The application of physical or chemical restraints on a patient is a serious measure, strictly regulated to ensure patient safety and uphold individual rights. Restraints are defined as any method that restricts a patient’s freedom of movement, and their use is reserved exclusively for emergency situations. Healthcare facilities must follow stringent federal standards, primarily set forth by the Centers for Medicare & Medicaid Services (CMS), which govern their use. Restraints must be discontinued at the earliest possible moment, once the immediate danger has passed, and are never to be used for staff convenience or discipline.
Types and Justification for Use
Restraints fall into two main categories: physical and chemical. A physical restraint is any manual method, physical or mechanical device, material, or equipment that restricts a patient’s ability to move their arms, legs, body, or head freely. Examples include wrist or ankle cuffs, vests, or even certain types of bed rails that immobilize a patient.
Chemical restraints involve the use of a drug or medication administered to manage a patient’s behavior or restrict movement. This medication is not a standard treatment or dosage for the patient’s medical condition, but is given solely to control behavior.
The use of any restraint is justified only when less restrictive interventions have been attempted and failed, and it is necessary to prevent immediate physical harm. This harm can be directed toward the patient themselves, such as pulling out a breathing tube, or toward staff members or other patients in the vicinity. Restraints must never be imposed as a means of coercion, discipline, convenience, or retaliation by staff.
Maximum Duration Based on Age
The maximum duration for a physician’s order is strictly limited based on the patient’s age and is used only for the management of violent or self-destructive behavior. Federal regulations, specifically the CMS Conditions of Participation, define precise time limits for the initial order before mandatory renewal is required. These limits apply to the duration of the physician’s order, not the actual time the restraint must remain in place.
For adult patients (18 years of age or older), the maximum duration for a single restraint order is four hours. Adolescents, aged 9 to 17, have a shorter maximum order length of two hours. The most restrictive time limit is for children under 9 years of age, for whom the initial order cannot exceed one hour.
The decision to continue the restraint beyond the initial maximum period requires a new order. Before any order can be renewed, the patient must be seen face-to-face by a physician or other licensed independent practitioner (LIP) who is responsible for the patient’s care. This in-person re-evaluation and subsequent order renewal can continue for up to a total of 24 hours.
If the restraint is needed beyond the 24-hour mark, a physician or LIP must see and formally assess the patient face-to-face before any new order can be written. This 24-hour mark serves as a hard stop, mandating a thorough reassessment of the patient’s condition and the continued justification for the intervention.
Continuous Monitoring and Reassessment Requirements
Once a patient is placed in restraints, continuous monitoring and regular assessment are mandatory procedures that occur for the entire duration of the intervention. Within one hour of the initiation of the restraint, the patient must be seen and evaluated face-to-face by a physician, LIP, or a trained Registered Nurse (RN) or Physician Assistant (PA). This initial one-hour evaluation is a safety check to assess the patient’s immediate response and determine if the restraint must continue.
The patient must undergo continuous observation to ensure their safety and well-being. This observation is typically performed in person by trained staff, or sometimes using both video and audio equipment in close proximity to the patient. This level of monitoring ensures that staff can intervene immediately if the patient’s condition changes or if the restraint is causing physical harm.
Regular Assessments
Trained staff must conduct regular, detailed assessments at frequent intervals, determined by hospital policy and the patient’s individual condition. These checks involve evaluating critical physiological needs, including:
- Circulation in the restrained extremities.
- Skin integrity under the restraint device.
- The patient’s range of motion.
- Hydration and elimination status.
- Overall psychological status.
The patient must be released from the restraint periodically for necessary care, including basic needs and opportunities for exercise, unless the physician’s order specifically prohibits it due to the immediate risk of harm.
Patient Rights and Procedural Safeguards
Patient rights and procedural safeguards are activated the moment a restraint is applied to protect the patient from inappropriate use and ensure dignity. Patients have the right to be informed about the circumstances that led to the restraint, the criteria for its removal, and their right to request its discontinuation.
The facility must demonstrate that the least restrictive intervention appropriate for the situation was used. The restraint must be applied only to ensure the immediate physical safety of the patient or others, reinforcing the non-punitive nature of the intervention.
After the restraint episode concludes, a mandatory debriefing process must take place involving the staff and, ideally, the patient. This discussion reviews the circumstances that necessitated the restraint and identifies potential alternatives to prevent future occurrences. The debriefing ensures continuous quality improvement and reinforces the commitment to minimizing restrictive interventions.