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Restraints Then and Now: How Viewpoints and Policies Have Changed

  • 6/19/2020

  • Clinical Notes

Teresa McKenney, BA, RN, CWCN

The debate over restraints in patient care goes as far back as the 1840s, when British Parliament established a commission to abolish restraint usage. Meanwhile, American mental health professionals used restraints as normal protocol well into the 2000s, often to control or punish agitated patients.1
 

Types of Restraints

Several different interventions are considered restraints. Physical or mechanical restraints generally connect the patient to a bed or chair, and may include belts, vests, jackets, mitts. Enclosure beds, siderails, and exit alarms are also sometimes considered physical restraints. Chemical restraints are medications given with the sole purpose of restricting movement—without treating an underlying medical condition.2
 

Establishing Facility Protocols

In recent years, The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) have established guidelines for more limited use of restraints.3,4 Typical approaches include:
  1. Formal protocols and extensive staff training.
  2. Restraints only if the patient is a threat to themselves or others (including those at risk of pulling out tubes, catheters, ventilators, etc.).
  3. A physician must order the restraints and only for a short amount of time.
  4. Patient must remain under continuous observation.

TJC further clarified that use of siderails may be considered a restraint depending on intent.4 For instance, if siderails are used to prevent a patient from exiting the bed (or attempting to), the siderails would be considered a restraint. If they’re used to prevent a patient from falling out of bed, the siderails would not be considered a restraint.

Within Long-Term Care facilities, CMS identifies siderails, concave mattresses, and position change alarms as restraints. Use of any of these measures requires documentation, physician orders, and ongoing re-evaluation.3
 

APNA and Behavioral Health Restraints

The American Psychiatric Nurses Association revised its position statement about restraints in 2018, with new guidelines to minimize the need for restraints among behavioral health patients. The group recognizes that all patients “have the right to be treated with respect and dignity” and in a manner “that respects individual choice and maximizes self-determination.”5

They recommend the eventual elimination of restraints altogether, focusing on “less intrusive, preventative, and evidence-based interventions in behavioral emergencies that aid in minimizing aggression while promoting safety.”5

References:
  1. Masters K. (2017). Physical Restraint: A Historical Review and Current Practice. Psychiatric Annals. 2017;47(1):52-55.

  2. Use of Restraints. (2019). NIH MedlinePlus. Retrieved from: https://medlineplus.gov/ency/patientinstructions/000450.htm

  3. Pub. 100-07 State Operations Provider Certification. (2008) Centers for Medicare and Medicaid Services. Retrieved from: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf

  4. Restraint and Seclusion – Enclosure Beds, Side Rails, and Mitts. (2017). The Joint Commission. Retrieved from: www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/000001668/

  5. APNA Position Statement on the Use of Seclusion and Restraint. (2018). Retrieved from: www.apna.org/m/pages.cfm?pageID=3728


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