Patient restraints, whether physical or chemical, are serious interventions used in healthcare settings to manage a patient’s behavior or movement. A physical restraint is any device or method that limits a patient’s ability to move freely, such as a four-point restraint or a bed with all four side rails raised. A chemical restraint involves administering medication specifically to restrict movement or manage behavior, not as standard treatment. Restraints are a measure of last resort, permissible only when a patient poses an immediate physical safety risk to themselves or others. Strict protocols govern their application and the frequency of patient monitoring due to the potential for harm and injury.
Criteria for Use and Time Limits
The decision to apply a restraint requires a medical order and is governed by strict legal and ethical requirements. Restraints must never be used for staff convenience, discipline, or retaliation. Before application, less restrictive interventions must be attempted and documented as ineffective to justify necessity. A physician or authorized licensed practitioner must issue the order, which cannot be a standing order or written on an “as needed” (PRN) basis.
The maximum duration for an order is carefully limited, especially when restraints are used for violent or self-destructive behavior.
- Adults (18 and older): Maximum four hours before renewal.
- Children/Adolescents (9 to 17): Maximum two hours.
- Children (under 9): Maximum one hour.
The total duration cannot exceed 24 hours without a physician or licensed practitioner conducting a face-to-face assessment before issuing a new order. Restraints must be discontinued at the earliest possible moment when the patient is no longer a safety risk. Time limits ensure mandatory, frequent re-evaluation of the continued need for the restraint.
Required Frequency of Patient Checks
Regulatory standards determine the frequency of patient checks, which are essential safety measures. For patients restrained due to violent or self-destructive behavior, continuous observation by trained staff is often mandated. Continuous monitoring requires staff to be in close proximity, either face-to-face or using video and audio equipment. For these patients, immediate physical safety checks must be performed and documented at least every 15 minutes.
These 15-minute checks focus on the patient’s physical well-being and the correct application of the restraint. A more comprehensive assessment must be performed by a registered nurse or licensed practitioner within one hour of application. This one-hour face-to-face evaluation determines the patient’s reaction, medical and behavioral status, and the necessity of continuing the restraint. For non-violent medical restraints, monitoring intervals may be less frequent, often every two or four hours, guided by hospital policy. Staff must always increase monitoring frequency if the patient’s condition changes or safety is compromised.
Essential Components of the Safety Assessment
The safety assessment performed during monitoring must be comprehensive, focusing on the patient’s physical and psychological well-being.
Physical Assessment
A physical assessment includes checking the patient’s circulatory status, particularly in the extremities that are restrained. Staff must check the color, temperature, and sensation of the restrained limbs to ensure blood flow is not compromised. Skin integrity requires checks for signs of injury, redness, or breakdown, especially around the pressure points where the restraint is applied. Respiratory status and vital signs must be monitored closely, as a patient struggling against restraints can quickly develop respiratory distress or a cardiac event. Staff must also address basic human needs by offering nutrition, hydration, hygiene, and elimination opportunities at regular intervals. Temporarily releasing the restraint for range-of-motion exercises or toileting is necessary to prevent complications like muscle stiffness or blood clots.
Psychological Assessment
Psychological assessment involves evaluating the patient’s mental status, level of agitation, and orientation to their surroundings. Clinicians must continually assess the patient’s emotional response to the restraint, recognizing that the experience can be traumatic. During every assessment, staff should look for signs that the patient is ready for the restraint to be removed, which includes ongoing attempts at verbal de-escalation and offering less restrictive alternatives. The goal is to manage the patient’s condition so that the restraints can be safely discontinued as soon as possible.
Documentation and Discontinuation Protocols
Accurate and timely documentation is required for every use of patient restraint, providing a verifiable record of safety measures and clinical justification. All monitoring checks, interventions, and the patient’s response must be recorded in the medical record. This includes documenting the specific alternatives attempted and the symptoms that warranted restraint use. The required one-hour face-to-face evaluation must be documented with a clear conclusion on the necessity of continuing the intervention.
Staff must remove restraints as soon as the patient meets the criteria for discontinuation. If the restraint is discontinued before the ordered time limit expires, a new order is required to reapply it. Following removal, a post-restraint debriefing is standard, involving the patient, staff, and sometimes family. This process reviews the incident, identifies factors that led to the restraint, and develops strategies to prevent future occurrences.