Physical restraints are methods or devices that deliberately restrict a person’s physical freedom of movement. These measures are only implemented when a person’s behavior presents an immediate and significant danger to themselves or others. Because they limit a patient’s autonomy and carry potential risks, their use is governed by strict regulatory guidelines. This intervention is reserved as a last resort, after all less-restrictive alternatives have been attempted.
Defining Physical Restraints and Their Forms
A physical restraint is defined as any manual method, device, material, or equipment attached to or adjacent to a person’s body that cannot be easily removed, thereby reducing their ability to move freely. The intent behind the device determines its classification; devices used for medical stabilization, such as a cast, are not considered restraints. This also separates physical restraints from chemical restraints, which involve administering medication solely to restrict movement or manage behavior.
Common types of physical restraints include wrist, ankle, and vest restraints, typically secured to a bed or chair. Lap belts and trays on wheelchairs are also considered restraints if the person cannot easily release them. Additionally, keeping all four side rails up on a hospital bed is classified as a physical restraint if the purpose is to prevent the patient from leaving the bed voluntarily.
Primary Settings of Use
Physical restraints are most often seen within institutional healthcare environments where patient safety is a constant concern. Acute care hospitals, especially in the Intensive Care Unit (ICU) and the Emergency Department, frequently utilize restraints. This prevents delirious or agitated patients from disrupting life-sustaining medical treatments, such as pulling out intravenous lines, feeding tubes, or ventilators.
Long-term care facilities, such as nursing homes, have historically used restraints, though regulatory efforts have decreased their prevalence. While sometimes used to manage wandering or reduce falls, evidence suggests restraints do not prevent falls and may increase the risk of serious injury. Psychiatric and behavioral health units also employ restraints during acute episodes of violent or self-destructive behavior.
Justification for Implementation and Required Oversight
The use of a physical restraint is strictly regulated and must be justified by an immediate threat to physical safety. Regulations from organizations like the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) mandate that restraints cannot be used for staff convenience, punishment, or coercion. Acceptable reasons are limited to ensuring the immediate physical safety of the patient, staff, or others, or allowing for the completion of necessary medical procedures.
Initiating a restraint requires an order from a physician or other licensed independent practitioner, which must be obtained as soon as possible after application in an emergency. These orders are time-limited, often to four hours for adults in acute care, and cannot be standing or “as needed” orders. Continuous monitoring and reassessment by a trained nurse are required to ensure the person’s comfort, safety, and physical condition. The restraint must be discontinued at the earliest possible moment, regardless of the time limit on the order.
Potential Complications and Preventative Alternatives
Despite the intent to protect, physical restraints can lead to severe negative outcomes, both physically and psychologically. Physical complications include skin injury, pressure ulcers from immobility, circulation issues, aspiration, and increased risk of deep vein thrombosis. In rare cases, improper use or continuous struggle can lead to death from asphyxiation or fatal entanglement.
Psychological consequences include increased agitation, fear, anger, and feelings of humiliation, potentially leading to emotional trauma and post-traumatic stress disorder. For the elderly, restraint use is associated with functional decline, longer hospital stays, and higher mortality rates. Because of these serious risks, healthcare systems prioritize restraint reduction strategies.
Alternatives to restraint focus on de-escalation techniques, environmental modifications, and individualized care plans. Implementing increased one-on-one observation, therapeutic communication, and optimizing the patient’s environment can often prevent the need for restraint. The goal is to proactively address the underlying causes of agitation, such as pain, anxiety, or delirium, with non-restrictive interventions.