Rationale and Comments

Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact, and supportive interaction with staff. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying reorientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. If physical restraints are used, they should only be used as a last resort, in the least-restrictive manner, and for the shortest possible time.

Sponsoring Organizations

• American Geriatrics Society

Sources

• Expert consensus

Disciplines

• Geriatric Medicine
• Psychiatric and Psychologic

References

• Bray K, Hill K, Robson W, Leaver G, Walker N, O’Leary M, Delaney T, Walsh D, Gager M, Waterhouse C; British Association of Critical Care Nurses. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nurs Crit Care. 2004 Sep-Oct;9(5):199–212.
  
• Center for Medicare & Medicaid Services. Electronic Code of Federal Regulations. Condition of participation: patient’s rights. 42 C.F.R. §482.13.
  
• Cotter VT, Evans LK. Avoiding restraints in hospitalized older adults with dementia. Best practices in nursing care to older adults with dementia. 2012;D1.
  
• Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157–65.
  
• Minnick AF, Mion LC, Johnson ME, Catrambone C, Leipzig R. Prevalence and variation of physical restraint use in acute care settings in the U.S. J Nurs Scholarsh. 2007;39(1):30–7.
  
• Maccioli GA, Dorman T, Brown BR, Mazuski JE, McLean BA, Kuszaj JM, Rosenbaum SH, Frankel LR, Devlin JW, Govert JA, Smith B, Peruzzi WT; American College of Critical Care Medicine, Society of Critical Care Medicine. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies – American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med. 2003;31(11): 2665–767.
  
• Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: their potential impact on rehabilitation of older people. Int J Nurs Pract. 2005 Jun;11(3):95–101.
  
• Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. J Am Geriatr Soc. 2011 Nov;59Suppl 2:S295–300.
  
• McPherson JA, Wagner CE, Boehm LM, Hall JD, Johnson DC, Miller LR, Burns KM, Thompson JL, Shintani AK, Ely EW, Pandharipande PP. Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med. 2013 Feb; 41(2): 405-13.