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AGS Position Statement
RESTRAINT USE

BACKGROUND

Physical or chemical restraints that inhibit voluntary movement are sometimes used in acute and long-term care settings with the goal to prevent injury and protect patients. The Food and Drug Administration (FDA) and Centers for Medicare and Medicaid Services (CMS) state that a protective restraint is any device that restricts a patient's movement and cannot be removed easily by the patient. All such devices must be labeled as to their intended use. Restraints include vest or wrist restraints, geriatric chairs with tables, side rails on beds, etc. Although the major focus of this statement is on physical restraints, the American Geriatrics Society advocates reducing use of all types of restraints. While the intended use of restraints is to "prevent harm," numerous studies have shown that restraints neither decrease the number of falls, nor ensure freedom from injury. The severity of injury may in fact increase in some restrained patients.

The Omnibus Budget Reconciliation Act 1987 (OBRA) set forth regulations regarding the use of restraints in nursing homes. Specifically, these regulations forbid restraint use for the purpose of discipline or convenience. They call for a comprehensive nursing assessment of problematic behaviors, physician concurrence prior to the institution of restraints, and use of restraints only as a last resort after all alternatives have failed. In addition, once the restraining device has been explained to the patient, family member or legal representative, it should be used only for a specific reason and only for a specified period of time, followed by reassessment. If a life-threatening symptom or illness occurs, the restraint may be temporarily used on an emergent basis. Finally, monitoring of the indication for restraint use must be ongoing, as well as documentation of methods and/or interventions used to reduce restraints.

In concert with these guidelines, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has set forth in their own guidelines that "Restraint and Seclusion Standards" apply to all behavioral health settings in which restraint and seclusion is used such as free-standing psychiatric hospitals, psychiatric units in general hospitals, and residential treatment centers that are owned by the hospital. Further, these standards apply only to restraint or seclusion that is applied for behavioral health reasons, regardless of where these patients are in the organization, emergency department, medical/surgical units, etc. Furthermore, JCAHO concurs with the definition of restraints being a device that's intended use is that of "physical restriction."

Restraint-free environments necessitate consideration of various alternative measures for preventing and managing problematic behaviors. Measures such as cushions and pads, enhanced physical therapy and recreational activities, environmental manipulations, and increasing staff attention may successfully lessen wandering and prevent injury to patients who might otherwise have been restrained. During the past several years, many facilities have been successful in becoming restraint-free. Strategies that have been implemented to achieve this result include: on-going education of staff, development of multidisciplinary teams that deal only with issues of restraints and restraint reduction, available funds for specialized equipment that enable staff to be successful with restraint reduction, strong interpersonal relationships among residents and caregivers as well as knowledge of proper communication techniques for all types of residents and a staff composed of an adequate number of registered nurses who utilize their education, observation skills and assessment skills in reducing and avoiding the use of restraints.

Despite alternatives to restraint use, and the good intentions of caregivers of older impaired patients, instances may arise when physical restraints may need to be considered. The Clinical Practice Committee of the American Geriatrics Society believes that considerations in the use of restraints (in the uncommon instance they are needed) should follow the principles outlined below.

POSITIONS

1. In non-emergency situations, physical restraints should be used very sparingly and only after careful and comprehensive review, assessment and documentation provide substantial evidence that no safer alternative or setting can be found to prevent their use.
   Comment:
   Use of restraints should be a collaborative decision among the patient/family, nursing staff, attending physician and other relevant care providers (e.g., social worker, physical therapist). Where such exists, a multidisciplinary team should be involved in decision-making regarding the use of restraints and available alternatives. The least restrictive device should be used. The restraint order in this case should be reviewed periodically. Reassessment at regular intervals is mandatory to determine if safer alternatives are available or if there has been a change in underlying behavior.
2. Behavior that precipitates a decision to restrain a patient should first trigger investigation and treatment aimed at understanding and eliminating the cause of the behavior.
   Comment:
   The focus of this attention should be on both patient and staff behavior regarding the need for restraint use.
3. All mechanical restraints must be applied in a manner, according to manufacturers recommendations, to decrease the chance of pressure damage and abrasion to skin and underlying tissues; proper size and type must be used.
   Comment:
   Patient safety, health and well-being should be the most important concern of all caregivers, especially in a situation where restraints are warranted.
4. On rare occasions, short-term use of restraints may be indicated to enable emergent treatment that may result in a less confused patient.
   Comment:
   In this situation, or when the patient is at significant risk of self-harm or injury to others, or at the patient's request, restraints may be used. Such use requires an order from a licensed practitioner, which should be renewed according to state and federal guidelines.
5. Both the patient and restraining device must be checked frequently and the restraining devise removed periodically.
   Comment:
   A restrained limb should be periodically exercised and, if possible, the patient should be ambulated at reasonable intervals. These activities should be performed according to CMS and JCAHO as well as state guidelines. Attention to need for hydration, elimination, comfort, and social interaction must be assured.
6. Restraints should be removed or discontinued at reasonable intervals to reaffirm the need for or effectiveness of their use.
7. Periodic staff education as to the hazards of restraint use, proper use and application of restraints and alternative behavior management strategies to their use must be ongoing.
8. Research into innovative alternatives to restraint use in acute and long-term care settings must be encouraged.

REFERENCES:
Evans L, Stumpf N: Tying down the elderly: A review of the literature on physical restraints. JAGS 37:65-74, 1989.
Morrison J, Crinklaw-Wiancko D, King D, et al: Formulating a restraint use policy.
JONA 17:39-42, 1987.
Stumpf N, Evans L: Physical restraint of the hospitalized elderly: Perception of patients and nurses. Nursing Research 37:132-137, 1988.
Nion L, Frangle J, Jakovic C, et al: A further exploration of the use of physical restraints in hospitalized patients. JAGS 37:949-956, 1989.
Robbins L: Restraining the elderly patient. Clinics in Geriatric Medicine 2:591-599, 1986.
Maletta G: Management of behavior problems in elderly patients with Alzheimer's disease and other dementia. Clinics In Geriatric Medicine 4:719-747, 1988.
Castle, N.G., Fogel, B. (1998) Characteristics of Nursing Homes that are restraint free. The Gerontologist. 38(2) 181-188.
Westmoreland, T. (HCFA) & Feigal, D (FDA) (8/2000) HCFA letter to Cathy Morris, President AHFSA c/o New Jersey Department of Health and Senior Services found at site: http://www.hcfa.gov/medicaid/Itcsp/q&a/t18-8100.htm
Jensen, B. et.al. (1998) Restraint Reduction: A new philosophy for a new millennium. JONA 28(7-8) 32-38.
Wiley, B. (2000) Redesign in the long term care industry: a restraint reduction or restraint elimination program in the nursing home. JHHSA, Fall 215-241.
Restraint and Seclusion: Complying with Joint Commission Standards (2002) Joint Commission Resources, RAS-100 (630-792-5800).
Abstract: http://www.jcaho.org/news/nb353.html

Note: Developed by the AGS Clinical Practice Committee and approved May 1991 by the AGS Board of Directors. Reviewed 1997 and 2002. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.