When Are Physical Restraints Appropriate?
Physical restraints should only be used as a last resort when a patient presents an acute danger to themselves or others, when there is significant disruption of the treatment plan including property damage, and only after less restrictive measures have failed or are not possible. 1, 2
Specific Indications for Restraint Use
Physical restraints are appropriate in three clearly defined situations:
Imminent danger to self or others: When the patient poses an immediate physical threat through intentional violent or self-destructive behavior that cannot be managed through verbal de-escalation or other interventions 1, 2, 3
Significant treatment disruption: When the patient's behavior causes considerable disruption to the treatment plan or substantial property damage that interferes with care delivery 1, 2
Failure of less restrictive alternatives: Restraints are only justified after attempting and documenting the failure of less restrictive interventions, or when such alternatives are clearly not feasible in the immediate situation 1, 2
Critical Regulatory Framework
The Centers for Medicare and Medicaid Services, The Joint Commission, and major medical organizations including the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry all emphasize that restraints should be considered a security measure, not a treatment modality, and used only as an absolute last resort 1
Required Documentation and Monitoring
When restraints are deemed necessary, strict protocols must be followed:
Immediate physician evaluation: A licensed independent practitioner must conduct an in-person evaluation within 1 hour of restraint placement 1, 2, 4
Continuous monitoring: Assessments every 15 minutes are mandatory for all ages, evaluating vital signs, signs of injury, extremity circulation and range of motion, nutrition/hydration status, and psychological comfort 1, 2
Time-limited orders: Restraint orders must be renewed frequently based on patient age—every 1 hour for children under 9 years, every 2 hours for ages 9-17 years, and every 4 hours for adults 1
Absolutely Prohibited Uses
Restraints are never appropriate in the following circumstances:
Staff convenience: Using restraints because of inadequate staffing or to make patient management easier for staff 2, 3
Punishment: Restraints must never be used as punishment for difficult behavior 2
Fear of liability: Restraining patients solely due to concern about falls or other adverse events without meeting the danger criteria is inappropriate 5
Safety Considerations and Mortality Risk
The decision to restrain carries significant risk. Between 1993 and 2003,45 deaths in child and adolescent psychiatric facilities were attributed to restraint use 1. Common life-threatening complications include:
Asphyxiation and strangulation: Particularly with prone positioning or improperly applied restraints 1, 6
Airway obstruction: Deaths have occurred from covering the face, restricting head movement, or pressure on the neck and back 1, 6
Cardiovascular complications: Rhabdomyolysis leading to hyperkalemia and cardiac arrest, especially in agitated patients or those with stimulant intoxication 1
Neurovascular damage: Skin breakdown, brachial plexus injuries, and circulatory compromise from improperly applied restraints 1, 2
Preferred Positioning and Application
When restraints cannot be avoided:
Supine positioning is preferred: Place the patient on their back with the head of the bed elevated and free cervical range of motion to minimize aspiration risk 1, 2
Avoid prone positioning when possible: Prone restraint has been associated with multiple deaths and should only be used if other measures have failed, with continuous monitoring for airway obstruction and minimizing pressure on the neck and back 1
Proper staff training is mandatory: Only trained personnel should apply restraints, with annual retraining required 1, 2
Chemical Restraint as an Alternative
In certain situations, particularly with suspected stimulant intoxication, chemical restraint may be preferable to physical restraint due to the risk of rhabdomyolysis-induced hyperkalemia causing cardiac arrest 1. Benzodiazepines such as lorazepam are preferred due to rapid onset and absorption 2.
Common Pitfalls to Avoid
Delaying reassessment: Do not wait the full 15 minutes between checks if neurovascular compromise is suspected—intervene immediately 2
Assuming proper application: Patient movement can cause restraints to tighten over time; objective circulation assessment is mandatory at each check 2
Inadequate monitoring: Continuous observation is required, not just periodic checks, as most restraint-related deaths occur in patients who were not continuously observed 6
Using improvised restraints: Non-standard or improvised restraints have been associated with deaths and should never be used 6