1. Restraints
WCMC is continually trying to minimize the use of restraints. The
number of restrained patients increased 49% this year and the
number of restraint episodes increased 34%! The majority of
restraints occurred in CCU.
Every effort is made to maintain patient safety by first using
methods other than restraints. Restraints are used only when
other methods have been tried and found to be ineffective. In an
emergency situation alternative methods do not always need to
be tried but should at least be considered prior to the use of
restraints.
Only competent trained associates may apply – release – and
reapply restraints.

2. Restraints(continued)
 Always notify the Nursing Supervisor ASAP when restraints
are initiated.
 Address the use of restraints at home in the Initial Interview
in the Social Services section “Signs of Abuse/Social
Deprivation. If restraints are used at home order a Social
Services consult.
 Leave the Restraint sticker on the front of the patient’s
chart, through all levels of care, until discharge from the
hospital system.
 Immediately report any patient death that occurs while in
restraints OR that occurs within 1 week of being in
restraints to Quality/Risk Management at 1062. Complete
and fax the CMS form to Quality Management at 1065
immediately.

3. Alternatives to Restraints
 Ask the family for assistance in  “Low” bed
management of at-risk behavior  Adequate sedation
 Evaluation of meds/status  Room close to desk
 Close monitoring by staff/family  Wrap around/Seat belt
 Progressive ambulation plan  Reorient often
 Offer snacks  Age-appropriate activities
 Frequent bed checks/bed alarm  Place in wheelchair at station
 Relaxing music  Allow uninterrupted rest periods
 Address the 3 P’s at regular  Redirection
intervals  Verbal mediation
 Limit excess noise  Escort from area
 Offer choices  1:1 monitoring
 Time out

4. Restraints (Definition)
Any method or device that restricts a patient’s freedom of
movement, physical activity, or normal access to his/her body
to ensure his/her safety.
Does not include
• Legal or forensic devices – handcuffs, shackles. Legal
personnel are required to continually monitor patients who
are prisoners or wards of the legal system.
• Devices applied only for a procedure-such as insertion of CVL
or CT, dressing change
• Devices used for positioning in OR/PACU

5. Restraints (Types)
PHYSICAL Any manual method or mechanical device that
immobilizes or reduces the ability of a patient to move his/her
extremities, body or head freely and which he/she cannot easily
remove.
Never restrain a patient in the prone position (to avoid positional
asphyxia). The majority of restrained patient deaths have occurred
with the patient restrained in the prone position.
If a patient is “taken down” in the prone position in a physical hold
during a Stat 13 or a emergency situation, immediately turn the
patient supine to avoid any injury.

6. Restraints(types)
CHEMICAL Any medication used to restrict a patient’s freedom of
movement or used for the emergency control of behavior and is not a
standard treatment or dosage for the patient’s medical or psychiatric
condition.
“Standard treatment” would enable the patient to function more
effectively than would be possible without the medication. This would not
be a chemical restraint.
Medications, including PRN, medications that are part of the regular
medical regimen for a known medical or psychiatric condition (such as
drug/ alcohol withdrawal, schizophrenia, etc.) are not considered restraint
even if their purpose is for violent behavior. For this reason it is wise when
writing an order for one time or PRN order for any sedative or
psychotropic medication to include the reason for the medication, such as
“Geodon 20mg IM now for violent behavior r/t schizophrenia”. This would
not be a chemical restraint.

7. Restraints (Physical)
Mittens
Limb –
• cloth
• non-locking hard
• non-locking leather
Tabletop Chair-if the patient
cannot remove the tabletop
Freedom splints
Net enclosed bed-do not use!
Cloth Vest-more injuries occur with
the vest. Use with caution .
Physical hold

8. Restraints (documentation)
 All documentation is completed by licensed nurses
 A physician order is required. Restraints may be applied by an
RN in an emergency situation before calling the doctor.
 Obtain a Restraint packet from CCU. Always complete the pre-
printed Restraint Orders, Restraint Tool and Restraint
Flowsheet.
 Place the Restraint sticker on the front of the patient’s chart
and complete when restraints are initiated and discontinued.
 Always inform the patient, even if they may not
understand, and family about the risks of restraint use/non-
use

9. Restraints (documentation)
Approximately every 2 hours
• Release restraints on a temporary basis during care
• Consider/attempt less restrictive restraints or alternative measures
• Assess if the need or reason for restraint is still present
• Perform neurovascular checks/skin integrity assessment
• Assess/meet the patient’s physical/emotional needs
• Provide toileting, hydration, and positioning as well
Every 4 hours
Assess & document the specific reason/need for restraint.
Every shift
• RN addresses patient behavior in the plan of care/problem list (Refer to
CCU-Potential for injury r/t use of restraints or Potential for injury

10. Restraints (documentation)
Observe/assess the patient on an ongoing basis for readiness for
discontinuation of restraints
Discontinue ASAP or as ordered by the physician Complete the
restraint sticker on the chart front
Discard the restraints - Do NOT send home with the patient
If behavior recurs after restraints are discontinued start at the
beginning of the process
Discontinuation is considered any time restraints are removed for
>1 hour – excluding for patient care, meals, treatments, tests, or
therapy
If a restrained patient is sent to another area (i.e. X-ray or
dialysis), a restraint competent nursing associate must be in
attendance

11. Restraints (Non-violent behavior)
Two major purposes for restraints:
• Non-violent/non self-destructive behavior
• Violent/self-destructive behavior
Majority of restraints are applied for non-violent behavior
which includes any of the following reasons:
• To protect the integrity of essential lines, tubes, and/or
dressings required for medical treatment
• To protect the patient from injury while in the bed or chair
• To protect the patient from injury due to wandering in an
unsafe manner

12. Restraints (Non-violent behavior)
 Physician orders are limited to one calendar day
(midnight to midnight)
 Place a new Restraint Order on the chart at midnight if
restraints are still needed
 Complete the following on the Restraint Orders;
• Reason for restraint
• Type of restraint
• Length of time of restraint (including the date)
• Place a “sign here” sticker on the MD order
Prompt the MD to sign order when rounding that day

13. Restraints (Violent behavior)
For the emergency management of aggressive, combative or
violent behavior that places the patient or others in imminent
danger of injury or harm
• Used most often in the ED, CCU and the psychiatric units
Notify physician ASAP after restraints are applied
• MD is required to assess the patient within 1 hour
• Exception: Restraints that are applied in ED or the
psychiatric units. A MD is always present in the ED to
assess the patient. On the psychiatric units a trained RN is
permitted to complete the 1 hour assessment.

14. Restraints (Violent behavior)
Orders are time-limited according to age
• 4 hours for patients 18 years or older
• RN calls the MD every 4 hours for a new order if restraints are still
required
• Check and/or observe the patient about every 15 minutes
• Constant observation is required for any patients in leather or
locking restraints
Debriefing is no longer required when restraints are discontinued.
However it is still therapeutic to discuss the episode of restraint
with the patient.

15. Physical Hold
PHYSICAL HOLD
 Any type of manual hold that the patient cannot easily
release himself from. It is intended to be as brief as possible
until a safer form of restraint can be initiated
 A physical hold is most used during a Stat 13 situation, for a
patient on 72 hour hold or to give a medication against a
patient’s will in an emergency situation for violent behavior
 It is only used for violent behavior
 A physician order to give a medication against a patient’s
will must be obtained before giving the medication

16. Physical Hold (continued)
 If a patient is in a physical hold only for <15 minutes complete
only the Restraint Orders and Restraint Tool.
 On the Restraint Tool in the “Type of Restraint” section check
Physical Hold.
 Document “Used for <15 minutes for injection of medication.”
Include in the Reason for Discontinuation of Restraint section
“Released after medication given. No patient injury noted.”
 If a patient is in a physical hold for <15 minutes and then placed
in restraints complete the Restraint Orders.
 On the Restraint Tool document after Physical Hold “Used for
<15 minutes until 4 points restraints applied”.
 Also complete the Restraint Flowsheet as usual regarding the 4
point restraints.

17. Restraints/Seclusion
 Time out is the voluntary restriction of a patient to a
designated area from which the patient is not physically
prevented from leaving and is used when a patient is out-of-
control and needs to be removed from the general patient area
 Seclusion is the involuntary confinement of a patient alone in a
room or area where the patient is physically prevented from
leaving
 Seclusion is used only for patients with violent behavior or self-
destructive behavior
 Seclusion is used only in the psychiatric units on WCMC South-
each have a special locked room that is used for seclusion
 Seclusion does not apply when patients have been placed on 72
hour hold and are restricted to their room