Restraints in the Acute Care Setting
By GERALD DRISCOLL, MSN, RN, CRNP
George, an 80-year-old male patient with a history of Alzheimer's-type dementia, COPD, CAD, CVA, MI and an unsteady gait, was admitted to the hospital for pneumonia and dehydration. It was noted that he had increasing disorganization in the afternoons. He has dislodged his IV line on numerous occasions and was found wandering the unit, entering other patient's rooms, disrobing and urinating in inappropriate areas.
Attempts by nursing staff to redirect George have often resulted in his becoming agitated and verbally assaultive. In an effort to avoid restraining him, the nursing staff has begun to keep a log of his behavior as an attempt to reduce George's wandering and interference with treatment.
Additional interventions included wrapping his IV line in a stockinette with a viewing window to decrease the possibility of his dislodging it, changing his toileting schedule to q 1.5 hours and supplying a bedside commode, since he has shown a reluctance to use the urinal hanging on the siderail. A rocking chair has also been placed in the room and he is encouraged to sit in it each day prior to the time that nursing noted a change in his behavior.
These interventions, in combination with continual reinforcement from nursing staff, have resulted in a decrease in George's wandering and interference with treatment and have precluded the use of both chemical and physical restraints.
The use of physical restraints to manage the behavior and medical care of the acute patient is routine and widespread. In the acute care setting, 6 percent-17 percent of adult patients are restrained. The prevalence of restraint increases with advanced age. Eighteen percent-22 percent of patients 65 years or older, and up to 22 percent of patients age 75 or older, are restrained at some point while in an acute care setting.1 In fact, an elderly patient is eight times more likely to be restrained than a younger patient.2
TYPES OF RESTRAINTS
Restraints fall into two distinct categories: physical and chemical. Physical restraints come in various forms, including vest/chest, waist or limb restraints, mittens with ties, geriatric chairs and siderails. These devices are intended to limit the physical movement of the patient or restrict the patient's normal access to his body. Siderails are restraints when used to limit the ability of the patient to leave the bed.
Chemical restraints are drugs that are not required to treat a medical condition and are administered to discipline or change behavioral symptoms, or to limit disruptive behavior. The effectiveness of chemical restraints is questionable because most agitated states are self-limiting.3 Psychoactive drugs that may be used as chemical restraints include lorazepam, haloperidol, droperidol, diphenhydramine and hydroxyzine.
REASONS FOR RESTRAINT USE
The most common reasons for the application of restraints is to prevent falls, reduce interference with treatment and control behavioral symptoms.
However, restraints have never been shown to actually reduce fall risk. In fact, restraints may contribute to greater injury if the patient becomes entangled in the restraint or entrapped in the siderail while attempting to remove the restraint or climb over the siderail.3 Additionally, decreases in muscle tone, physical conditioning and sensory deprivation also contribute to an increase in the risk of injury associated with restraint use.
The application of restraints to protect dislodgment of intravenous (IV) lines, Foley catheters, nasogastric tubes and endotracheal tubes is a common, but often futile, practice. Research has demonstrated that as many as 68 percent-82 percent of patients were chemically or physically restrained at the time of self-extubation. Restraints alone do not prevent these incidents and may in fact increase their incidence by escalating feelings of anxiety in the patient that contribute to restlessness, agitation and self-extubation.4
The use of physical restraints to control or prevent disruptive behavior often has the opposite effect. Restraints may contribute to disruptive behavior by escalating the agitated state. Particularly in the elderly, restraint use has been noted to contribute to confusion and cognitive decline. The removal of restraints often decreases these agitated behaviors.2
The use of chemical restraints to control aggressive or agitated behaviors has questionable benefits. Similar to physical restraints, chemical restraints may not only be ineffective, but may actually escalate an agitated state.3 Agitation may be self-limiting and the administration of anxiolytics and antipsychotics may not only be unnecessary, but in many cases may result in oversedation and an increased risk of falling.
The poor clinical effectiveness of restraints is clear. Physical restraints have been indicated in numerous injuries and deaths, as well as having profound negative emotional effects on the patient and the patient's family, most notably a feeling of personal loss.2 Complications of restraint use include restraint-related death (due to asphyxiation or strangulation) and siderail-related entrapment injuries/ death, as well as skin irritation and breakdown, impaired circulation, incontinence, nerve damage, constipation, aspiration pneumonia, diminished functional capacity and increases in agitation.2
ALTERNATIVES TO RESTRAINT USE
A key component to reducing the use of restraints in the acute care setting is recognizing that each patient has unique problems. Therefore, it is necessary to tailor an individualized approach to care. Nursing interventions should focus on assessing the patient in order to identify the problem and then aim to provide specific alternatives to restraint use.
Initially, assess the patient's physical and emotional status, physical capabilities, social circumstances and environment.5 This assessment process will help the nurse to gain insight into the patient's specific behavior and its possible causes. Provide reality basing and reorientation to the patient as often as necessary, making note of the circumstances, procedures or specific times of day that escalate the agitated or confused state of the patient. Prepare a flow sheet if necessary to document specific behaviors ("crying and hand wringing" vs. "agitated") and the time of day/circumstances of the behaviors in order to recognize specific patterns in behavior.
Simple and often effective general alternatives to restraints include providing physical comforts such as mouth care, hydration, ambulation, toileting, personal hygiene and pain control. Alternatives specific to problems that often result in restraint in the acute care setting include:
1. Allow patients to gently examine and explore dressings, IV lines, tubes and other equipment while you explain to them the reason for treatments and interventions. Continue to reinforce the explanation on a regular basis.
2. Regularly assess the need for treatments and initiate less invasive or modified treatments whenever possible. Discontinue urinary catheters. Provide frequent toileting and skin care.
3. Disguise treatments by keeping IV bags and urinary catheter bags beyond the patient's field of vision.
4. Wrap infusion sites with a stockinette or bandage that has a viewing window cut into it to assess the IV site. Use a loose abdominal binder to cover abdominal feeding tubes.
5. Provide a calm and relaxing environment with minimal noise and confusion.
6. Involve the patient and the patient's family in rounds, activities and the arrangement of furniture to provide a familiar environment. Encourage the patient's family to bring pictures and objects from home that are familiar to the patient, such as pillows or blankets.
7. Identify patients who may be at risk for falls early on and involve physical therapy for strengthening and ambulation.
8. Use wedge cushions and reclining chairs in place of vest or waist restraints.
9. Use mittens without ties instead of wrist restraints.
10. Consider the use of rocking chairs to assist in energy reduction in the agitated or confused patient.
11. Discontinue routine use of siderails, or use only the upper half-rails when possible. Make sure the rails have narrow vertical bars and the mattress fits the bed snugly.
12. Allow patients to make choices in their care whenever possible in order to foster a sense of control.
STANDARD OF CARE
There is little evidence to suggest that failure to apply restraints is a negligent act; in fact, the use of restraints may actually increase the risk of litigation. Liability is based upon the failure to provide care consistent with professional and regulatory standards.
The Joint Commission on Accreditation of Hospitals (JCAHO) standards for restraint use limits restraints to, "emergent, dangerous behavior; addictive disorders; as an adjunct to planned care; as a component of an approved protocol; or, in some cases, as part of standard practice."6 JCAHO standards include several elements concerning how an organization uses restraints (see Table). These elements are patient focused and are intended to preserve the patient's dignity, rights and well-being.
Additionally, the Health Care Financing Administration established a new rule--effective Aug. 2--that requires all patients placed in restraints to be evaluated face-to-face by a physician within one hour of restraint use. This rule applies to all hospitals and mental health facilities participating in Medicare and Medicaid.
Only those falls and injuries that result from a deviation from the standard of care are potentially subject to litigation. For example, injuries that result from the improper application of restraints, failure to properly monitor the restrained patient, the lack of use of restraint alternatives prior to the initiation of restraints, failure to follow institutional protocols, and improper documentation of behavior and alternatives attempted can place the nurse at risk for legal liability.
Ethically, the nurse should be aware that application of restraints may be a violation of the patient's freedom or right of self-determination. Similar to any other treatment, a competent patient has the right to refuse restraints. Agitation alone does not necessarily imply incompetence.
During the period of time that a patient is in restraints, be sure to monitor the patient properly by checking the patient at least every 15 minutes. Be aware that many facilities, such as psychiatric hospitals, require 1:1 supervision of restrained patients. Offer these patients something to drink, help with toileting and allow them to exercise their limbs by releasing them one limb at a time for a few minutes.
Monitor the patient closely for breakdown in skin integrity, especially at the point of application of the restraints on the wrists and ankles. Document the time the patient was placed in restraints, the reason for the restraints, alternatives attempted prior to restraints and their outcomes. While the patient is in restraints, document each time the patient is checked, the patient's behavior at that time, PO intake, toileting, limbs exercised, as well as any other interventions or assessments.
RECOGNIZE RISKS, BENEFITS
Use of restraints and siderails may potentially lead to negative outcomes. Nurses must recognize the risk-to-benefits of each decision to use restraints. While a restraint may be needed to prevent removal of a life-sustaining treatment, it is best to use the least restrictive method of restraint possible and for the shortest period of time. In all situations, restraints should only be used as a last resort and after all other interventions have failed.
1. Fitzpatrick, M.A. (1996). Restraint reduction among the hospitalized elderly in intensive care units: Effects of reduction and restraint decision guides. Unpublished doctoral dissertation, Temple University, Philadelphia.
2. Wilson, E.B. (1996). Physical restraint of elderly patients in critical care. Critical Care Nursing Clinics of North America, 8(1), 61-70.
3. Fletcher, K. (1996). Use of restraints in the elderly. AACN Clinical Issues, 7(4), 611-620.
4. Winslow, E. (1996). Do restraints really protect intubated patients? Amer J Nurs, 96(6), 51.
5. Cruz, V., Abdul-Hamid, M., & Heater, B. (1997). Research-based practice: Reducing restraints in an acute care setting-phase 1. Journal of Gerontological Nursing, 23(2), 31-40.
6. The Joint Commission. (1996). Accreditation manual for hospitals: Vol. 1. Standards (p. 189). Oakbrook Terrace, IL: Author.
Gerald Driscoll is a nurse practitioner in the psychiatric intensive care unit at Friends Hospital, Philadelphia.
Table: Essential Guidelines for Restraint Use6
* Provide for the preservation and protection of the patient's rights, dignity and well-being
* Based on the assessed needs of the patient
* Least restrictive restraint decision making
* Safe application and removal
* Monitoring and continual reassessment of the patient
* Providing for patient needs during use
* Time limited restraint orders from licensed independent practitioners
* Documentation in the medical record when restraints are used or individual orders written
CONTINUING EDUCATION OFFERING: The goal of this CE offering is to provide nurses with information about the safe use of restraints in acute care settings that can be applied to their practice.
(Editor's note: The Learning Scope offers a unique opportunity for nurses to earn continuing education credit. By reading this peer-reviewed article, completing and passing the test that follows and sending the answer sheet to Nurse Learning Scope, c/o Merion Publications, you can receive 1.2 contact hours. The credit is issued through the Pennsylvania State Nurses Association.)