The Correct Use of Physical Restraints in the Inpatient Setting

By Patrick Horine

The use of patient restraints in the hospital setting is more common than many healthcare professionals realize. As a result, policies on their use are often at risk of being misapplied. That also means there are many instances where patient restraints may be reduced without impeding the delivery of care.

There are no recent statistics on the use of patient restraints, although a 2007 study in the Journal of Nursing Scholarship concluded they were being used at the rate of 50 per 1,000 patient days. That translates to roughly 27,000 patients who were being restrained in U.S. hospitals during any given day of the year (Minnick, Mion, Johnson, Catrambone, & Leipzig, 2007). Patient restraints can include wrist and ankle belts, mitts, vests, or even tall siderails on a bed.

Most healthcare providers do not overuse patient restraints maliciously, but systematic overuse can have disastrous results—both for the patients and the institution. Western State Hospital in Olympia, Washington, recently lost its certification to participate in the Medicare program due to excessive use of restraints, costing the psychiatric facility $53 million a year in federal funding (O’Sullivan, 2018). According to survey reports, patients at the hospital had been restrained for hours at a time, despite not showing any signs of being a danger to themselves or others.

In acute care facilities, patient restraints are most commonly used in hospital ICUs, where patients are often semiconscious and rarely fully lucid. The rationale is usually to keep patients still who otherwise may be at risk for falling out of bed or pulling critical tubes from their body. Hospital staff want to avoid instances of patient self-extubation (breathing tube removal) because the act can be physically harmful and deprive the patient of oxygen while the tube is being reinserted or replaced.

Some healthcare staff might be anxious about leaving patients unrestrained when they are at high risk of falling. If you’ve read through enough Centers for Medicare & Medicaid Services (CMS) 2567 reports on patients being exposed to immediate jeopardy, or imminent risk of harm, in a healthcare facility, you’ll come across many narratives recounting severe injuries and deaths related to falls. But CMS regulations specifically bar the use of restraints in preventing falls, as a falling patient with constricted mobility is likely to suffer an even greater injury.

There are also other reasons to curb restraints. Ravi Parikh, MD, a hematology/oncology fellow at the University of Pennsylvania Health System, wrote in The Atlantic in 2014 that restraints are often overused. He cited studies suggesting they increase patient anxiety, making patients more likely to experience delirium and working at cross-purposes to the healing process (Parikh, 2014).

When DNV GL Healthcare surveys a hospital for the first time, citations regarding the use of patient restraints are not uncommon. That happened with Sentara Halifax Regional Hospital in South Boston, Virginia. It had merged in 2014 with Sentara Healthcare and switched accrediting bodies as a result. DNV GL surveyors issued to the hospital a condition-level deficiency—one step below an immediate jeopardy finding—because Sentara Halifax’s standard operating procedure was to restrain all patients in the ICU, a policy out of compliance with evidence-based guidelines.

As part of the hospital accrediting process, DNV GL follows the guidelines of ISO 9001. Originally issued after World War II in an effort to standardize manufacturing processes, DNV adapted these guidelines for hospital operations. As currently used, their primary focus is on continuous process and systems improvement and the breaking down of departmental silos.

Sentara used ISO to improve its internal communications and to rewrite its rules on use of patient restraints to follow evidence-based guidelines. Once the new rules were put into effect, usage of restraints in the hospital almost immediately declined by 95%. Additionally, in the year following the changes, the number of patient self-extubations declined by two-thirds. These results seem to support Parikh’s hypothesis that patients held to their beds are much more likely to be anxious and respond in kind.

Patient restraints can play a critical role in a hospital setting. But following a thoughtful rather than an overly cautious—and therefore heavy-handed—policy can actually improve care quality and patient outcomes.

Patrick Horine is president of DNV GL Healthcare, which accredits some 500 hospitals in 49 states to participate in the Medicare program. The use of patient restraints in the hospital setting will be examined at DNV GL’s annual Symposium October 2–4 in Denver.

References

Minnick, A. F., Mion, L. C., Johnson, M. E., Catrambone, C., & Leipzig, R. (2007). Prevalence and variation of physical restraint use in acute care settings in the U.S. Journal of Nursing Scholarship, 39(1), 30–37.

O’Sullivan, J. (2018, June 26). Inspections of Western State Hospital showed recurring health and safety violations. Seattle Times. Retrieved July 23, 2018, from https://www.seattletimes.com/seattle-news/politics/inspections-of-western-state-hospital-showed-recurring-health-and-safety-violations

Parikh, R. (2014, August 18). Rethinking hospital restraints. The Atlantic. Retrieved from https://www.theatlantic.com/health/archive/2014/08/rethinking-hospital-restraints/375647