Restraint Use: Regulations and Quality Monitoring

The use of physical and chemical restraints in healthcare settings is a patient safety issue that is heavily regulated. Restraints can cause physical harm, psychological distress, and even death. CPHQ candidates should understand the regulatory framework, clinical considerations, and quality monitoring practices related to restraint use.

Definitions and Types

Physical restraints are any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move freely. Examples include wrist restraints, vests, mitts, and side rails when used to restrict movement. Chemical restraints are medications used to control behavior or restrict movement that are not part of the standard treatment for the patient's medical or psychiatric condition. Importantly, CMS defines restraint by function, not by device name. This means that any device or practice that restricts a patient's freedom of movement is considered a restraint, regardless of what it is called.

CMS Regulations

CMS Conditions of Participation include specific requirements for restraint use. Restraints may be used only to ensure the physical safety of the patient or other individuals, only when less restrictive alternatives have been tried and found ineffective, and only upon the order of a physician or other licensed independent practitioner. Orders must specify the type of restraint and the duration. For non-behavioral health restraints, orders must be renewed according to facility policy. For behavioral health restraints (those used to manage violent or self-destructive behavior), orders are limited to 4 hours for adults, 2 hours for children ages 9 to 17, and 1 hour for children under 9. Face-to-face assessment is required within specific timeframes.

Monitoring and Assessment

Patients in restraints must be monitored at regular intervals, typically every 1 to 2 hours, depending on the type of restraint and organizational policy. Monitoring should include assessment of circulation, skin integrity, hydration, nutrition, toileting needs, vital signs, range of motion, readiness for discontinuation, and the patient's physical and psychological status. Documentation must reflect each monitoring assessment and the rationale for continued use. Restraints should be removed at the earliest possible time when the clinical justification no longer exists.

Alternatives to Restraints

Organizations should emphasize restraint reduction and the use of alternatives. Common alternatives include de-escalation techniques, one-to-one observation, environmental modifications (such as lowering the bed or using floor mats), addressing underlying causes of agitation (pain, infection, medication side effects), involving family members in providing reassurance, diversional activities, and technology solutions (such as bed alarms and video monitoring). A culture that views restraints as a last resort rather than a convenient solution is essential for reducing inappropriate use.

Quality Monitoring

Quality professionals should monitor restraint use through tracking restraint rates (episodes per patient day or per 1,000 patient days), monitoring compliance with ordering requirements and monitoring protocols, reviewing restraint-related injuries, analyzing trends by unit, shift, and patient population, and benchmarking against national data. Restraint reduction initiatives should be supported by staff education, leadership commitment, and a non-punitive approach to understanding why restraints are used. The goal is not to eliminate all restraint use (as it may be clinically necessary in some situations) but to ensure that it is used only when appropriate and that proper safeguards are in place.