct application of physical force to restrict a patient’s freedom of movement (JCAHO, 2004).Physical force can be human, mechanical devices, or a combination. Restraints should be used only when essential to prevent the patient from harming himself, staff, or other patients.

In the long term care setting, leaving patients in bed can be considered a form of restraint and is not to be used for the staff's convenience. Bedrails are a type of restraint that, unless medically indicated, deprives the elderly of their dignity and autonomy.

Medication to control behavior should be used only as part of a therapeutic plan, after appropriate assessment by professionals. Chemical restraint is a term used to describe the inappropriate use of medications for purposes unrelated to the patient's medical condition (Charatan, 1999). An example is the inappropriate use of a sedating psychotropic drug to manage or control behavior.

A licensed, independent practitioner must order the restraint or seclusion; however, the facility may authorize qualified staff members, usually registered nurses, to initiate the use of restraints before an order is obtained. The authorized staff member can discontinue restraints or seclusion when the assessment reveals that restraints or seclusion are no longer necessary.

If your patient has any type of physical restraint, he has to be checked hourly and remove the restraint at least every 2 hours. While it's off, assess, turn, reposition and toilet the patient. Without these interventions, the patient could develop constipation, urine incontinence or retention, and pressure ulcers.

Physical restraints should always be tied with a slipknot for easy release in an emergent situation. The restraint should be knotted on a fixed part of the furniture, like the bed frame. Fixing it to a movable part, like a side rail, could inadvertently tighten the restraint causing patient injury, or loosen the restraint causing it to be ineffective.

Acute Medical and Surgical (Non-psychiatric) Restraints

Restraint standards for medical or surgical purposes apply when the primary reason for use directly supports medical healing (JCAHO, 2004). Restraints can be used for emergent, dangerous behavior, as an adjunct to the plan of care, as a component of a protocol, or in some cases it can be a part of a standard practice. The use of restraints for acute medical or surgical purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 24 hours. The use of restraints for behavioral reasons in nonbehavioral health care settings follow the standards for acute medical and surgical restraints. Examples are (JCAHO, 2004):

	Hospitalized in an acute care hospital that does not have a psychiatric unit
	Hospitalized in an acute care hospital in other than a psychiatric unit to receive medical or surgical services
	In the emergency department for assessment, stabilization, or treatment, even if awaiting transfer to a psychiatric hospital or psychiatric unit
	Awaiting transfer from a nonpsychiatric bed to a psychiatric bed or psychiatric unit after receiving medical or surgical care

Behavioral Health Care Restraint and Seclusion

Behavioral health care restraint or seclusion is primarily used when a patient with an emotional or behavioral disorder is a threat to self or others (JCAHO, 2004). Behavioral health care restraint standards apply to behavioral health care setting like psychiatric hospitals, psychiatric units, and residential treatment centers. The use of restraints for behavioral health care purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 30 days. The behavioral health care restraint and seclusion standards do not apply in the following situations (JCAHO, 2004):

	Restraint associated with acute medical or surgical care
	When staff physically redirect or hold a child, without the child's permission, for 30 minutes or less
	A time-out when the patient is restricted for 30 minutes or less from leaving an unlocked room and when its use is consistent with the patient's treatment plan
	Instances in which a patient is restricted to an unlocked room or area, consistent with a unit's rules or regulations and hospital policy and procedure
	The use of restraint with patients who receive treatment through formal behavior management programs; these patients exhibit intractable behavior which is severely self-injurious or injurious to others, have not responded to traditional interventions, and are unable to contract with staff for safety
	Forensic restrictions and restrictions imposed by correction and law enforcement authorities for security purposes.
	Protective equipment such as helmets
	Adaptive support in response to the patient's assessed physical needs like postural support or orthopedic appliances
	Standard practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post procedure care processes like surgical positioning, intravenous arm boards, radiotherapy procedures, or protection of surgical and treatment sites in pediatric patients

Consequences of Restraint Use

In contrast to common beliefs, restraints contribute significantly to patient morbidity and mortality (McCue, Urcuyo, Lilu, Tobias & Chambers, 2004). Physical or chemical restraints may be needed to protect your patient, but consider them a last resort because of their serious drawbacks. Use of physical restraints is often rationalized as necessary to prevent falls, to prevent resistance to treatment, and to manage uncontrollable behavior. But, research shows that prolonged use of restraints is associated with adverse events, such as fall-related injuries and decreased physical and psychological function. Research also shows that the use of restraints does not decrease the risk of falls or injuries in elderly patients (McCue, et al., 2004).

The effects of restraint stress are a functional decline, psychological distress, agitation, impaired circulation, incontinence, immobility, serious accidents, and heighten memory impairment. Physical restraints increase agitation and worsen delirium. It can cause skin tears and bruises if the patient fights to remove them.

Chemical restraints generally benefit the staff more than the patient. Chemical restraints increase sedation and heighten confusion. Chemical restraints, such as haloperidol, can quiet a patient who attempts to get out of bed, or a noisy patient. However, it is a psychotropic drug that should be reserved for patients who exhibit psychotic behaviors, like hallucinations, delusions, and paranoia. Haloperidol’s anti-cholinergic effects (constipation, urine retention, dry mouth, and blurred vision) are especially detrimental to an older adult.

A 50-state survey conducted by the Hartford, Connecticut newspaper revealed at least 142 deaths in the past decade connected to the use of physical restraints or the practice of seclusion (McCue, et al., 2004). This report suggested that the actual number of deaths is many times higher because the association with restraints, in many such deaths, goes unreported. According to a separate statistical estimate conducted by the Harvard Center for Risk Analysis, between 50 and 150 restraint deaths occur every year across the country (McCue, et al, 2004).

In one study of death of restrained patients, 40% of the deaths were caused by asphyxiation (JCAHO, 1998). Asphyxiation was related to three situations. In come cases, excessive weight was put on the back of the patient in a prone position. Some patients had a towel or sheet placed over their head to protect staff from spitting or biting. And finally, some patients had an obstructed airway from pulling the patient's arms across the neck area. The remaining cases were caused by strangulation, cardiac arrest or fire. All of the strangulation deaths were geriatric patients who were placed in vest restraints. Half of the strangulated patients died when they slipped between unprotected split side rails. All deaths by fire were of male patients who were trying to smoke or were using a cigarette lighter to burn off the restraints. In 40% of the deaths, two-point, four-point or five-point restraints were used. A therapeutic hold was used in 30% of the deaths, vest restraints were used in 20% and waist restraints were used in 10%.

Interventions and Alternatives to Restraints

The most common reasons for restraining patients are (McCue, et al., 2004, p 217):

	Bulleted List Level 1
	Prevent interference with medical treatments (such as self-extubation and intubation).
	Protect medical devices (such as intravenous lines, indwelling urinary catheters, and feeding tubes).
	Prevent falls and protect the patient from harm.
	Control disruptive behavior (such as agitation, wandering, and combativeness).

A patient is more likely to be restrained if he has a history of unsafe behavior, needs extensive and complicated therapy such as in an intensive care unit, or has been restrained in the past (Sweeney-Calciano, Solimene & Forrester, 2003). The use of restraint or seclusion should be strictly limited to emergencies where there is an imminent risk of an individual physically harming himself or others and when nonphysical interventions would not be effective. By planning for more appropriate care interventions, a facility can ensure that restraints are used only as a last resort. Care interventions can include environmental management, nursing management, and other psychosocial interventions.

Using restraints may represent a failure to assess a patient’s needs. There must be systems in place that facilitate the safe use of physical restraints, with appropriate clinical justification, staff training, policies, and care procedures. Special attention should be paid to high-risk situations such as when restraints are used in the emergency department and for behavioral health needs.

Studies show that a combination of staff education and consultation leads to a decrease in the use of physical restraints in long term care facilities, without increases in the use of psychoactive drugs, in staff time or in injuries related to falls (Lapointe, 2000). Difficulties in hiring and retaining nursing assistants may lead to an increase in the improper use of restraints. Long term care facilities, in particular, have to focus on maintaining appropriate staffing levels and constantly training new staff to strictly follow the facility's restraint policy (Lapointe, 2000).

Before implementing restraints, look for underlying reasons for the behavior and eliminate the cause if possible (Sweeney-Calciano, et al., 2003). Be sure the patient is physically comfortable, and provide frequent bathroom breaks every two hours. Reduce the stimuli in the environment by dimming lights and reducing noise.

If the patient is confused, orient the patient by using visual cues like clocks, calendars and reminder notes. During the day, keep lights on and curtains open; at night, keep the room dark. Re-introduce yourself every time you enter the room.

Distraction tactics may help divert unwanted behavior like wandering.

Make the environment safe. Use low beds or put the mattress on the floor for patients who will not call for assistance to get up. Arrange furniture so that it does not block the walkways and keep debris and liquids off the floor. Keep the call bed within reach and use a nightlight.

You may not be able to change your patient's behaviors, but you can possibly rethink your procedures to identify ways to adapt to the patient. Some suggestions are:

	To promote safety, keep your patient's personal items, water pitcher, and call light within reach at all times and make sure he wears his eyeglasses, hearing aid, or other devices.
	Check the patient at least every hour. Remind him to call for assistance if he wants to visit the bathroom.
	If your patient has family or friends, you might ask them to stay with him at night or other times when he tries to climb out of bed. If no one's available, look into the possibility of using companions, especially at night when staffing is minimal. Although this intervention is costly, it's safer than restraints.
	Move the patient to a nonstimulating, quiet area, such as a private room, if possible. Keep in mind that moving a patient close to a busy nurses' station so you can keep a close eye on him could overstimulate him and worsen symptoms. Try to keep noise to a minimum, but closely watch your patient.

In the long-term care setting, nursing, physical therapy, occupational therapy, and pharmacy staff should screen all newly admitted patients for the appropriateness of chemical and physical restraints. If chemical or physical restraints are used, staff should develop a care plan to gradually reduce the restraint (either physical or chemical) and to monitor the resident for safety and efficacy. Dementia, special care units should have a safe and supervised area for wandering because wandering may be helpful to the resident.

Keeping the side rails up for elderly patients in long term care is no longer the standard of care. The reason to keep them down is that the patient is more likely to hurt himself if he gets out of bed while they're raised. Split rails are especially hazardous because the patient could become wedged between them. Put the bed in the lowest position. Although some long-term-care facilities place the patient's mattress on the floor, this practice is unsafe in the acute care setting. If your patient tries to get out of bed, try to redirect or distract him. Consider using pillows or wedges to position him in a chair or in bed with the side rails down so he can't readily stand. If he's unsteady when ambulating, consult a physical or occupational therapist about potential benefit from a walker or cane or strengthening exercises to improve muscle tone. If the patient is steady on his feet, he may do better if you teach him how to get up safely. Place a trapeze and overhead frame on the bed to help him get up, and provide a bedside commode or a clear path to the bathroom. To help strengthen muscles and tire him so he sleeps well, walk with him in the room or the hallway.

Agitated and hostile patients often respond positively to quiet music. Select music that's soothing or familiar to the patient’s generation. Keep the volume low but loud enough that he can hear it. Television programs may be too stimulating.

Give your patient something to do. Personal items, stuffed animals, lifelike baby dolls, and activity aprons or pillows may have a calming effect on a confused, agitated elder. Activity aprons or pillows have devices that encourage psychomotor tasks. Fasteners, bows, and zippers offer alternatives to restraints while providing familiar sensory stimulation. To prevent the patient from pulling out tubes, cover them with gauze or netting or secure them with gentle tape that won't tear the skin.

Least-Restrictive Device

If interventions aren't successful and you need to apply a physical restraint as a last resort, use the least-restrictive device possible. For example, a lap buddy is a soft vinyl device that attaches to a wheelchair rather than the patient. Although the patient can remove it when he's oriented, it serves as a reminder that he shouldn't get up without assistance and protects him in the event that he becomes confused again.

Another alternative is a geriatric chair: set in a reclining position or with a lapboard. This is less restrictive than a safety belt or roll belt. And a roll belt, in turn, is less restrictive than a vest restraint. Mitts are generally more suitable than wrist restraints because they're less restrictive and allow the patient to move his arms freely. Another option is elbow restraints that keep the arm straight but allow free arm movement.

Delirium

An episode of Delirium often leads to restraint use. Delirium is an acute cognitive impairment (confusion) that lasts for hours or days. It is sometimes confused with Dementia. However, Dementia is a chronic state of confusion, such as seen in Alzheimer's disease that progresses over months or years.

As part of your nursing assessment, determine if the patient has risk factors for delirium. If so, determine which ones can be eliminated or treated. You can't change all of the factors, but you can intervene to minimize symptoms, reduce the use of restraints and safeguard your patient.

The elderly are especially susceptible to delirium because they're likely to have multiple risk factors. Physiologic problems, stress and changes in routine can trigger this temporary problem. The following factors increase your patient's risk for delirium:

	Advanced age
	Pain
	Hypoxia
	Immobilization
	Relocation
	Impaired vision or hearing or sensory deprivation
	Recent surgical procedure or anesthesia
	Infection
	Multiple diseases
	Fever
	Trauma
	Electrolyte disturbances
	Sleep deprivation
	Alcohol abuse
	Medication use:

	Anticholinergics
	Cardiovascular drugs
	High doses of opioids
	Anticonvulsants
	Antibiotics
	Corticosteroids
	Sedatives/hypnotics
	Antidepressants
	Diazepam (Valium)

In the early stages of delirium, the patient may be restless or disoriented. Memory may be impaired, and the patient may appear irritable, perplexed, or withdrawn. The patient may stay awake at night and sleep during the day. As delirium progresses, the patient’s behavior typically fit into one of two types: 1) hyperactivity or agitation and 2) Hypoactivity. Hyperactivity or agitation is the most common manifestation of delirium. The patient has a tendency to wander and may become verbally or physically aggressive. He may also hallucinate or display other psychotic behavior. Hypoactivity occurs less often, a patient with delirium is quiet and prone to apathy, decreased responsiveness, and withdrawal. These passive behaviors may be missed or attributed to the effects of medication or depression. Delirium usually improves or resolves within a few days to 3 weeks. But, some patients never return to their previous cognitive state.

Characteristics	Delirium	Dementia
Onset	Acute	Insidious
Duration	Days to weeks	Permanent
Associated conditions	Systemic illness commonly present	No systemic conditions necessary
Attention span	Poor	Typically unaffected until late stages
Arousal level	Fluctuates from lethargy to agitation	Normal until late stages
Orientation to person, place and time	Variably impaired for person and place, almost always impaired for time	Variably impaired for person and place, almost always impaired for time
Cognition	Disorganized thoughts; hallucinations and delusions common	Hallucinations, illusions and delusions common
Speech and Language	Dysarthric, slow, often inappropriate and incoherent	Aphasia common in middle and late stages
Memory	Temporarily impaired memory	Loss of recent memory, remote memory impaired in later stages
Treatment	Protect the patient and treat the causes	Protect the patient and treat the behaviors
(Ignatavicius, 1999)

External Agencies

Freedom from misuse of restraints or seclusion is an important element in the patient protection rules issued by US Department of Health and Human Services. These rules set forth six standards to ensure minimum protections of each patient's physical and emotional health and safety. They are a patient's right to notification of his or her rights; the exercise of a patient's rights regarding his or her care; privacy and safety; confidentiality of the patient's records; freedom from restraint use during acute medical and surgical care (unless clinically necessary); and freedom from seclusion and restraints used to manage behavioral symptoms (unless clinically necessary).

Enforcement activities in nursing homes have always included a review of a facility's use of restraints. Inappropriate use of restraints is on the list of violations that are characterized as an immediate and serious threat to the health and safety of patients (Lapointe, 2000). This means that an infraction of restraint standards may result in a facility being closed.

JCAHO is also concerned about restraint use, and closely monitors standards of care regarding restraint use. This standard is based on the premise that patients have the right to live without fear of chemical or physical restraints. Restraints should be avoided if at all possible. The JCAHO goal for long term care facilities is to achieve a restraint-free environment. To achieve this goal the JCAHO recommends that (JCAHO, 2001):

	The use of physical or chemical restraints be prohibited for purposes of discipline or staff convenience
	The use of restraints be prohibited except to treat a patient’s medical symptoms
	Patients be allowed to refuse restraints
	The decision to use restraints should never be based solely on a request from a patient’s representative.
	Restraints be used only when alternatives to restraints are not effective, as determined by an interdisciplinary team
	Restraints should be used only when absolutely necessary to ensure the safety of the resident, other patients, and staff.

To meet the restraint-free goal, staff interaction with patients should be positive and supportive in both verbal and nonverbal ways. Staff should interact regularly and appropriately with the resident so that the resident is not neglected (JCAHO, 2001).

References

Charatan, F. (1999). US reconsiders use of seclusion and restraints in psychiatric patients, British Medical Association, 7/10/99

Huffman, G. (1999). Bedrails in the hospital: Are they a necessary evil? American Academy of Family Physicians, 10/1/99.

Ignatavicius D. (1999). Resolving the delirium dilemma, Springhouse Corporation.

JCAHO, (1999). Preventing Restraint Deaths. Sentinel Event Alert, Joint Commission on Accreditation of Healthcare Organizations. Nov. 18, 1998, Issue 8.

Joint Commission on Accreditation of Healthcare Organizations. (2004). 2004 Automated CAHM update 3. Retrieved October 15, 2004 from http://www.va.gov/.

Lapointe, M. (2000). Restraint Policies Merit Regular Review, Healthcare Review, 10/23/2000.

McCue, R., Urcuyo, L., Lilu, Y., Tobias, T. & Chambers, M. (2004). Reducing restraint use in a public psychiatric inpatient service. The Journal of Behavioral Health Services & Research. 31(2). 217-226.

NAMI (National Alliance for the Mentally Ill)(1998), Calls for Major Reforms in Use of Physical Restraints in Psychiatric Facilities; Hails Hartford Courant for Exposing Inhumane Practices, Deaths, PR Newswire Association, Inc., 10/16/1998.

Staff. (1999). ECRI Studies Safety Risks, Regulatory Requirements, and Alternatives for Physical Restraint Use, PR Newswire Association, Inc., 11/24/99.

Staff, (1999b). NEW PATIENT PROTECTION RULES UNVEILED, Clinicians Publishing Group, 9/1999.

Sweeney-Calciano, J., Solimene, A., & Forrester, D. (2003). Finding a way to avoid restraints. Nursing. 33(5). 1-3.