Physical restraints are defined as any device or material that restricts a patient’s ability to move freely and cannot be easily removed by the patient. They are used to prevent the patient from causing immediate physical harm to themselves or others, typically in hospital or psychiatric care settings. The use of restraints is heavily regulated by bodies like the Centers for Medicare & Medicaid Services and The Joint Commission. These regulations mandate strict protocols governing their application, timeframes for use, assessment, and ultimate removal.
Time Limits for Restraint Orders
The duration for which a restraint order is valid is strictly time-limited and depends on the specific circumstances and the patient’s age. Restraints used to manage violent or self-destructive behavior have the shortest time limits, reflecting the high-risk nature of this intervention. For adult patients aged 18 and older, a physician’s order for this type of restraint is only valid for a maximum of four hours before a new order is required.
The time limits are even shorter for younger patients. An order lasts no more than two hours for children and adolescents between the ages of nine and seventeen, and is limited to just one hour at a time for children under nine.
Orders for non-violent restraints, often termed medical-surgical restraints, are used when a patient is confused and attempts to disrupt life-sustaining treatment, such as pulling out a feeding tube or intravenous line. These orders are typically valid for a longer period, often up to 24 hours, but they cannot be written as a “prn” or as-needed order. Regardless of the maximum time frame, the regulations stipulate that restraints must be discontinued at the earliest possible moment.
After the initial order expires, a licensed independent practitioner must conduct a re-evaluation of the patient before issuing a renewal order. For violent restraints, this re-evaluation often involves a required face-to-face assessment within one hour of the restraint’s initiation. These short time limits mandate frequent clinical review, ensuring the ongoing necessity of the restrictive measure is continually justified.
Required Intervals for Safety Checks and Release
While the medical order sets the maximum legal duration, the physical application of restraints is interrupted frequently for safety checks and temporary release. This mandated schedule determines how often restraints are effectively removed or loosened during the order. For patients restrained due to violent behavior, continuous, one-to-one observation by a trained staff member is often required for the entire duration.
During this continuous monitoring, the patient’s physical and psychological status must be formally assessed at least every 15 minutes. These frequent checks involve assessing for any signs of injury, monitoring the patient’s circulation and sensory status in the restrained extremities, and observing their level of consciousness. The staff also uses these intervals to talk with the patient and check on their comfort level and readiness for discontinuation.
A more complete physical release and repositioning of the patient must occur at longer, regular intervals, typically at least every two hours. This temporary release is crucial for preventing serious complications associated with immobility. During this time, the restraints are removed or loosened to allow for a full assessment of skin integrity and to perform range of motion exercises for the patient’s limbs.
The two-hour interval is also used to address fundamental patient needs that cannot be met while restrained. This includes providing necessary hydration and nutrition, offering the patient an opportunity for toileting or hygiene, and changing the patient’s position to prevent pressure ulcers. This temporary, supervised release for care is a non-negotiable step in maintaining the patient’s safety.
Clinical Criteria for Discontinuing Restraints
The ultimate goal of using restraints is to permanently discontinue them as soon as the immediate danger or clinical necessity has passed. The process of permanent removal is not solely dependent on the order’s expiration but relies on a continuous assessment of the patient’s condition by the clinical team. Registered nurses and licensed practitioners are authorized to make the decision to remove the restraints once the criteria for safe discontinuation are met.
The primary criteria for permanent removal involve the patient demonstrating that the behavior which necessitated the restraint is no longer present. For a violent patient, this means a cessation of threats, agitation, and a return to a calmer mental status. For a medically restrained patient, it means they are oriented enough to follow directions and are no longer attempting to interfere with life-sustaining equipment.
The clinical team actively works to help the patient meet these behavioral criteria by using less restrictive measures. These strategies may include verbal de-escalation, one-to-one sitters, or adjusting medications to treat underlying conditions causing confusion or agitation. The decision to transition to these alternatives and ultimately remove the restraints requires a multidisciplinary approach, involving nurses, physicians, and behavioral specialists.