The Medical Use Of Restraints

WHAT YOU SHOULD KNOW:

• Restraints are methods used by caregivers to limit movement of a patient. They are used to protect the health and safety of the restrained patient, other patients, and caregivers. Restraints are used only when other methods to control behavior have not worked. Physical restraint means a caregiver handles or holds the patient, or the patient is held in place using a mechanical restraint. This is an object that limits a patient’s movement and cannot be easily removed by the patient. Chemical restraint is the use of medicines to calm a patient, limit his movement, or both. Environmental restraint means putting a patient into a limited area, such as a locked room, for a period of time.
  
  
• Restraints may be needed to control behavior that is violent or self-destructive. This may be dangerous behavior caused by mental illness or substance abuse (drugs or alcohol). Restraints may also be needed when behavior is non-violent or non-self-destructive. For instance, restraints may help keep a patient from removing a feeding tube or a tube that helps him breathe. Restraints can help caregivers provide medical care and keep patients safe.

INSTRUCTIONS:

Guidelines for the medical use of restraints:

The Joint Commission (TJC) is one of many medical organizations that provide guidelines for the medical use of restraints. General guidelines for the use of restraints include:

• Restraints are used only when other methods to control behavior have not worked. Restraints are used only when there is a risk of a patient harming himself or others.
  
  
• Restraints are not used for punishment, to make a patient easier to care for, or to make a patient do something. They are not used because of a patient’s past restraint use, or a patient’s behavior history.

Caregivers must do the following before restraints are used:

Caregivers may ask about the patient’s health history and do a physical exam. Caregivers will try to learn the cause of a patient’s behavior to help avoid the use of restraint. However, if the patient is at risk of harming himself or others, caregivers may need to apply restraints first. Caregivers will work with the patient to find ways to avoid using restraint. Caregivers may try any of the following:

• Violent or self-destructive behavior management: De-escalation is when caregivers use methods to help calm a patient and help the patient better control his behavior. Caregivers will work with patients to learn what may cause a patient to become upset and possibly violent. De-escalation can begin as soon as signs that a patient may lose control of his behavior are noticed. Caregivers may do the following:
  
  
  • Speak to the patient calmly and with respect. Caregivers may also offer the patient food or drink.
    
    
  • Listen to the patient’s concerns and try to understand them. Caregivers may ask what is bothering the patient or making him anxious or agitated.
    
    
  • Explain what may occur if the patient cannot calm himself, and help the patient identify ways to avoid the use of restraints.
    
    
  • Direct the patient's attention away from what is causing him stress.
    
    
  • Put the patient in a time-out. This is when the patient stays in an unlocked room for 30 minutes or less.
    
    
  • Ask a patient with dementia what his needs are, such as if he needs food or drink. This may help keep hunger or thirst from making him agitated and violent. Caregivers may also provide a calm environment to help prevent agitation in patients with dementia. This may include lowering noise levels and providing music or massage. It may also include allowing patients to keep familiar items such as photos of loved ones.
  
  
• Non-violent or non-self-destructive behavior management: Caregivers may do the following to avoid the use of restraints:
  
  
  • Explain to the patient why certain treatments are needed. For instance, explain why a feeding tube is used and when it will be removed. This may help prevent the patient from removing the tube on his own.
    
    
  • Observe the patient to learn his needs. This may help prevent behaviors that can require restraint. For instance, a toileting schedule may help keep the patient from wandering to the bathroom on his own and risking a fall.

Caregivers will do the following when using physical and mechanical restraint:

• Caregivers will tell the patient the type of restraint that may be used and the reason for it. Caregivers will tell the patient what he needs to do to avoid the use of restraint.
  
  
• When the restraint process begins, a caregiver explains to the patient what will happen. This caregiver protects the patient’s head while other caregivers each manage an arm or leg. The patient may be restrained on his back or side. If the patient is restrained on his stomach, he is positioned so he can move his head to the side to make breathing easy.
  
  
• Caregivers will monitor the restrained patient at all times.
  
  
• Caregivers will do an assessment of the restrained patient every 15 minutes. This includes checking the patient’s vital signs, such as blood pressure, pulse (heart rate), and breathing. Caregivers will check to make sure the restraints are on the patient correctly and that they are not too tight. Caregivers will check whether the patient needs to change positions, which helps prevent skin sores. Caregivers also will check whether the patient needs food, water, medical care, or to use the toilet.
  
  
• An order of restraint can last up to four hours. Restraint use will be stopped as soon as the patient behaves as required by caregivers. This may include the patient agreeing to act in a safe manner or no longer making threats against others.
  
  
• When the restraint order ends, the caregiver who ordered the restraint will examine the patient.

Caregivers will do the following when using chemical restraint:

• Caregivers need to know what medicines a patient currently takes. They need to make sure these medicines are safe for use together with medicines used for restraint.
  
  
• Medicines used for chemical restraint are commonly offered to the patient in pill form first. If the patient refuses, medicines may be given as a shot or in an IV. An IV is a small tube put into a vein to give medicines or liquids.
  
  
• After the medicine is given, the patient’s health is monitored. Heart function may be checked using an EKG (electrocardiogram). Vital signs are checked often until the medicine wears off.

Caregivers will do the following when using environmental restraint:

• The patient will be observed constantly by caregivers. This may be done in person or with a video camera.
  
  
• Caregivers will make sure the seclusion room is safe and calm. Furniture in the room is heavy and not easy to move. There should be windows with unbreakable glass so caregivers can monitor the patient. The space should have clear exits and may have panic buttons (buttons to press for immediate help).
  
  
• Personal objects may be kept by the patient if they do not increase the risk of harm to the patient or caregivers. These personal objects may include clothing and jewelry.
  
  
• Caregivers will review the need for seclusion every two hours.
  
  
• Seclusion ends as soon the patient behaves as caregivers have requested. This may include stopping violent behavior that risks harm to others.

Consenting to the medical use of restraints:

Trained caregivers usually decide when the use of restraints is needed. Caregivers will always tell the patient what is going to happen before applying restraints. In some cases, a patient may give permission for restraint use. This may occur when a patient understands the need for treatment and how restraints can help keep him safe. Some patients may have a behavioral health advance directive. This is a document that describes how the patient wants his care or restraint to be handled when he acts out violently.

Actions that caregivers must take after restraints are removed:

• Within 24 hours, caregivers meet with the patient to talk about the restraint event. They discuss why restraint was needed and how restraint use could have been avoided. They also discuss how restraint use can be avoided in the future.
  
  
• During this meeting, caregivers ask if the patient’s physical and mental needs were met while restrained. If needed, a mental health caregiver helps the patient cope with the restraint event.

How the patient's family or significant others should be involved when restraints are considered or used:

Caregivers will ask the patient if he wants his family to be told about or involved with the use of restraint. If the patient says yes, the patient’s family is asked if they want to be involved. With consent from the patient and his family, caregivers:

• Tell the family when restraints are used.
  
  
• Explain to the family the rules on the use of restraint.
  
  
• Ask family members about any physical disability that may increase the patient’s risk if restraints are used. Caregivers may ask about past health care, health problems, or physical abuse. They may also ask about ways to help the patient control his behavior.
  
  
• Ask family members to help calm the patient and help him understand how he can avoid restraint.
  
  
• Involve the family in the discussion that takes place after the restraint use.

More information about the medical use of restraints:

If you or a family member has been placed in restraints, you may feel frustrated, angry, or sad. These are normal feelings. It may help to find out all you can about the use of restraints. For more information, contact:

• Joint Commission on Accreditation of Healthcare Organizations
  One Renaissance Blvd.
  Oakbrook Terrace , IL 60181
  Phone: 1- 630 - 792-5000
  Web Address: http://www.jointcommission.org
  

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The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Learn more about The Medical Use Of Restraints (Aftercare Instructions)