What are the indications and regulations for using chemical and physical restraints in patients with behavioral health conditions?

Indications and Regulations for Chemical and Physical Restraints in Behavioral Health

Restraints should only be used when a patient presents an acute danger to themselves or others, or causes significant disruption to the treatment program, and only after less restrictive interventions have failed or are impractical. 1, 2, 3

Strict Indications for Restraint Use

Physical and chemical restraints have only two legitimate indications according to the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics:

• Imminent danger: When the patient is an acute danger to harm themselves or others through intentional actions 1, 2, 3
• Severe treatment disruption: When there is significant disruption of the treatment plan, including serious property damage 1, 2, 3
• After less restrictive measures fail: Restraints can only be applied when less restrictive options have failed or are documented as impractical 1, 2, 3

Absolutely Prohibited Uses

Restraints must never be used in the following circumstances:

• As punishment for patients 1, 2, 3
• For staff convenience 1, 2, 3
• To compensate for inadequate staffing patterns 1, 3
• Where prohibited by state guidelines 1
• By untrained staff 1

Pre-Restraint Requirements

Before considering restraints, you must implement a structured de-escalation approach:

Level 1 (Nonrestrictive Interventions)

• Verbal prompting, modeling, and negotiating 3
• Time-out interventions 3
• Unit-specific de-escalation protocols 1, 3

Level 2 (Restrictive Interventions)

• Structured containment measures 1
• Increased monitoring and supervision 1

Level 3 (Most Restrictive)

• Physical, mechanical, or chemical restraints only when Levels 1 and 2 have failed 1, 3

Mandatory Pre-Restraint Assessment

• Evaluate for cognitive limitations, neurological deficits, and learning disabilities 1, 3
• Complete medical evaluation to identify factors requiring procedural modifications 1, 3
• Review history of aggressive behavior, including triggers and warning signs 1

Physical Restraint Protocols

Hierarchy of Restraint Selection

Seclusion should be considered first choice when containment is necessary, as it is medically safer than restraint and preserves greater patient autonomy 1. However, this must account for situations requiring conversion from seclusion to restraint (e.g., when the patient is injuring themselves in seclusion) 1.

For physical restraints when seclusion is inadequate:

• Children: Physical restraint is preferred 1
• Adolescents: Mechanical restraints are preferred due to increased strength and greater likelihood of drug-induced aggression or psychosis 1

Critical Safety Requirements

Airway protection is paramount - restraints that cause airway obstruction must never be used (e.g., choke holds, covering face with towel or bag) 1, 3:

• Supine positioning (preferred): Head of bed elevated, free cervical range of motion to decrease aspiration risk 1, 2
• Prone positioning: Only if other measures have failed or are not possible; deaths have been associated with its use 1. If used:
  • Monitor continuously for airway obstruction 1
  • Minimize or eliminate pressure on neck and back 1
  • Discontinue as soon as possible 1
  • Never bury the patient's airway 1

Application Standards

• Each limb must be wrapped with a protective collar before the restraint strap is applied to prevent direct pressure on skin and neurovascular structures 2
• Restraints must be applied by trained staff who understand proper tension 2, 3
• Remove smoking materials from physically restrained patients 1, 3

Complications to Monitor

Physical restraints have caused deaths, particularly with prone positioning 1, 3. Common complications include:

• Skin breakdown at restraint sites 1
• Neurovascular damage 1, 3
• Rhabdomyolysis (especially in patients who continue to struggle), potentially leading to kidney failure 1
• Accidental strangulation from vest restraints 1
• Brachial plexus injuries 1
• Electrolyte abnormalities, hyperthermia, deep vein thrombosis, pulmonary injury, and asphyxia 1

Special consideration: In cases of agitation due to suspected illicit stimulant use, chemical restraint may be preferable to physical restraint, as rapid increase in serum potassium from rhabdomyolysis may result in cardiac arrest 1, 2

Chemical Restraint Protocols

Definition and Distinction

Chemical restraint is the involuntary use of psychoactive medication in crisis situations to contain out-of-control aggressive behavior 1, 2, 3. This must be distinguished from the pharmacological management of a patient's underlying psychiatric illness 1, 2, 3.

Medication Selection

According to the American Academy of Child and Adolescent Psychiatry:

• Offer oral medication before parenteral administration 3
• Benzodiazepines (e.g., lorazepam) are preferred due to fast onset and rapid absorption 2, 3
• Consider combination of benzodiazepine plus antipsychotic for acutely agitated patients 3
• Review available medical and psychiatric history, including concurrent medications, before ordering 1, 2, 3

Contraindications for Combined Interventions

The combination of seclusion plus mechanical restraint is not recommended 1. When combining interventions (seclusion plus chemical restraint, physical restraint plus chemical restraint, mechanical restraint plus chemical restraint), the rationale should be reviewed by the physician at the time they are ordered 1.

Mandatory Regulatory Requirements

Ordering and Initial Evaluation

According to Centers for Medicare and Medicaid Services (2006) and The Joint Commission:

• Interventions must be ordered by a licensed independent practitioner 1
• In-person evaluation within 1 hour: A licensed independent practitioner must evaluate the patient in person within 1 hour of restraint placement, regardless of patient age 1, 2
• The treating physician must be consulted as soon as possible if the restraint is not ordered by them 1

Renewal Requirements by Age

Restraint orders must be renewed at specific intervals based on patient age 1, 2:

Age Group	Renewal by Qualified Staff	In-Person LIP Evaluation
<9 years	Every 1 hour	Every 4 hours
9-17 years	Every 2 hours	Every 4 hours
>18 years	Every 4 hours	Every 8 hours

Continuous Monitoring Requirements

Assessments every 15 minutes are mandatory for all restrained patients, regardless of age 1, 2:

• Extremity circulation and range of motion (check skin color, temperature, capillary refill, pulses, sensation, ability to move digits) 2
• Vital signs 2
• Signs of injury due to restraint 2
• Nutrition and hydration status 1, 2
• Physical and psychological status/comfort 1, 2
• Airway patency and respiratory effort 2

Critical action: If any signs of neurovascular compromise are detected, loosen or remove the restraint immediately, reassess clinical need for continued restraint, and consider alternative methods 2

Documentation and Oversight

• Family notification is required when seclusion or restraint is used 1, 3
• Facilities must have a committee providing oversight of seclusion and restraint practices 3
• Document triggers, warning signs, response to treatment, and prior restraint events 1

Staff Training Requirements

The American Academy of Child and Adolescent Psychiatry mandates repeated training in aggression management 1, 3:

• Updated information on seclusion and restraint practices 1
• Frequent practice with restraint equipment 1
• Training in documentation and audits 1
• Annual certification in cardiopulmonary resuscitation 1, 3
• Annual education updates from academic, regulatory, patient advocacy, and professional resources 1

Common Pitfalls to Avoid

• Never assume restraints are appropriately tight just because they were initially applied correctly; patient movement can cause restraints to tighten over time, and objective assessment of circulation is mandatory 2
• Do not delay loosening restraints if neurovascular compromise is suspected; the 15-minute assessment interval represents the maximum time between checks, not a suggestion to wait if problems are suspected 2
• Minimize restraint of medically compromised or unstable patients 1
• Minimize use of high vests, waist restraints, and beds with unprotected split side rails 1
• Never cover the patient's face or head 1

Special Considerations for Trauma History

For children and adolescents with trauma history, the development or reactivation of posttraumatic stress disorder with symptoms of flashbacks, nightmares, and intrusive thoughts is a potential consequence of seclusion, physical restraint, and chemical restraint, particularly when carried out in a coercive fashion 1. In these cases, seclusion may be preferred over physical or mechanical restraints for behavioral management 3.