Least restraint principle in hospital care

Clinical question

How can I ensure restraints are used safely and only as a last resort with patients who are hospitalized?

Bottom line

When treating older adults in the acute care hospital setting, it is sometimes necessary to limit behaviour and freedom of movement for the safety of patients and those around them. These intentional limitations—including physical restriction, seclusion, observation, sedation, environmental manipulation, and rapid tranquilization—are restraints¹ and are often ordered in rapidly evolving, high-pressure situations, particularly in understaffed environments.

All forms of restraint can be associated with harm. Exploring alternative strategies and interventions can reduce the need for restraint. A detailed review of this topic was published in 2024 in the Canadian Geriatrics Society Journal of CME.²

Evidence

• A study by Kwok et al showed that reducing physical restraints resulted in a shorter hospital length of stay, particularly for those with cognitive impairment.³ The study also provided evidence of improved mobility and ability to perform activities of daily living following restraint reduction interventions.

• Table 1 summarizes risks for each form of restraint.^4-7 Potential consequences include loss of autonomy, changes in self-image, agitation, depression, worsened delirium, humiliation, loss of trust in health care staff, posttraumatic stress disorder, dehydration, and incontinence. Patients may suffer consequences of restricted mobility including venous thromboembolism, pneumonia, decreased muscle mass (deconditioning), contractures, and pressure ulcers.

• When patients in hospital display challenging behaviour, the health care team should focus on preventive approaches and de-escalation while addressing underlying issues (eg, hunger, pain), especially for patients who may not be able to identify and express these needs clearly. A full clinical and environmental assessment is needed to identify and manage reasons for difficult behaviour.²

Table 1.

Types of restraints and specific risks to individuals

TYPE OF RESTRAINT	DESCRIPTION	EXAMPLES	SPECIFIC RISKS TO THE INDIVIDUAL
Environmental	Modification of physical surroundings to control a patient’s behaviour	Locked doors; disguised exits; improvised barriers; use of bed alarms, sensors, cameras, or trackers Use of 1:1 supervision (eg, sitters)	Potential for seclusion and isolation Risk of injury if patient attempts to escape
Physical	Direct application of physical holding techniques or mechanical methods to involuntarily restrict movement of patient	Manual hold (eg, holding arm for a blood test)	Skin tears, bruising, laceration Psychological trauma
		Bed rails	Strangulation, suffocation, bodily injury. Death if patient or parts of the body are caught More serious falls if patient climbs over barriers Skin bruising and lacerations
		Positioning wheelchairs (eg, Broda chairs) or padded reclining chairs with wheeled bases (“geri” chairs)—chairs are reclined so it is difficult to stand or positioned with a table to act as a barrier to standing	Pressure ulcers
		Soft mitt (large glove that covers the hands to avoid [eg] pulling lines and tubing)	None
		Mechanical restraints: wrist, ankle, torso restraints (can be used in combination as 2-, 3-, 4-, or 5-point restraints), lap belts	Strangulation especially if applied incorrectly Pressure ulcers Limb ischemia Skin bruising and lacerations Death4-6
Chemical or pharmacologic	Psychoactive medication given to intentionally inhibit a behaviour or movement and not used to treat illness specifically	Antipsychotic medications, benzodiazepines, mood stabilizers, antidepressant medications*	Drug-specific side effects but generally associated with falls and fractures, cognitive impairment or delirium, respiratory depression, excessive sedation, etc

^*See Rabheru for management of agitation in patients in an acute care hospital setting.⁷

Approach

Restraints (including monitoring devices) should be used only if authorized by a plan of treatment to which the patient (or substitute decision maker) has consented. Capable patients have the right to assume personal risk and refuse any form of restraint when it does not involve serious risk of harm to others. Clinicians should do a capacity review and document findings before implementing any form of restraint by assessing the patient’s understanding and appreciation of their behaviour and its consequences; reasoning; and ability to communicate.⁸ Health teams should explore alternatives to restraints (Table 2).^9,10

Table 2.

Alternatives to restraints for patients with challenging or unsafe behaviour

BEHAVIOUR	SUGGESTED ALTERNATIVE TO REDUCE RISK
Falls	Medication review, reduce sedating medications (reduce sleep medications, opioids, and antihypertensive medications; assess polypharmacy; consider anticholinergic burden, etc)9 Redirection with simple instructions. For patients who do not speak English as a first language, consider the use of an interpreter via video or telephone, or application-based interpretation services Call-bell demonstration Clutter-free room Mattress on the floor; low bed; fall mat on the floor Physiotherapy focused on strength, gait, and balance Supervised walking Acceptance of risk and injury—needs discussion with substitute decision maker with careful explanation of risk of falls vs risk of restraint Glasses, hearing aids, walking aids easily available 1:1 supervision with a sitter; alarm devices, trackers, and fall pendants10; locked ward—these are considered environmental restraints. Involve family
Wandering	Redirection with simple instructions Call-bell demonstration Clutter-free room Delirium screening Regular toileting Assess for hunger, pain, thirst, cold, etc Room close to nursing station Encourage frequent mobilization with supervision Provide entertainment, distraction, and diversion (photo albums, music, television, etc) Glasses, hearing aids, walking aids easily available 1:1 supervision with a sitter; alarm devices, trackers, and fall pendants10; locked ward—these are considered environmental restraints. Involve family
Agitation and aggression	Medication review (eg, steroids, alcohol, illicit substances, and consider risk of withdrawal) Delirium screening Regular toileting Assess for hunger, pain, thirst, cold, etc Increase or decrease social interactions Provide diversional activities (music, snacks, magazines, etc) Ask family to alter visiting times to overlap with peak times of agitation (eg, late afternoon if displaying notable late-day confusion) Be more flexible with visiting times Redirect with simple commands Relaxation techniques (eg, soothing music, ask family to provide examples of past coping or calming strategies or activities) Allow pacing 1:1 supervision (this is considered an environmental restraint). Involve family
Pulling out lines and tubes for short-term interventions (catheterization, phlebotomy, vaccination, etc)	Pain relief or comfort measures Redirection with simple instructions Careful explanation of procedures and treatments Gentle touch Involve family in planning care and ask for their help with supervision Camouflage tubing on IV lines, wrap IV lines, position lines out of reach (eg, insert lines in feet, use clothing to camouflage lines) Change IV administration to intermittent (eg, administer overnight when sleeping) Assess whether intervention or treatment is required or whether it can be delayed until behaviour settles (eg, switch IV antibiotics to oral, slow IV fluids overnight when asleep [less likely to pull at lines]) and encourage oral fluids Consider 1:1 nursing (this can be considered an environmental restraint). Involve family

IV—intravenous.

Implementation

The “least restraint” principle should be applied to all hospitalized patients. The least restraint principle means taking a preventive approach to unsafe behaviour and using restraint judiciously for a limited time as a last resort.

Review intrinsic factors. Identify and address unmet care needs including anxiety, thirst, toileting (ie, urinary retention, urinary urgency, and constipation), pain, hunger, loneliness, misinterpretation of environmental stimuli, and fear. Assess for delirium using tools such as the Confusion Assessment Method¹¹ or the 4AT.¹² If the patient is found to have delirium, carefully identify causes using the DIMS-PLUS5 (drug, infection, metabolic, and structural and systems; senses, sleep, setting, stasis, and stress) framework¹³; treat underlying causes where possible.

Review extrinsic factors. Review events and triggers leading up to challenging behaviour. Review staff approaches, attitudes, and behaviour, and whether staff are triggering or de-escalating behaviour. Review the environment to ensure safety and comfort and minimize danger. Assess noise levels and avoid ward or bed moves where possible to allow familiarization with the environment. Have a familiar friend or family member stay with the patient to provide reassurance and de-escalate behaviour during difficult periods (being aware that in some forms, this can constitute restraint).

Explore, clarify, and document personal behavioural triggers. This will often require collateral history taking to establish a patient’s baseline cognition and behavioural status, previous triggers, and possible calming strategies. Clarify whether the patient has a history of dementia, delirium, cognitive impairment, behavioural and psychological symptoms of dementia, and other mental health issues (if applicable).

Reduce nonurgent investigations or treatments. This may include reducing routine blood tests and noncritical medications to focus on essential care.

Develop a nonpharmacologic care plan considering a patient’s individualized behavioural triggers. Where possible, patients should be involved in identifying their choice of strategies or alternatives in the event their behaviour becomes unsafe.¹⁴

Apply the Gentle Persuasive Approaches technique. Staff should be trained in de-escalation techniques such as Gentle Persuasive Approaches.¹⁵ Staff should be able to identify when additional support is required and the limitations of each approach.

Consider alternatives to restraint. Depending on the behaviour, other options should be considered (Table 2)^9,10 and specialist input may be beneficial (eg, geriatricians, geriatric psychiatrists, psychiatrists, behavioural support teams).

Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (http://www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.