The Medical Use Of Restraints

GENERAL INFORMATION:

What are restraints? A restraint is any method that limits a patient’s ability to move around freely or reach normal body parts. A patient may be restrained using one or a combination of different ways.

What are the types of restraints?

• Environmental restraint: The area where a person can move freely is limited for a period of time. Environmental restraints include a secure unit or garden, a time-out room, or seclusion. A time-out is when a patient is moved to another place that is quiet and away from the stressful situation. A time-out may help a patient calm down and develop self-control. Seclusion is when a patient needs to be locked alone in a safe room.
• Physical restraint: Physical restraint may also be called mechanical restraint. This involves the use of devices placed on the body to keep a person on a chair or bed. These devices may be placed on the wrists, ankles, or chest, and cannot be easily removed by the patient. Mechanical restraints may be cloth bands, leather straps, arm boards tied to the bed, or upper body vests. Bed rails may or may not be considered restraints. This depends on why the bed rails are being used, if the patient agrees with their use, and if their use is required for safety or other reasons.
• Chemical restraint: A chemical restraint may be any medicine that helps a patient calm down and relax. It may be used to control behavior or limit his movement. This medicine is not the regular medicine the patient may already be using to treat medical or emotional problems.

Why may restraints be needed?

• Behavioral reasons: A patient may need restraints if his behavior is out of control, which puts himself or others in danger. This may happen as a result of drug use, head or brain injury, or mental problems.
• Medical or surgical reasons: Restraints may be needed during a procedure or after surgery. A patient may be put in wrist restraints to keep him from pulling out tubes or other medical devices that are needed for his treatment. Restraints may also help him stay still during a procedure to avoid injury. Certain restraints, such as environmental restraints, are not used for medical or surgical reasons.

Are there guidelines for the medical use of restraints? Yes. The Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and several other medical organizations have guidelines in place for the medical use of restraints. The following general guidelines are in place for the medical use of restraints:

• Medical restraints are only to be used when other options have failed or cannot be used. For behavioral reasons, restraints are only considered when a patient may harm himself or others, or damage property. The type of restraint will depend on the situation. The decision on when to use it must be made by trained caregivers working with the patient. Use of restraints should be limited to four hours. They may be used for a longer time, but there must be two-hour periods where restraints are not used. The patient should be freed from restraint once he regains self-control.
• Medical restraints are not to be used as punishment. These should not be used to make it easier for caregivers to take care of the patient. Restraints should not be applied only because the patient has hurt himself on purpose or acted violently in the past. Guidelines may differ between care settings, and for other reasons. Some state guidelines may not allow the use of restraints.

What guidelines are in place for the use of environmental restraint?

• A time-out may be needed to decrease stimulation that may put a patient in danger of himself or others.
• Clothes and other personal items that do not pose risks to the patient may be still be worn. Belts, shoelaces, or jewelry, such as a necklace, may need to be taken from the patient when he goes inside the seclusion room. The room should have good lighting. It should also be free from harmful objects, such as exposed wires, screws, nails, or wood splinters.
• Caregivers will make sure the patient is safe inside the seclusion room. They will keep a close watch on him either in person or through video and audio equipment.

What guidelines are in place for the use of physical or mechanical restraint?

• Any mechanical restraint that may block the patient’s airway should not be used. This may include restraints applied with pressure to the neck, chest, abdomen (stomach), back, or hip area. The patient’s face should also not be covered.
• Mechanical restraints to be used must be easy to remove in case of an emergency.
• Mechanical restraints should not be used on the patient if he has a medical condition that puts him at risk of having airway problems. This may include weighing much more than what is suggested by caregivers, or when the patient is affected by drugs.
• When restraining a patient physically, one caregiver in the team should support and protect the patient’s head and neck.
• While the patient is in restraints, he must have access to a call bell. Call bells are used to call a caregiver.

What guidelines are in place for the use of chemical restraint?

• Caregivers may need to know the patient’s other medicines if a chemical restraint is to be given.
• The patient should have the choice of taking the medicine by mouth before an injection is considered. Medicines taken by mouth may only be given when the patient is sitting or standing up.
• The patient’s family or significant other may be asked for their approval before a chemical restraint is likely to be used.

What other interventions may be tried before medical restraints are considered or used? Caregivers will work with the patient and his family to keep him safe so restraints may not be needed. Following are some things that can be done to keep the patient safe and decrease the need for restraints.

• Behavioral management:
  • The patient may be taught different ways to help him control his behavior early so restraints will not be needed. This may include anger and stress management.
  • Caregivers who work with the patient may be able to predict when the patient is becoming anxious. When this happens, they may try to decrease his anxiety by talking to him, offering food, or giving assistance.
  • During an outburst, caregivers may try to decrease tension by approaching the patient in a calm and concerned manner.

• Medical or surgical management:
  • Caregivers may put the patient in a room near the caregivers’ station. This allows them to watch the patient closely and answer quickly when he calls for help.
  • Caregivers will check on the patient regularly to see if he has problems that may cause him discomfort. Problems may include inability to pass urine, incorrect positioning of medical tubes, and uncomfortable body position. Caregivers may make changes to help the patient get a better sleep.
  • During a procedure, you or a caregiver may do things to direct the patient’s attention away from the procedure.
  • Have someone stay with the patient whenever possible. The patient may be less anxious when someone familiar is with him, such as a family member. Caregivers called “sitters” may be used to stay with the patient all the time to keep him safe.
  • You and your family can do things that may help keep the patient relaxed and calm. These may include listening to music or watching TV.

What must caregivers do before medical restraints are considered? Caregivers will do a complete assessment on the patient. This includes talking about the patient’s medical conditions, his medicines, and doing a physical check up. If the patient is being treated for a mental health problem, caregivers will also need to know about past aggressive behavior. Triggers, warning signs, and whether restraints were used before are important information. These will help caregivers decide what type of care is best for the patient.

What must caregivers do while medical restraints are in use? A licensed caregiver must order restraints. He will come in and check on the patient when he has been put in restraints. Caregivers specially trained in how to care for patients in restraints will check on the patient often. This is to make sure the patient is safe and all his needs are met. Following are the safety checks that caregivers will do while the patient is in restraints:

• Check the patient’s vital signs every 15 minutes. These include taking his temperature, blood pressure, and counting his pulse (heartbeat) and respirations (breaths).
• Check the patient’s arms and legs range of motion or ability to move. Caregivers will also change the patient’s position often, making sure his body is positioned in correct alignment.
• Give the patient liquids to drink and food to eat. They will help the patient eat and drink if the restraints keep him from doing it himself. The patient will also be helped to the toilet at regular times.
• Check that the patient has no pain or discomfort while he is in restraints. The patient’s skin will be checked often to make sure the restraints are not causing sores or bruising. Caregivers will also look for any signs of injury or blood flow problems.
• Check on the patient to see if restraints are still needed. If the patient was put in restraints because of aggressive behavior, he will be released from the restraints as soon as his behavior is not harmful to himself or others.

What must caregivers do after medical restraints are used? The caregiver who ordered the use of restraint will check on the patient again. The patient will be able to talk to caregivers who will explain and help him understand what happened. Caregivers may suggest ways to develop self-control in the patient. Measures will be taken to prevent the same or similar incidents that made restraints necessary from happening again.

How should the patient’s family or significant others be involved when medical restraints are considered or used?

• Role of the caregivers to the family or significant others of the patient:
  • Caregivers should explain to the patient’s family or significant other about the need for the restraint.
  • Caregivers should make sure that the needs of the patient and family or significant other are answered before restraint is used. The parents or family should be involved when making decisions. They can decide if they want to be present during a procedure where restraints may be used.
  • Caregivers should notify the family or significant other around the time when restraint is used.

• Role of the family or significant others to the patient:
  • Explain to the patient the procedure or why he is in the hospital in words he understands. Tell the patient what he should do, and how he can willingly join in his treatment.
  • Take part in the patient’s procedure, such as holding the patient during the procedure. This may help comfort the patient and decrease his anxiety.

Does a person need to agree to the use of medical restraints? A patient needs to know what is going to happen to him. Information should be given in the best way possible, using plain words to answer the patient’s questions. The consent of the patient should be asked as long as he understands the need for the treatment. A person with problems making decisions may not be able to provide consent. In this case, someone who has permission may decide for him. Sometimes, a trained caregiver may decide on use of medical restraints. This may happen during an emergency when the person who can give consent for the patient is not available.

What are the risks of using medical restraints?

• Airway or lung problems: The patient may have trouble breathing if he is restrained lying on his stomach, especially if face down. Anything that may cover his face, including a towel or bag, may block his airway. He may not be able to swallow easily when lying down. This may cause saliva (spit) or food to go to his lungs or cause the patient to choke.
• Elimination problems: The patient may have problems with bowel movements (stools). He may become constipated (have dry, hard stools) because of not drinking enough liquids. Sometimes, the patient may lose control of his bowels or bladder.
• Mental problems: Restraints may cause the patient to feel nervous, jumpy, panicky, or uneasy. He may easily feel under stress or hurt emotionally. After being restrained, the patient may have sleeping problems or nightmares (bad dreams). He may avoid activities, places, or people that may remind him of the experience. Being restrained may also be embarrassing to him.
• Physical injury: Restraints may cause bruises or sores on the part of the body where they were applied. If they are too tight, blood may not be able to flow through the body correctly. The patient’s skin may get injured if he does not change body positions for a long time.
• Other accidents: Accidents and medical problems may happen to certain people when restraints are used. These include heart problems, lung conditions, or airway blockage. During an emergency, such as a fire, the patient may not be able to leave the area immediately.