Regulatory Issues in Use of Physical Restraints in Aggressive, Violent Patients

Use of physical restraints should be considered a last resort, when other steps have not sufficiently controlled aggressive, potentially violent behavior. When restraints are needed for such a situation, they are legal in all states as long as their use is properly ordered and documented in the patient’s medical record. Restraints have the advantage of being immediately removable, whereas drugs may alter symptoms enough or in a way that delays assessment.

The Joint Commission on Accreditation of Healthcare Organizations Standards on Restraint and Seclusion provides guidelines for use of restraints in the psychiatric setting. They state that restraints must be applied under the direction of a licensed practitioner (LP) who is authorized by hospital policy in accordance with state law to do so. The LP must assess the patient within the first hour of restraint placement. The order for continued restraint of adults may be written for up to 4 hours at a time. The patient must be evaluated by an LP or registered nurse during the 4-hour interval and before further continuation of the restraint order. After a minimum time interval, which is specified by state law and is no longer than 24 hours, the LP must reevaluate the patient in person before continuing the restraint order. Children aged 9‒17 years must be assessed every 2 hours, and those < 9 years, every hour.

Hospital accreditation standards require that patients in restraints be continuously observed by a trained sitter. Immediately after restraints have been applied, the patient must be monitored for signs of injury; circulation, range of motion, nutrition and hydration, vital signs, hygiene, and elimination are also monitored. Physical and mental comfort and readiness for discontinuation of restraints as appropriate are also assessed. These assessments should be done every 15 minutes.

Seclusion and restraints should be used simultaneously only under special circumstances and with continuous monitoring.