Editing Infection Control and Safety (section)

== Restraints and Restraint Alternatives ==

A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move the arms, legs, body, or head freely, or a drug used as a restriction to manage behavior that is not a standard treatment or dosage for the patient's condition. Restraints are a '''last resort''' after alternatives have failed.

=== Alternatives to try first ===

Identify and treat the cause of the behavior: pain, hypoxia, hypoglycemia, infection, full bladder, constipation, medication effect, sensory deprivation, or unmet need. Reorient frequently and provide clocks, calendars, glasses, and hearing aids. Provide familiar objects, family or sitter presence, and consistent caregivers. Use distraction and activity, diversional items, and regular toileting. Reduce noise and provide uninterrupted sleep. Camouflage tubing under clothing, use mittens or a wrap for dressing protection, use a lower bed with mats, and use bed and chair alarms and video monitoring.

=== Legal and regulatory requirements ===

* Requires an '''order from a physician or other licensed independent practitioner'''. '''PRN or standing restraint orders are prohibited.'''
* In an emergency, a trained registered nurse may apply a restraint and must obtain the order as soon as possible, generally within one hour.
* '''Violent or self-destructive behavior:''' a face-to-face evaluation by the physician, other licensed independent practitioner, or a trained registered nurse is required '''within one hour''' of initiation. Order time limits are '''4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9'''. Orders may be renewed within these limits for up to 24 hours, after which a new in-person evaluation is required before a new order.
* '''Nonviolent, non-self-destructive (medical or surgical) restraint,''' such as protecting an endotracheal tube: the order is renewed according to hospital policy and at minimum the need is reassessed and the order renewed at least once each calendar day.
* Use the '''least restrictive''' device that is effective, obtain informed consent or notify the family per policy, and discontinue at the earliest possible time. Discontinuation does not require a new order.

=== Safe application and monitoring ===

Apply the restraint over clothing or padding, never directly on bare skin over a bony prominence. Allow two fingers to slide between the restraint and the limb. Secure ties to the '''movable bed frame''', never to the side rails and never to a fixed part of the bed that would tighten when the bed is raised or lowered. Use a '''quick-release knot''', never a square knot or a bow that can tighten. Keep scissors accessible. In a wheelchair, secure to the frame behind the chair out of the patient's reach.

Monitoring for nonviolent restraint is typically every 2 hours, and for violent restraint every 15 minutes with continuous observation, per facility policy. At each check assess circulation, sensation, and motion distal to the device, skin integrity, respiratory status, and correct placement. '''Release the restraint at least every 2 hours''' to provide range of motion, reposition, toilet, offer fluids and nutrition, and perform skin care, and release one limb at a time in a violent patient. Never restrain a patient in the prone position or in any way that impedes breathing. Never leave a restrained patient alone with the restraint released. Document the behavior that necessitated the restraint, the alternatives tried and their results, the type and placement, the patient's response, all monitoring, and the criteria for discontinuation.

'''Application note.''' Restraint reduces agitation only in appearance. Restrained patients are at higher risk of pressure injury, aspiration, deconditioning, delirium, strangulation, and death. If an exam option offers a genuine alternative that would keep the patient safe, that option is almost always correct.