BACKGROUND AND STATEMENT OF PROBLEM

A.  Definition: The CMS defines physical restraint as “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely” (USDHHS, 2006, p. 71383). Examples include wrist or leg restraints, Geri chairs, and, in certain situations, mitts, full side rails, and reclining chairs.

B.  Etiology: Hospital nurses’ reasons for use of physical restraint are prevention of patient disruption of medical devices and therapy (75%), confusion (25%), and fall prevention (20%) (Minnick et al., 2007; Perez et al., 2019).

C.  Epidemiology

1. Prevalence of physical restraint use on individual non-ICU rates has decreased significantly, with the overall rate on medical and surgical units being 1.6%. Variations exist across units (Minnick et al., 2007; Staggs et al., 2017).
2. Individual ICU rates range from less than 20% to greater than 80% (Perez et al., 2019; Rose et al., 2016).

PARAMETERS OF ASSESSMENT

A.  Assess for underlying cause(s) of agitation and cognitive impairment leading to patient-initiated device removal (refer to Chapter 9, Assessing Cognitive Function in the Older Adult; Chapter 19, Late-Life Depression; Chapter 20, Delirium: Prevention, Early Recognition, and Treatment; and Chapter 21, Dementia: Assessment and Care Strategies).

1. If abrupt change in perception, attention, or level of consciousness:
   • Assess for life-threatening physiological impairments
   • Review respiratory, neurological, fever and sepsis, hypoglycemia and hyperglycemia, alcohol or substance withdrawal, and fluid and electrolyte imbalance
   • Notify physician of change in mental status and compromised physiological status
2. Differential assessment (interprofessional)
   • Obtain baseline or premorbid cognitive function from family and caregivers
   • Establish whether the patient has history of dementia or depression
   • Review medications to identify drug–drug interactions, adverse effects
   • Review current laboratory values

B.  Assess fall risk: intrinsic, extrinsic, and situational factors (refer to Chapter 23, Assessing, Managing, and Preventing Falls in Acute Care)

C.  Assess for medications that may cause drug–drug interactions and adverse drug effects (refer to Chapter 24, Reducing Adverse Drug Events in the Older Adult).

NURSING CARE STRATEGIES

A.  Interventions to minimize or reduce patient-initiated device removal

1. Disruption of any device
   • Reassess daily to determine whether it is medically possible to discontinue device; try alternative mode of therapy (DuBose et al., 2010; Mion et al., 2001; Nirmalan et al., 2004).
   • For mild to moderate cognitive impairment, explain device and allow patient to understand nurse’s guidance.
2. Attempted or actual disruption: ventilator
   • Determine underlying cause of behavior for appropriate medical and/or pharmacological approach
   • More secure anchoring
   • Appropriate sedation and analgesia protocol
   • Start with less restrictive means: mitts, elbow extenders
3. Attempted or actual disruption: nasogastric tube
   • If for feeding purposes, consult with nutritionist and speech or occupational therapist for swallow evaluation
   • Consider gastrostomy tube for feeding as appropriate if other measures are ineffective
   • Anchoring of tube, either by taping techniques or commercial tube holder
   • If restraints are needed, start with least restrictive: mitts, elbow extenders
4. Attempted or actual disruption: IV lines
   • Commercial tube holder for anchoring
   • Long-sleeved robes, commercial sleeves for arms
   • Consider Hep-Lock and cover with skin sleeve. White gauze may also be used, but case reports exist in which patients focus on the white gauze and unravel it.
   • Taping, securement of IV line under gown, sleeves
   • Keep IV bag out of visual field
   • Consider alternative therapy: oral fluids, drugs
5. Treatment (interprofessional)
   • Treat underlying disorder(s)
   • Judicious, low-dose use of medication if warranted for agitation
   • Communication techniques: low voice, simple commands, reorientation
   • Frequent reassurance and orientation
   • Surveillance and observation: Determine whether family member(s) is willing to stay with patient, move patient closer to nurses’ station, perform safety checks more frequently, redeploy staff to provide one-on-one observation if other measure is ineffective
6. Attempted or actual disruption: bladder catheter
   • Consider intermittent catheterization if appropriate
   • Proper securement, anchoring to leg; commercial tube holders available

B.  Interventions to reduce fall risk

1. Patient-centered interventions
   • Supervised, progressive ambulation even in ICUs (Devlin et al., 2018; Truong, Fan, Brower, & Needham, 2009)
   • Physical therapist (PT)/Occupational therapist (OT) consultation: weakened or unsteady gait, trunk weakness, upper arm weakness
   • Provide physical aids in hearing, vision, walking
   • Modify clothing: skidproof slippers, slipper socks, robes no longer than ankle length
   • Utilize bedside commode if impaired or weakened gait
   • Postural hypotension: behavioral recommendations such as ankle pumps, hand clenching, reviewing medications, elevating head of bed
2. Organizational interventions (Mion et al., 2001)
   • Examine pattern of falls on unit (e.g., time of day, day of week).
   • Examine unit factors that can contribute to falls that can be ameliorated (e.g., report in staff room vs. walking rounds to improve surveillance during shift change).
   • Restructure staff routines to increase number of available staff throughout the day.
   • Set and maintain toilet schedules.
   • Install electronic alarms for wanderers.
   • Consider bed and chair alarms (note: no to little evidence on effectiveness; Shorr et al., 2012).
   • Move patient closer to nurse station.
   • Increase checks on high-risk patients.
   • Perform video surveillance for high-risk patients.
3. Environmental interventions (Amato et al., 2006)
   • Keep bed in low, locked position.
   • Ensure safety features, such as grab bars, call bells, and bed alarms, are in good working order.
   • Ensure bedside tables and dressers are within easy reach.
   • Clear pathways of hazards.
   • Bolster cushions to assist with posture; maintain seat in chair.
   • Ensure adequate lighting, especially in bathroom at night.
   • Choose furniture to facilitate seating: reclining chairs (note: may be considered restraint in some instances), extended armrests, high back.

C.  Review medications using Beers Criteria for potentially inappropriate medications.

EVALUATION AND EXPECTED OUTCOMES

A.  Patient will:

1. Remain free of restraints.
2. Be put in physical restraints only as a last resort.

B.  Nursing staff will:

1. Be able to accurately assess patients who are at risk for use of physical restraint.
2. Only use physical restraints when less restrictive mechanisms have been determined to be ineffective.
3. Have an increased use of nonrestraint, safety alternatives.

C.  Organization will

1. Have a decrease in incidence and/or prevalence of restraints.
2. Not have an increase of falls, agitated behavior, and patient-initiated removal of medical devices.

FOLLOW-UP MONITORING OF CONDITION

A.  Monitor restraint incidence comparing benchmark rates over time by unit.

B.  Document prevalence rate of restraint use on an ongoing basis.

C.  Focus education on assessment and prevention of delirium and falls.

D.  Consult with interprofessional members to identify additional safety alternatives.

RELEVANT PRACTICE GUIDELINES

A.  American Nurses Association (2012)

B.  Agency for Healthcare Research and Quality (2018)

C.  Society of Critical Care Medicine (Devlin et al., 2018; Maccioli et al., 2003)

ABBREVIATIONS

CMS            Centers for Medicare & Medicaid Services

ICU             Intensive care unit

LIP              Licensed independent practitioner

OT               Occupational therapist

PT                Physical therapist

USDHHS    U.S. Department of Health and Human Services

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 27:  Bradas, C., Sandhu, S., & Mion, L. (2021) Physical Restraints and Side Rails in Acute and Critical Care Settings.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 485-499).   New York: Springer.