Focus on…Safe Use of Restraints

Choosing the right restraint

Nurses at the bedside are experts in driving the safest, most effective patient care. In some cases, nursing assessment and clinical judgment suggest the need to apply restraints. A patient who is violent or self-destructive or whose behavior jeopardizes the immediate physical safety of him- or herself or another person may meet the behavioral health requirements for restraints. Examples of such behaviors include:

  • hitting, kicking, or pushing
  • pulling on an I.V. line, tube, or other medical equipment or device needed to treat the patient’s condition
  • attempting to get out of a bed, chair, or hospital room before discharge, in patients who are confused or otherwise unable to follow safety directions.

Before using restraints, always explore alternatives for keeping the patient and others safe. When considering such options, discuss with the patient any conditions that may need to be addressed, such as pain, anxiety, fear, or depression. If distraction and other alternatives prove ineffective at calming the patient and he or she continues to pose a risk, consult with other healthcare team members. You may want to use an algorithm to help determine if your patient requires restraints. (access the author’s algorithm.) Placing a patient in restraints requires a consult from the behavioral health team to consider behavioral restraint options—for instance, certain medications, distraction, seclusion, blanket wraps, or manual locked restraints. If such options don’t apply to your patient, proceed with restraints applicable for nonviolent, nonself-destructive patients, such as mitts, soft wrist restraints, or a chest vest. (See Decision tree for nonviolent, nonself-destructive restraint.)

Restraint options

Which type of restraint to use depends on the patient’s behavior and condition.

Hand mitts and freedom sleeves

If the patient is confused and impulsive and doesn’t follow directions but can be redirected, consider hand mitts to decrease grabbing ability. Or consider “freedom sleeves” (also called soft splints). These are a good deterrent for patients trying to remove a medical device from the face or head (such as a nasogastric tube or drain). With freedom sleeves, patients have difficulty bending their arms. Be aware, though, that the sleeves don’t necessarily prevent them from removing I.V. lines. Hand mitts and freedom sleeves let the patient move the arms up and down but limit the ability to bend and grab tubes or drains. They can be removed by unstrapping the hook-and-loop closures and sliding them off the arms. Be sure to monitor patients closely because they may try to remove these restraints themselves.

Enclosure bed

An enclosure bed helps prevent patient injury by stopping the patient from getting out of bed unassisted. It may be a good option for patients who meet the criteria for this bed. (For more information, read “Enclosure bed: A protective and calming restraint” in this issue.)

Chest vests and lap belts

Chest vests and lap belts (also called waist belts) may be warranted for confused or impulsive patients who are continually trying to get out of bed or a chair after repeated redirection, when it’s unsafe for them to get up unaided. Apply the vest or belt according to the manufacturer’s instructions. Fasten it securely to an immovable part of the bed or chair. Make sure you can easily slide your fingers underneath the vest or belt so it’s not too tight. It shouldn’t press uncomfortably against the skin, which could cause redness or impede expansion of the patient’s midsection during respiration. Instruct the patient to call for assistance when he or she wants to get up.

Limb restraints

Soft bilateral limb holders on both wrists may be appropriate for patients who are becoming increasingly agitated, can’t be redirected with distraction, and keep trying to remove needed medical devices. When device removal would pose serious harm to the patient and cause a significant setback to recovery, or if the patient is a physical threat to him- or herself or others, limb restraints help protect the patient and staff and remind the patient not to pull on the device. Typically, these restraints are used for patients in intensive care units who have endotracheal tubes, intracranial pressure monitoring devices, chest tubes, external fixators, skeletal traction, or other devices whose removal would imperil the patient’s health. In many cases, these patients are receiving sedatives or opioids to relieve pain and anxiety, impairing their safety awareness. In more extreme cases, patients who are severely agitated or intoxicated, are undergoing alcohol or drug withdrawal, or can’t follow safety directions may require arm and leg restraints, chemical restraint, or both. These methods should be used only for short periods. Monitoring requirements may call for one-to-one observation. Soft limb restraints are preferred, but locked cuff restraints can be used if soft restraints prove ineffective. Chemical restraints require a pro­vider assessment and a one-time order with close patient monitoring. Four-point restraints, which restrain both arms and both legs, usually are reserved for violent patients who pose a danger to themselves or others. Caregivers may use a combination of chemical sedation and four-point restraints to calm the patient as long as he or she poses a danger. Monitor the patient in four-point restraints every 15 minutes. Know that these restraints must be reduced and removed as soon as safely possible. To reduce a four-point restraint, remove it slowly—usually one point at a time—as the patient becomes calmer. During removal, reorient the patient and contract with him or her for safe behavior.

A last resort

Keeping patients and others safe is extremely important, but restraints should be used only as a last resort. When they’re needed, choose the least restrictive restraint possible. Reassess a restrained patient continually and remove restraints as soon as possible. During the restraint episode, educate patients and their families about the restraints and keep them engaged in the care the patient’s receiving. Be sure to document your assessment findings and progress toward restraint removal to help “tell the story” of the restraint incident.

References

Centers for Medicare & Medicaid Services. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Revision protocol (09-26-2014). P.131 482.13(e)(8)(i). http://cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf. Accessed November 15, 2014.

Huang YT. Factors leading to self-extubation of endotracheal tubes in the intensive care unit. Nurs Crit Care. 2009;14:(2):68-74.

Click here for information on distraction techniques and on applying restraints.

Christy Rose is a staff nurse in the surgical intensive care unit at Denver Health Medical Center in Denver, Colorado.

Read the next article: Enclosure bed: A protective and calming restraint

When and how to use restraints

Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others.

As nurses, we’re ethically obligated to ensure the patient’s basic right not to be subjected to inappropriate restraint use. Restraints must not be used for coercion, punishment, discipline, or staff convenience. Improper restraint use can lead to serious sanctions by the state health department, The Joint Commission (TJC), or both. Use restraints only to help keep the patient, staff, other patients, and visitors safe—and only as a last resort. Continue reading »

Assessing and documenting patient restraint incidents

Restraining a patient is considered a high-risk intervention by the Centers for Medicare & Medicaid Services, The Joint Commission (TJC), and various state regulatory agencies, so healthcare pro­viders must carefully assess and document the patient’s condition.

Assessing the patient’s medical condition

Review the patient’s medical record for preexisting conditions that can cause behavioral changes—for instance, delirium, intoxication, and adverse drug reactions. If the behavior results from an underlying medical problem, accurate assessment allows timely medical intervention and may reduce the restraint period required or even eliminate the need for restraint.

Assessing the patient’s behavior

To establish the patient’s behavioral baseline, assess his or her mental status, mood, and behavioral control. This allows clinicians to later determine how the patient is tolerating restraint and helps ensure restraint will be discontinued as soon as clinically indicated.

Medications can be an important part of a restraint intervention. Appropriate use of as-needed medications can shorten the restraint time. Assess the patient’s response to medications.

Assessment during the restraint period

A restrained patient is susceptible to injuries caused by restricted breathing, circulatory problems, and mechanical injuries. Once restraints have been applied, take steps to ensure a safe, injury-free outcome. Perform a quick head-to-toe assessment to help identify areas of concern or conditions that require further monitoring.

Being restrained is a traumatic experience for the patient, so continually assess how he or she is dealing with the stress.

Documentation

Accurate documentation of the restraint episode is vital to safe, effective patient care and provides information that can improve the quality of care. Document the reason for restraint and that you explained the reason to the patient and family.

You can use a flowsheet to document assessments. The flowsheet should include the following:

  • patient behavior that indicates the continued need for restraints
  • patient’s mental status, including orientation
  • number and type of restraints used and where they’re placed
  • condition of extremities, including circulation and sensation
  • extremity range of motion
  • patient’s vital signs
  • skin care provided
  • food, fluid, and toileting offered.

Also, include the education you provide to the patient and family. Remember—the goal is to remove the restraints as soon as possible.

Post-restraint debriefing

When the restraint episode ends, a nurse or other qualified caregiver should debrief the patient. Reviewing the restraint episode with the patient yields important information that can help lead to restraint-free treatment. Information gained from debriefing helps the treatment team design therapeutic interventions that may help prevent the need for restraints. Be sure to document the debriefing.

Toward restraint-free care

Accurate assessment and documentation of restraint episodes provide valuable information to improve treatment processes, ultimately helping nurses create an environment where restraint-free care is possible.

References

CMS Manual System. Pub. 100-07 State Operations. Provider Certification. Transmittal 37. Subject: Revise Appendix A, “Interpretive Guidelines for Hospitals.” October 17, 2008. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf. Accessed November 19, 2014.

The Joint Commission. Sentinel Event Alert. Issue 8, November 18, 1998. Preventing Restraint Deaths. www.jointcommission.org/assets/1/18/SEA_8.pdf. Accessed November4, 2014.

Jim Woodard is the associate chief nursing officer at Porter Adventist Hospital in Denver, Colorado.

Enclosure bad

Enclosure bed: A protective and calming restraint

An enclosure bed can be used as part of a patient’s plan of care to prevent falls and provide a safer environment. This specialty bed has a mesh tent connected to a frame placed over a standard medical-surgical bed. Although it’s considered a restraint because it limits the patient’s ability to get out of bed, an enclosure bed is less restrictive than other types of restraints. It can be used as an alternative when a vest restraint would cause more agitation and wrist restraints aren’t appropriate.

My 750-bed academic medical center became interested in the enclosure bed in 2007 as a way to decrease patient falls and patient-sitter costs. We’ve seen the enclosure bed have a calming effect on patients and give them more freedom than wrist and ankle restraints. Our hospital rents the bed; for a 24-hour period, the daily rental expense is much lower than the cost of a patient sitter. (See A look at the enclosure bed.)

Indications

Use of the enclosure bed hinges on the patient’s behavior, so a patient-specific comprehensive assessment must be done. The bed may be indicated for patients who are at high risk for falls; are confused, impulsive, restless, or agitated; are unable to ask for assistance or respond to redirection; or who climb out of bed when it’s unsafe to do so.

Other patients who might benefit from an enclosure bed include those with Alzheimer’s disease or other types of dementia, traumatic brain injury, seizure disorder, Huntington’s disease, or developmental delays. The bed also may be indicated for patients recovering from stroke, as well as for patients with delirium associated with alcohol withdrawal who have completed treatment for acute withdrawal.

Inclusion criteria

To be considered for the enclosure bed, the patient must be at high risk for falling and must demonstrate one or more of the following:

  • impulsiveness
  • agitation
  • inability or unwillingness to ask for assistance or respond to redirection
  • unsteady gait
  • wandering behavior.

A history of falling alone isn’t enough to warrant use of the enclosure bed or other restraints.

Exclusion criteria

Patients shouldn’t be placed in an enclosure bed if they are violent, combative, self-destructive, suicidal, or claustrophobic. Although the bed has small holes for one or two I.V. lines and an indwelling urinary catheter, patients with multiple lines generally are excluded. If the patient becomes increasingly agitated, terrified, or distraught after being placed in the bed, clinicians must reassess the situation and try a different intervention.

Evaluation period

Before our hospital decided to add the enclosure bed to our approved specialty rental inventory, staff nurses and other providers conducted an evaluation to identify patient risk behaviors that could be managed in this bed. The hospital conducted a 6-month trial of the enclosure bed, during which staff used the bed and completed an evaluation tool. The tool asked specific questions about staff comfort level with the bed, ease of use, family response to the bed, and whether the bed met the patient’s needs.

Education and implementation

Based on staff feedback and positive patient outcomes during the evaluation, the enclosure bed was added to potential interventions to prevent falls and to provide a safer environment for patients. Our facility has developed processes to request or order the bed, monitor the patient while in the bed, and discontinue the bed.

The enclosure bed was introduced as a type of restraint to providers who have the authority to order restraints. Staff nurses received education on indications for the bed, how to operate it, and documentation requirements. Nursing staff at the unit level worked with provider teams to implement the enclosure bed.

Education consisted of reviewing the procedural checklist, watching an instructional video and completing a self-learning module on restraint use. During the demonstration on how to zip the panels and use the locks on the zippers, nurses had the chance to get into the bed to see what it’s like.

Required processes

Before an enclosure bed is requested, nursing staff must review with the provider team the behavior that puts the patient at risk for falls and injury, as well as for impulsive behavior that harm the patient or staff. One example is an impulsive patient with early-onset dementia who is hitting and kicking at staff.

As with all restraints, an enclosure bed requires a provider restraint order that must be renewed every 24 hours. Before a patient is placed in the bed, staff try less restrictive options, such as distraction, bed and chair alarms, reducing stimuli, and moving the patient to a room closer to the nursing station. Once the decision to use an enclosure bed is made, clinicians must educate the family about the bed, its function, the reason for using it, how the panels are zipped and unzipped, and how the bed contributes to a cocoon-like environment. If family members aren’t available in the hospital, the charge nurse contacts a family member by phone to explain the change in the patient’s care.

Using a restraint flowsheet, nursing staff document the patient’s response to the enclosure bed and the frequency with which they met the patient’s care needs during bed use.
When the patient’s behavior improves, the enclosure bed is discontinued. The specialty bed coordinator is notified and the vendor picks up the bed.

Placing the patient in the bed

Before using the bed, inspect it for proper assembly. Then unzip the bed and adjust the head of the bed. Once the patient has been placed in the bed, sit in a chair next to the bed for a few minutes with the sides unzipped to help him or her get acclimated. Adjust the head of the bed so the patient can sit in it comfortably. Then zip the sides and see how the patient reacts to the enclosure. If the patient will be left alone, place a call button within reach.

The patient’s activity schedule should include getting him or her out of the bed multiple times a day. Staff should assist the patient to ambulate at least three times daily. The patient should sit in a bedside chair for all meals, if able to tolerate ambulation and activity. According to the Centers for Medicare & Medicaid Services’ Interpretive Guideline §482.13(e) (6), “a temporary, directly supervised release…for the purposes of caring for a patient’s needs
(e.g. toileting, feeding, or range-of-motion exercises) is not considered a discontinuation of the restraint. As long as the patient remains under direct staff supervision, the restraint is not considered to be discontinued because the staff member is present and is serving the same purpose as the restraint.”

Outcomes

In our hospital, the enclosure bed was incorporated quickly into the safety plan for med-surg patients. The adult med-surg nursing staff has used the bed with more than 200 patients. On average, patients stay in the bed about 6 days; no patient falls or injuries have occurred. In some facilities, using the bed decreases overall sitter expenses. Our experience has shown a slight reduction in sitter hours when the bed is used.

Based on our positive experiences and patient outcomes, we will continue to use the enclosure bed as an option for fall prevention and patient safety.

Several patients have been discharged from our hospital with a plan of care that included an enclosure bed. In the home, the bed can be used for patients with agitation secondary to dementia or for pediatric patients with significant chronic neurologic or behavioral problems. The experience the families gained with the enclosure bed in the hospital helped provide a safe discharge plan for several patients.

Involving staff with an initial trial of the bed, identifying appropriate patient criteria, and educating staff, patients, and families about the bed’s benefits have contributed to successful implementation of this specialty bed.

Click here for information on caring for a patient in an enclosure bed, using the enclosure bed with pediatric patients.

References

Centers for Medicare & Medicaid. Interpretive Guidelines for Hospitals. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Conditions of Participation for Hospitals, 42 CFR Appendix A.§482.13(e)(6). October 2008. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ R37SOMA.pdf. Accessed November 9, 2014.

Jennifer L. Harris is a senior advanced practice nurse at the University of Rochester Medical Center-Strong Memorial Hospital in Rochester, New York.

Read the next article: Assessing and documenting patient restraint incidents