Logan Reid
Restraints are sometimes necessary in hospitals to prevent patients from harming themselves or others. The use of restraints, however, can have serious physical and psychological consequences, and they should only be used as a last resort. Due to the risks involved, the use of restraints is highly regulated, and hospital staff must follow strict procedures, including obtaining informed consent and regularly reviewing the need for restraints. Proper documentation is a crucial aspect of these procedures, ensuring accountability and justifying the use of restraints. This paragraph will explore the topic of how often restraints in hospitals should be documented, highlighting the key considerations and guidelines that govern this sensitive practice.
| Characteristics | Values |
|---|---|
| How often | Reevaluation should be frequent and regular |
| What to document | Patient response, patient reevaluation, management changes, harm or injury, restraint orders, consulting teams, behaviour leading to restraint, alternatives to restraint, patient consent |
| Who should document | Attending clinician, consulting teams, ordering clinicians, provider |
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What You'll Learn
Restraint orders and renewal
Restraints are defined by the Centres for Medicare and Medicaid Services (CMS) and the Joint Commission as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely". Restraints can also be chemical, in the form of drugs or medication, and are used to restrict a patient's behaviour or freedom of movement.
Restraint orders should be documented and renewed regularly, with the specific medical or behavioural restraints used, as well as the patient's behaviour leading to the restraint, detailed. The process of ordering and monitoring restraints is important for effective care. The restraint orders themselves should be documented, including renewed orders and the names of the ordering clinicians. The patient's response to the restraints should be recorded, along with how often they were re-evaluated, and any changes made to their management as a result. Any harm or injury caused or made possible by the restraints should be noted, and the attending clinician should be aware of their implementation.
The format of documentation may differ between institutions, but the information should be written and signed in the patient's medical record. Hospitals in the United States often require the renewal of non-violent, non-self-destructive restraint orders every 24 hours, with an evaluation by the clinical team and documentation that the restraints are still required. This allows for regular re-evaluation of the patient's mental status and need for restraints, and gives the patient the opportunity to be released from restraints if possible.
Restraints should not be used as punishment and should only be applied as a last resort, with the patient's informed consent, or that of their surrogate if they lack decision-making capacity. They should be used only when other methods to control a patient and ensure safety have been attempted, and should be removed as soon as the patient and caregiver are safe.
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Patient response and re-evaluation
Restraints should only be used as a last resort and when other methods to control a patient have been attempted and found insufficient. When a patient is restrained, they need special care to ensure they can have a bowel movement or urinate when needed. Restraints should not be used to cause harm or as a punishment.
Hospitals often require the renewal of non-violent restraint orders every 24 hours. This provides an opportunity for the clinical team to re-evaluate the patient's mental status and need for restraints. During these re-evaluations, clinicians should consider the patient's response to the restraints, including any physical or psychological complications. Physical complications can include strangulation, poor circulation, cardiac stress, immobility, muscle weakness, skin injury, infection, incontinence, dehydration, and diminished appetite. Psychological complications can include retraumatization of those with a history of sexual trauma, PTSD, or previous military combat.
The patient's response to the restraints should be documented, including any changes in behaviour or mental state. This information should be signed and included in the patient's electronic medical record. The attending clinician and any consulting teams participating in the patient's care should be aware of the implementation of restraints and have access to this documentation. This documentation ensures that the patient's response is monitored and considered in their ongoing care.
In addition to regular re-evaluations, the need for restraints should be continually assessed, and restraints should be removed as soon as they are no longer required. This assessment should consider the patient's behaviour and any alternatives to restraints. Hospitals should also ensure that only trained staff apply restraints and that the patient's informed consent has been obtained, or the consent of their surrogate if the patient lacks decision-making capacity.
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Harm or injury caused
The use of restraints in hospitals is a complex issue that requires careful consideration and ongoing review. Restraints are defined by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely". This can also include drugs or medications used to restrict a patient's behaviour or freedom of movement.
The potential for harm or injury caused by restraints is significant and well-documented. Physical complications can include strangulation, poor circulation or ischemia, cardiac stress, immobility, muscle weakness, skin injuries, infection, incontinence, dehydration, malnutrition, bed sores, and diminished appetite. The psychological impact of restraints can also be detrimental, with patients experiencing feelings of fear, anger, embarrassment, and loss of dignity. Restraints have also been linked to mental health issues such as retraumatization in patients with a history of sexual trauma, PTSD, and previous military combat.
In addition to the direct physical and psychological consequences, the use of restraints can also have indirect negative effects. For example, restraints have been found to be ineffective in some cases, with patients still experiencing falls or removing their medical devices despite being restrained. This raises questions about the overall effectiveness of restraints in promoting patient safety.
Furthermore, the use of restraints can be particularly concerning for certain populations, such as the elderly, who are already at a higher risk of experiencing physical or pharmacological restraints in hospitals. The potential for harm in this vulnerable population is greater, and the impact of restraints on their mobility and mental health can be more pronounced.
Due to these risks, restraints should only be used as a last resort when all other methods to ensure patient and caregiver safety have been exhausted. Hospitals have protocols in place to regularly reevaluate the need for restraints and to ensure that they are used appropriately and for the shortest amount of time necessary. Any harm or injury caused by restraints should be carefully documented, along with the specific type of restraint used, the behaviour leading to its use, and any alternatives that were tried. This documentation is crucial for patient care and safety, as well as for legal purposes.
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Informed consent
Obtaining informed consent for the use of restraints involves explaining the reasons for their application, the potential risks and benefits, and exploring alternative options. Physicians or licensed practitioners must discuss these details with the patient or, if the patient lacks decision-making capacity, their surrogate or health proxy. This process ensures that the patient or their representative understands the need for restraints and provides consent based on comprehensive information.
The documentation of informed consent is a crucial step in this process. It should include the specific type of restraints used, the behaviour that led to their application, and the alternatives considered. Additionally, clinicians should record how often the patient's condition and need for restraints are re-evaluated, along with any changes in management. Any harm or injury caused or potentially related to the use of restraints must also be documented. This ensures a comprehensive record of the patient's care and allows for transparency and accountability.
Hospital policies on restraint orders may vary, but a common strategy is to require renewal of nonviolent, non-self-destructive restraint orders every 24 hours. This regular re-evaluation is essential for ensuring that restraints are only used for as long as necessary and provides an opportunity to transition to alternative interventions if feasible. The attending clinician should be aware of the implementation of restraints, and their knowledge, along with that of consulting teams, should be documented.
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Alternatives to restraint
The use of restraints in hospitals has come under scrutiny due to ethical concerns, patients' rights, and the harmful physical and psychological effects on restrained individuals. As such, alternatives to restraint must be attempted and documented. These alternatives include:
Environmental Changes
Changes to the hospital environment, such as reducing ambient distress levels and modifying the interaction style between patients and nursing staff, can help reduce the need for restraints.
Increased Staffing
Having more staff can lessen the need for restraints as it increases patient-staff interaction and allows for better monitoring and crisis management.
Bed Alarms
Bed alarms can be used so that if a patient gets up, an alarm sounds to alert staff. This can be an effective alternative to physical restraints.
Sitters
A sitter can be placed in the room with the patient to monitor their behavior and relay any requests to the nursing staff. If the patient needs to move around or use the bathroom, the sitter accompanies them.
Distraction Techniques
Distracting patients through reading to them, playing cards or music, or walking with them can be an alternative to restraint. For elderly patients, providing a plush toy or baby doll may have a calming effect.
Pastoral Care
Involving pastoral care staff or connecting patients with a religious figure, such as a minister, priest, or rabbi, can provide spiritual support and potentially reduce the need for restraints.
It is important to note that the use of restraints should be a last resort, and hospitals should explore alternative methods to ensure the safety of patients and staff whenever possible.
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Frequently asked questions
Restraint orders should be renewed every 24 hours, with an evaluation by the clinical team and documentation stating that restraints are still required.
Documentation should include the patient's response to restraints, how often they were re-evaluated, and any changes in management. Any harm caused by the restraints should also be noted, along with the ordering clinician's name.
A physician or licensed practitioner must give a time-limited order for the use of restraints.
Restraints should only be used as a last resort, when other methods to control a patient have failed. They are appropriate when a patient poses a significant danger to themselves or others.
Physical restraints include soft restraints, leather restraints, Posey vests, and veils or net beds.
