Detecting blind spots in your restraint process

Every day, hospital caregivers manage severe physical or mental health crises where the risk of patient self-harm or violence endangers everyone. The decision to restrain a patient is one of the toughest choices to face, but it is sometimes necessary to ensure safety. Restraint use in hospitals is more common than many realize, with rates remaining steady since 2011 at around 0.63 percent of all admissions, equating to nearly two million episodes annually.^1,2

Physical restraint requires clear plans to minimize risks to caregivers and patients. Decisions about restraint are complex, and improper management can lead to citations from CMS or your accrediting organization. By addressing frequently overlooked aspects of restraint use, hospitals can reduce injuries, improve patient outcomes, and ensure regulatory compliance.
 

What constitutes a restraint?

CMS defines a restraint as “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move freely; or a drug or medication used to manage behavior or restrict freedom of movement, and not a standard treatment for the patient’s condition.”³ While most organizations understand this definition in the context of traditional four-point or wrist restraints, potential blind spots arise when restraint is less obvious.

• Physical holds: Situations in which caregivers hold a patient to prevent harm, such as stopping them from injuring themselves or pulling out an IV, still restrict movement and meet the definition of a restraint. When these events occur, staff must recognize this as restraint and activate the next steps in the restraint policy, such as orders, assessments, and documentation.
• Side rails: In many cases, side rails such as gurneys in the operative suite or ER are raised for patient safety and mobility. However, if raised side rails stop a patient from voluntarily exiting the bed when it would be considered reasonable to do so, this would restrict the patient’s freedom of movement and cross the line into restraint. Examples include raising all four rails or positioning a bed against a wall to limit exit options. Though intended for safety, side rail use can be dangerous. Patients can become entrapped or fall from greater elevations when attempting to climb over the railing, causing serious injury or death. Clear policies define acceptable side rail use, and clinical staff must understand and follow them.
• Enclosure beds: These beds, which use nets or barriers to prevent a patient from exiting freely, are classified as restraints. An exception is made for age-appropriate use with infants or toddlers. Make sure that departments where enclosure beds are used are included in your restraint plan and that staff members meet all the training requirements for restraint use.
• Hand mitts: Typically, the use of hand mitts does not constitute a restraint; however, if mitts are pinned to bedding, applied so tightly that the patient’s hands are immobilized, or are so bulky that the patient’s hand function is severely limited, the definition of restraint would be met. Ensure your policy and processes are clear when it comes to hand mitts.

 
Navigating the nuances of chemical restraints

Chemical restraints — medications used to restrict a patient’s movement or control behavior — are often hard to identify. These activities can go undetected in hospitals if guidelines are not clearly established. It is the circumstance under which certain medications are prescribed and not the medications themselves that constitute restraint. Medications intended for chemical restraint are those administered when alternative interventions have proven unsuccessful. The medications are administered with little patient collaboration and with the intent to reduce risk and regain control. 

In contrast, PRN medications are given to meet the patient’s therapeutic needs. They can be requested or refused by the patient. PRN medications require patient consent, whereas chemical restraints do not. Be sure that your clinical staff and providers recognize chemical restraint, use it only when all other interventions have failed, and follow all restraint policies when it occurs.

 

Understanding the rationale for restraint use

• Sedated patients: Many sedated patients in hospital special care units have nonviolent restraints applied to prevent self-extubation or other critical lines from being pulled. CMS clearly states that restraints of any kind should be implemented only while unsafe conditions exist and discontinued at the earliest possible time. Patients who are sedated and not posing a threat should not be restrained. Ensure that restraints are not routinely applied to sedated patients as a default protocol in your organization.
• Fall prevention: Patients should never be restrained due to the risk of harm from falls. In fact, studies indicate that restrained patients tend to fall more frequently and suffer more severe injuries, including death, than those who are not restrained.⁴ Restraint records, particularly for older or confused patients, should be carefully reviewed to ensure compliance with this guideline.

 
The importance of staff training

Training must be conducted during orientation and at regular intervals to help ensure patient and staff safety. This includes hands-on training for all staff who will participate in applying or monitoring restraints. While most hospitals train nurses, consider the following frequently overlooked requirements:

• Non-nursing staff: Hospital security guards, respiratory therapists, and behavioral health staff involved in applying or monitoring restraints must receive the same training CMS requires, including CPR, first aid, and de-escalation techniques. Those who might respond to a patient who has become violent and combative might apply a physical hold or assist when needed. Validate that these staff members are prepared to respond safely and appropriately. 
• Trainers’ qualifications: CMS requires that those providing training have relevant education, experience, and expertise in managing patient behavior. Make sure that your trainers are well-qualified and that their credentials are properly documented.
• Physician education: Regulations require hospital policy to outline the expected training for physicians and other licensed practitioners authorized to order restraint. At a minimum, there should be a documented process identifying which practitioners can order restraints and showing proof that they have been trained regarding the hospital’s policies.

 
Mastering documentation requirements

The rules around restraint documentation can be intricate and overwhelming. Don’t overlook these potential blind spots. 

• Renewal orders: CMS mandates that orders for violent restraints be renewed at regular intervals based on the patient’s age. If the patient’s condition warrants continuation of restraint, new orders and assessments are required every 24 hours. For nonviolent restraints, CMS allows hospitals to implement their own policies for renewal. However, this flexibility does not mean a renewal order is unnecessary. Safeguard your patients by requiring providers to reassess, renew, and reorder nonviolent restraint at frequencies that ensure safety, dignity, and independence. 
• Death reporting requirements: CMS requires that hospitals report all deaths that occur while a patient is restrained within 24 hours of restraint removal and report any death that occurs within one week of restraint use when it is reasonable to assume that the use of restraint or seclusion contributed to a patient’s death. CMS does make an exception for deaths that occur when no seclusion has been used and only soft, nonrigid wrist restraints are in place. For these cases, the organization must maintain an internal log of any death that occurs while a patient is in such restraints or any death that occurs within 24 hours after a patient has been removed from such restraints. Ensure that this required log is kept up to date and is available upon request from CMS or an accrediting body.   

Restraint is a measure of last resort, a difficult option no caregiver makes lightly. ACHC standards mirror CMS requirements, and we collaborate with hospitals nationwide to meet these expectations for safe, respectful patient care. By improving awareness and proactively addressing blind spots, hospitals can better protect patients’ rights, promote safer care, and fulfill their highest duty to do no harm.

NRHA adapted the above piece from the Accreditation Commission for Health Care, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.

About the author: Donna Gorby, RN, provides standards interpretation for acute care and critical access hospitals at ACHC. She has served in leadership roles including vice president of quality and medical staff services, director of nursing, and regulatory compliance officer. Donna holds a master’s degree in leadership development, a bachelor’s degree in nursing, and a Lean Six Sigma Black Belt. She has been a nurse for more than 30 years and is passionate about health care leadership, regulatory compliance, and patient safety.

References 

¹ American Hospital Association, “Fast facts on U.S. hospitals, 2024,” https://www.aha.org/statistics/fast-facts-us-hospitals

² Ishaan Gupta, et al., Mayo Clinic proceedings: Innovations, Quality & Outcomes, “Physical restraint usage in hospitals across the United States: 2011-2019,” January 3, 2024, https://www.mcpiqojournal.org/article/S2542-4548(23)00078-4/fulltext 

³ Centers for Medicare & Medicaid Services, “State Operations Manual Appendix A – survey protocol, regulations and interpretive guidelines for hospitals,” April 19, 2024, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 

⁴ Umberto Spennato, et al., “Prevalence, Risk Factors and Outcomes Associated with Physical Restraint in Acute Medical Inpatients over 4 Years–A Retrospective Cohort Study,” January 17, 2023, https:/www.mdpi.com/2308-3417/8/1/15