The Medical Use Of Restraints In Children

GENERAL INFORMATION:

What are restraints? A restraint is any method that limits your child's ability to move around freely or reach normal body parts. Your child may be restrained using one of, or a combination of four different ways.

What are the four types of restraints?

• Environmental restraint: The area where your child can move freely is limited for a period of time. This may also be called room restriction, a time-out, or seclusion. A time-out is when your child is moved to another place that is quiet and away from the stressful situation. A time-out may help your child calm down and develop self-control. Seclusion is when your child needs to be locked alone in a safe room. Bed rails may or may not be considered restraints. This depends on why the bed rails are being used, if the patient agrees with their use, and if their use if required for safety or other reasons.
  
  
• Physical restraint: This involves having one or more persons restrain your child through body contact alone. Physical restraint may also be called clinical holding or holding down. This type of restraint is often used in very young children. Physical restraint is also commonly used during procedures.
  
  
• Mechanical restraint: This involves the use of devices placed on the body to keep your child on a chair or bed. These devices may be placed on the wrists, ankles, or chest, and cannot be easily removed by your child. Mechanical restraints may be cloth bands, leather straps, or arm boards tied to the bed or crib. Other restraints include metal handcuffs, upper body vests, seat belts, body carrier, or body webs. Some devices, such as wrist-to-waist or ankle-to-ankle devices, may be used in adolescents. These devices limit the ability to attack others while allowing movement.
  
  
• Chemical restraint: A chemical restraint may be any medicine that helps your child calm down and relax. It may be used to control behavior or limit his movement. This medicine is not the regular medicine your child may already be using to treat medical or emotional problems.

Why may restraints be needed?

• Behavior reasons: Your child may need restraints if his behavior is out of control, which puts himself or others in danger. This may happen as a result of drug use, head or brain injury, or mental problems.
  
  
• Medical or surgical reasons: Restraints may be needed during a procedure or after surgery. Your child may be put in wrist restraints to keep him from pulling out tubes or other medical devices that are needed for his treatment. Restraints may also help him stay still during a procedure to avoid injury. Certain restraints, such as environmental restraints, are not used for medical or surgical reasons.

Are there guidelines for the medical use of restraints? Yes. The Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and several other medical organizations have guidelines in place for the medical use of restraints. The following general guidelines are in place for the medical use of restraints:

• Medical restraints are only to be used when other options have failed or cannot be used. For behavioral reasons, restraints are only considered when your child may harm himself or others, or damage property. The type of restraint will depend on the situation and the age of your child. The decision on when to use it must be made by trained caregivers working with your child. Restraints should only be used for one hour for children younger than nine. For children and adolescents aged 9 to 17, restraint use should be limited to two hours. Your child will be freed from restraint once he regains self-control.
  
  
• Medical restraints are not to be used as punishment. These should not be used to make it easier for caregivers to take care of your child. Restraints should not be applied only because your child has hurt himself on purpose or acted violently in the past. Guidelines may differ between care settings, and for other reasons. Some state guidelines may not allow the use of restraints.

What guidelines are in place for the use of environmental restraint?

• A time-out may be needed to decrease stimulation that may put your child in danger of himself or others.
  
  
• If seclusion is to be used, your child will be asked to walk by himself to seclusion. He will be carried safely to the room if he refuses to walk on his own.
  
  
• Clothes, belts, shoelaces, jewelry, and other belongings may need to be taken from your child when he goes inside the seclusion room. The room should have good lighting. It should also be free from harmful objects, such as exposed wires, screws, nails, or wood splinters.
  
  
• Caregivers will make sure your child is safe inside the seclusion room. They will keep a close watch on your child either in person or through video and audio equipment.

What guidelines are in place for the use of physical restraint?

• At least two caregivers are needed to physically restrain your child. While restraint is ongoing, other caregivers must still be able to meet the needs of other children.
  
  
• Physical restraint should be used in a quiet environment, away from other children.
  
  
• Caregivers may wear gloves, gowns, and face masks if your child is likely to bite, spit, or cause them injury.

What guidelines are in place for the use of mechanical restraint?

• Any mechanical restraint that may block your child's airway should not be used. This may include choke holds, high neck vest, or waist restraints. Your child's face should also not be covered.
  
  
• If your child will be restrained lying on his back, his head must be able to move freely.
  
  
• If your child will be restrained lying on his stomach, his head must not be buried. There should not be too much pressure on his back for him to be able to breathe easily.
  
  
• Your child's wrists and ankles must be wrapped in protective collars if restraints are to be applied. The bed to be used should be strong and stable enough to support your child even if he struggles.
  
  
• Mechanical restraints to be used must be easy to remove in case of an emergency.
  
  
• Mechanical restraints should not be used on your child if he has a medical condition that puts him at risk of having airway problems. This may include weighing much more than what is suggested by caregivers, or when your child is affected by drugs.

What guidelines are in place for the use of chemical restraint?

• Caregivers may need to know your child's other medicines if a chemical restraint is to be given.
  
  
• Your child should have the choice of taking the medicine by mouth before an injection is considered. Medicines taken by mouth may only be given when your child is sitting or standing up.
  
  
• The child's parent or guardian may be asked for their approval before a chemical restraint is likely to be used.

What other interventions may be tried before medical restraints are considered or used? Caregivers will work with your child and your family to keep your child safe so restraints may not be needed. Following are some things that can be done to keep your child safe and decrease the need for restraints.

• Behavioral management:
  
  
  • Your child may be taught different ways to help him control his behavior early so restraints will not be needed. This may include anger and stress management.
    
    
  • Caregivers who work with your child may be able to predict when your child is becoming anxious. When this happens, they may try to decrease his anxiety by talking to him, offering food, or giving assistance.
    
    
  • During an outburst, caregivers may try to decrease tension by approaching your child in a calm and concerned manner.
  
  
• Medical or surgical management:
  
  
  • Caregivers may put your child in a room near the caregivers' station. This allows them to watch your child closely and answer quickly when he calls for help.
    
    
  • Caregivers will check on your child regularly to see if he has problems that may cause him discomfort. Problems may include inability to pass urine, incorrect positioning of medical tubes, and uncomfortable body position. Caregivers may make changes to help your child get a better sleep.
    
    
  • During a procedure, you or a caregiver may do things to direct your child's attention away from the procedure. Talking, singing, or using books with pictures may help distract your child's attention.
    
    
  • Have someone stay with your child whenever possible. Your child may be less anxious when someone familiar is with him, such as a family member. Caregivers called "sitters" may be used to stay with your child all the time to keep him safe.
    
    
  • You and your family can do things that may help keep your child relaxed and calm. These may include listening to music, holding a favorite toy, or reading to your child.

What must caregivers do before medical restraints are considered? Caregivers will do a complete assessment on your child when he is being treated for a mental health problem. A complete assessment includes talking about your child's medical conditions, his medicines, and doing a physical check up. Caregivers will also need to know about past aggressive behavior, including triggers, warning signs, and whether restraints were used before. This will help caregivers decide what type of care is best for your child.

What must caregivers do while medical restraints are in use? A licensed caregiver must order restraints. He will come in and check on your child when he has been put in restraints. Caregivers specially trained in how to care for patients in restraints will check on your child often. This is to make sure your child is safe and all his needs are met. Following are the safety checks that caregivers will do while your child is in restraints:

• Check your child's vital signs every 15 minutes. This includes taking his temperature, blood pressure, and counting his pulse (heartbeat) and respirations (breaths).
  
  
• Check your child's arms and legs range of motion or ability to move. Caregivers will also change your child's position often, making sure his body is positioned in correct alignment.
  
  
• Give your child liquids to drink and food to eat. They will help your child eat and drink if the restraints keep him from doing it himself. Your child will also be helped to the toilet at regular times.
  
  
• Check that your child has no pain or discomfort while he is in restraints. Your child's skin will be checked often to make sure the restraints are not causing sores or bruising. Caregivers will also look for any signs of injury or blood flow problems.
  
  
• Check on your child to see if restraints are still needed. If your child was put in restraints because of aggressive behavior, he will be released from the restraints as soon as his behavior is not harmful to himself or others.

What must caregivers do after medical restraints are used? The caregiver who ordered the use of restraint will check on your child again. Your child will be able to talk to caregivers who will explain and help him understand what happened. Your child may be asked to write down on paper what he felt or thought while he was restrained. Caregivers may suggest ways to develop self-control in your child. Measures will be taken to prevent the same or similar incidents that made restraints necessary from happening again.

How should the child's family or significant others be involved when medical restraints are considered or used?

• Role of the caregivers to the family or significant others of the child:
  
  
  • Caregivers should explain to the child's family or significant others about the need for the restraint.
    
    
  • Caregivers should make sure that the needs of the child and family are answered before restraint is used. The parents or guardians should be involved when making decisions. They can decide if they want to be present during a procedure where restraints may be used.
    
    
  • Caregivers should notify the family or significant others around the time when restraint is used.
  
  
• Role of the family or significant others to the child:
  
  
  • Explain to your child the procedure or why he is in the hospital in words he understands. Tell your child what he should do, and how he can willingly join in his treatment.
    
    
  • Take part in your child's procedure, such as holding your child on your lap during the procedure. This may help comfort your child and provide a safe and secure restraint.

Does your child need to agree to the use of medical restraints? A child needs to know what is going to happen to him. Information should be given in the best way possible, using plain words to answer the child's questions. The consent of the child should be asked as long as he understands the need for the treatment. A young child or an adolescent with problems making decisions may not be able to provide consent. In this case a parent or guardian may decide for him. Sometimes, a trained caregiver may decide on use of medical restraints. This may happen during an emergency when the parent or guardian is not available.

What are the risks of using medical restraints?

• Airway or lung problems: Your child may have trouble breathing if he is restrained lying on his stomach, especially if face down. Anything that may cover his face, including a towel or bag, may block his airway. His lungs may not be able to expand (fill with air) enough because of too much pressure placed on his back. He may not be able to swallow easily when lying down. This may cause saliva (spit) or food to go to his lungs or cause your child to choke.
  
  
• Elimination problems: Your child may have problems with bowel movements (stools). He may become constipated (have dry, hard stools) because of not drinking enough liquids. Sometimes, your child may lose control of his bowels or bladder.
  
  
• Mental problems: Restraints may cause your child to feel nervous, jumpy, panicky, or uneasy. He may easily feel under stress or hurt emotionally. After being restrained, your child may have sleeping problems or nightmares (bad dreams). He may avoid activities, places, or people that may remind him of the experience. Being restrained may also be embarrassing to him.
  
  
• Physical injury: Restraints may cause bruises or sores on the part of the body where they were applied. If they are too tight, blood may not be able to flow through the body correctly. Your child's skin may get injured if he does not change body positions for a long time.
  
  
• Other accidents: Accidents and medical problems may happen to certain people when restraints are used. These include heart problems, lung conditions, or airway blockage. During an emergency, such as a fire, your child may not be able to leave the area immediately.

Where can I find more information about the medical use of restraints? Accepting that your child will be placed in restraints may be hard. You, your child, and your family may feel worried, scared, or angry. These are normal feelings. Talk to your child's caregiver about your feeling and those of your child. Contact the following for more information:

• 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
  

• Centers for Medicare and Medicaid Services
  7500 Security Boulevard
  Baltimore, MD 21244
  Phone: 1-877-267-2323
  Web Address: http://www.cms.hhs.gov
  

CARE AGREEMENT:

• Your child has the right to be free anytime from restraints unless medically needed. Your child also has the right to safe care and to be treated with respect when restraints are used. Restraints should not cause your child pain or harm.
  
  
• You have the right to help plan your child's care. To help with this plan, you must learn about your child's health condition, how it may be treated, and when restraints may be needed. You can then discuss treatment options with your child's caregivers. Work with them to decide what care may be used to treat your child.

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