A mechanical restraint in healthcare is a physical device used to limit a patient’s movement. This practice is employed in clinical settings to manage a patient’s behavior or physical actions when they pose an immediate risk to themselves, staff, or others. Because they restrict a person’s freedom, the application of mechanical restraints is heavily regulated. The ultimate goal is to use the least restrictive measures possible, making restraint a last-resort intervention.
What Defines a Mechanical Restraint
A mechanical restraint is defined as any device, material, or equipment that is attached to or placed next to a person’s body and restricts the free movement of their arms, legs, body, or head. The defining characteristic is the intent behind the application, which is to control a patient’s behavior or physical actions for safety purposes. Restraints are not used for patient convenience, as a substitute for adequate staffing, or for punishment.
Exclusions
This definition is distinct from devices used for routine medical or surgical procedures, such as an arm board used during an intravenous (IV) insertion. Similarly, supportive devices like bed rails used to prevent a patient from accidentally falling out of bed are not restraints, provided they do not restrict a patient’s movement against their will.
Common Devices
Common mechanical restraint devices include wrist and ankle restraints, typically straps used to secure a patient’s limbs to a bed or stretcher. Other devices include vest restraints, designed to prevent a patient from getting up from a chair or bed. Mitten restraints cover the hands to prevent a patient from pulling out tubes or scratching themselves.
Criteria for Clinical Application
The application of a mechanical restraint is governed by the “last resort” principle, meaning it is only utilized after all less restrictive and alternative interventions have been attempted and proven ineffective. The circumstances must involve an emergency where the patient’s behavior presents an immediate physical danger to themselves, to healthcare staff, or to other patients.
Before any application, a face-to-face assessment of the patient’s condition and the imminent threat must be performed by a qualified healthcare professional. This assessment confirms the necessity of the restraint and that the least restrictive form of intervention is chosen. The process requires a physician’s or licensed independent practitioner’s order, which must be obtained as soon as possible after the restraint is initiated.
The order for restraint must clearly specify the type of restraint to be used and the maximum duration for which it is authorized. This initial order is time-limited:
- Four hours for adults.
- Two hours for children and adolescents aged nine to 17.
- One hour for children under nine.
The use of restraints for non-violent, non-self-destructive behaviors, convenience, discipline, or staff shortage is strictly prohibited.
Legal and Ethical Oversight Requirements
Once a mechanical restraint has been applied, strict oversight requirements are activated to ensure patient safety and dignity. These requirements are set by federal guidelines, such as those from the Centers for Medicare and Medicaid Services (CMS), and enforced by accrediting bodies like The Joint Commission. The patient must be continuously or frequently monitored to check for any signs of physical distress.
Monitoring includes frequent checks of circulation, respiration, skin integrity, and range of motion, as restraints can quickly impede blood flow or cause pressure injuries. The patient’s condition, comfort needs, and readiness for the restraint to be discontinued must also be regularly reassessed by trained staff.
If the restraint needs to continue beyond the initial time limit, a new order must be obtained, which requires a new face-to-face evaluation by a medical professional. Comprehensive documentation is mandatory for every step of the process, including the patient’s behavior, alternatives attempted, the type of restraint used, and the frequency and results of monitoring.
Risks and De-escalation Alternatives
The application of mechanical restraints carries significant potential for both physical and psychological harm. Physical complications can include nerve damage, impaired circulation, pressure ulcers, and aspiration if the patient vomits while restrained. The use of restraints, particularly in a prone position, also poses a risk of positional asphyxia, a factor that has led to strict guidelines against this practice.
Psychologically, being restrained can be a traumatic experience, often leading to feelings of fear, helplessness, and a worsening of underlying mental health conditions, sometimes contributing to post-traumatic stress disorder (PTSD). Because of these serious risks, the focus in modern healthcare is placed on prevention and de-escalation.
De-escalation techniques are the preferred methods for managing escalating behavior. These involve verbal intervention, such as using a calm tone of voice, maintaining a safe distance, and actively listening to the patient’s concerns. Environmental modifications, like reducing noise or moving the patient to a quiet space, can also help reduce agitation. Staff training is crucial for equipping healthcare professionals with the skills to address behavioral crises without resorting to physical devices.