Restraining a patient

Hospitals commonly use restraint on patients as a mean to prevent injury or harm to self or others. However, if appropriate care is not taken, restraint itself can cause serious injuries and even deaths to patients. Also, as restraint is an act of restricting an individual’s freedom of movement, generally against his/her will, it can be considered as an infringement of patient’s rights, if used without strong and valid reason. It is for these reasons, use of restraint on a patient must be guided by a comprehensive policy, that takes care of safety and rights of patients.

The guidelines given below are intended to serve as a reference for hospitals for making their policy on restraint of patients.

Definition and methods of patients’ restraint

Restraint is the application of a method that immobilizes or reduces the ability of a patient to move one or more of his/her body part freely or put restrictions on patient’s behaviour and is not a part of standard treatment for the patient’s condition. The methods of restraining a patient include

Physical restraint – Patients freedom of movement is restricted by direct application of force by other humans or by mechanical devices (such as handcuff) or a combination.
Chemical restraint – This includes administration of certain medications such as sedatives to manage patient’s behaviour
Seclusion –Seclusion is a type of restraint in which the patient is confined to a room from where he/she cannot exit freely

Purpose of restraint

Restraint can be used only for the following purpose

1.       To protect the immediate physical safety of patient, staff or others. Such as in case of patients having an episode of violent behaviour or self-harming behaviour

2.       To prevent interference/obstruction with medical treatment being given, such as self-extubation

3.       To prevent falls on injury of any kind due to involuntary, uncontrolled movement or lack of maintaining balance, such as in case of a semiconscious patient with involuntary movements

Restraint CANNOT be used as a means of coercion, discipline, convenience, or staff retaliation.

Restraint order and application

· Restraints can be applied only when it is clinically justified or when warranted by patients behaviour that threatens the physical safety of patient, staff or others.
· Restraint shall be used as a last measure and when less restrictive measures are ineffective.
· Application of restraint can be ordered by the treating physician of the patient. The order shall be in written and must specify the following

o   Reason for restraint

o   Type/method of restraint to be used. In case of chemical restraint, the drug and dose must be prescribed

o   Duration for which restraint to be re-applied (Duration cannot exceed 24 continuous hours. Refer the next point)

o   Monitoring frequency of the patient

· Restraint shall be applied using the safe technique, least restrictive but effective and by personnel trained in the application of restrained.
· In a case when restraint is required on an emergency basis and the treating physician is not available, the decision of restraint can be taken by the duty doctor or the authorised nurse. In such cases, reasons for restraint must be documented in patient’s record. The treating physician shall be informed as soon as possible and a confirmation shall be obtained for continuing restraint. The treating physician must then visit the patient as soon as possible, take the necessary decision regarding restraint. This shall be documented. In any case, continuous restraint shall not exceed more than 24 hours.

Duration of restraint and its discontinuation

The restraint shall be ordered for as less time as possibly necessary. Restraint shall not be ordered or applied for more than 24 hours on a continuous basis. If the restraint is required beyond this time limit, a fresh written order shall be given by the physician.
· Temporary removal of restraint for activities such as toilets shall not be considered a break in continuity of restraint.
· The necessity of continuing restraint shall be assessed once every 4 hours in case of adults and once every 2 hours in case of children. If restraint is not found to be necessary, it shall be discontinued, with physician’s order, regardless the scheduled of the expiration of restraint order
· In any case restraint shall not be continued beyond the ordered duration unless a fresh order is given.
· If restraint is causing harm to the patient, such as asphyxia, pain etc., it shall be discontinued and less restrictive measure shall be employed

Safe application of restraint

While applying restraint safety of patient shall be given prime importance. Restraint shall be applied using ‘Non-Violent Physical Crisis Intervention’ technique. Following elements of safety must be ensured while applying restraint
· Restraint does not cause pain to the patient
· The patient is not restrained on the floor or an area which can cause injury to the patient
· The restraint itself shall not cause asphyxia, block in blood circulation or injuries

Monitoring and care of the patient under restraint

For each restraint order, a monitoring frequency shall be fixed. Minimum frequency shall be once in 2 hours which can be increased depending on patient’s condition and restraint type.  Following parameters shall be monitored

For patients under physical restraint

- Position, circulation and skin integrity of the restrained area
· Patient’s vital parameters
· Appropriate application of the device
· Screening for pain due to the restraining device
· Maintenance of privacy
· Comfortable body and room temperature
· Toileting, fluid and nutrition need

For patients under chemical restraint
· Patient’s vital parameters
· Maintenance of privacy
· Comfortable body and room temperature
· Toileting, fluid and nutrition need

If any problem is found during monitoring, it shall be addressed. For example, if the patient needs to go to the toilet, temporary removal of restraint shall be done under supervision. If the patient feels pain, the restraint shall be re-applied properly.

Protecting patients’ rights

The rights of the patient under restraint shall be protected. This include,
· Ensuring that privacy of the patient is being maintained
· Patient shall not be neglected or behaved rudely with
· Wherever applicable, the patient must be explained the reason for restraint.
· Family must be made aware of the reason for restraint and for how long will it continue

Adverse events reporting and actions

Any untoward incidence occurring to a restrained patient must be reported immediately to a designated authority. Such incidence includes, but not limited to

· Death of patients related to restraint. These can include,

o   Death while the patient was in restraint

o   The death that occurs within 24 hours after removal of the restraint

o   Deaths that happen within one week of removal of the restraint, when it is reasonable to believe that use of restraint may have contributed to the death

· Injury occurring to the patient due to restraint
· Aggravation of patients’ disease condition due to restraint
· An incident of breach of patient’s rights such as privacy was compromised, the patient was neglected or the patient was abused
All such events shall be investigated and appropriate corrective and preventive measures shall be taken

Documentation

Following points must be documented in patient’s record

 - Evaluation and description of patients’ condition or behaviour that warrants the need for restraint
· Any alternative or less restrictive measures attempted
· Order of restraint by the authorized person, specifying the reason, type, duration and monitoring requirement
· Patients assessment during periodic monitoring
· Periodic assessment for the necessity to continue restraint
· Order for discontinuation of restraint with reason, date and time
· Adverse events that occurred with the patient under restraint
· Records of investigation and corrective/preventive measures taken for reported events