Originally published March 2016
When there’s a possibility that patients may harm themselves or others, physical or chemical restraint may be required. However, the use of restraints is not without risk. Injuries to staff and patients, cardio-respiratory problems, sudden unexpected death, stress, reduced psychological well-being for staff and patients, and decreased mobility, can all be associated with the use of restraints.1
What can physicians do to reduce the risk? Legislation and best practices on the use of restraints offer strong guidance. As well, the experts involved in the CMPA’s medical-legal cases involving restraints identified what doctors can do to make restraints safer, such as clearly communicating with patients about restraint use and effectively monitoring restrained patients.
The CMPA’s experience
A 10-year review of the Association’s cases revealed 69 closed medical-legal matters involving the use of restraints: 36 legal cases, 26 regulatory authority (College) complaints, and 7 hospital matters.
The doctors most often involved were psychiatrists, emergency physicians, and family physicians with emergency room privileges.
In the analyzed cases, restraint was commonly used to contain violent behaviour, reduce the potential for the patients to harm themselves or others, and allow physicians to conduct a proper assessment. Typically, restraint was initiated when other less invasive means of de-escalating a situation had failed.
Mental health and substance use issues were prevalent among the patients in the studied cases. Of the patients with these issues, half complained about the use of involuntary admission and chemical or physical restraint. Yet, all such complaints had favourable outcomes, with experts in the cases acknowledging that restraint was required for the safety of the patient or others.
Geriatric patients with dementia who required restraint were primarily treated with medications for aggressive behaviour. In some of the reviewed cases, elderly patients experiencing agitation were given medications that experts did not feel met the standard of care for individuals of that age. The experts criticized the choice of medication, the dosage, or both. Further, expert opinion in cases with geriatric patients highlighted the need to further investigate the factors underlying the agitation before increasing sedative medication. Lack of communication with family members about restraint use was also criticized.
Inadequate supervision and monitoring resulted in significant patient safety issues in several patients in the case series. Two patients died of asphyxiation while restrained. Another died of a pulmonary embolus when allowed to walk to the shower after five days in restraints. Medication errors were seen in cases involving chemical restraints, including over-sedation with respiratory compromise.
Among the reviewed cases were five College complaints involving the physical restraint of children 16 years of age or younger during immunization or examination. The Colleges criticized the physicians involved for not explaining the need and the method of restraint adequately and compassionately to the parents and children.
Physicians should be familiar with any relevant legislation governing the use of restraints in their jurisdiction.
For example, Ontario has had the Patient Restraint Minimization Act in place since 2001. It stipulates that a hospital may apply restraints if necessary to prevent harm to the patient or others, to enhance the patient’s freedom or enjoyment of life, and if it is part of a treatment plan authorized by the patient or their substitute decision-maker. The legislation outlines important considerations in the use of restraints including the adequate monitoring of patients. It also emphasizes the importance of trying alternate methods, staff training, and appropriate record-keeping. Most hospital policies dictate that a physician order is required for restraints and that restraint orders are reassessed every 24 hours.
The Act does not apply in psychiatric facilities where the Mental Health Act governs the use of restraints. The Restraint Minimization Act does not affect the ability to restrain or confine an incapable individual who requires immediate action to prevent serious bodily harm when no substitute decision-maker is available.
In Quebec’s Act Respecting Health Services and Social Services, requirements are similar: “118.1. Force, isolation, mechanical means or chemicals may not be used to place a person under control in an installation maintained by an institution except to prevent the person from inflicting harm upon himself or others. The use of such means must be minimal and resorted to only exceptionally, and must be appropriate having regard to the person’s physical and mental state.”2
Managing medical-legal risk
Although most of the CMPA medical-legal cases had favourable outcomes for physicians’ care, restraining a patient can nonetheless create liability risk for ordering doctors. The issues identified by the experts in the Association’s cases highlight opportunities to address patient safety.
Experts who examined the care in these cases noted the need for effective communication and documentation. It is essential that physicians speak with patients or families, clearly explaining why and how restraints are being employed. Those discussions and the information relied on to make the clinical decision in favour of restraints should be documented.
Inadequate staff or monitoring was particularly significant in the CMPA restraint cases where the outcome was patient death. These cases call attention to the need for adequate resources and equipment to effectively monitor and safely secure restrained patients.
The cases also indicate that physicians should follow current standards of care and institutional policies when giving medication, including appropriate monitoring and follow-up.
Medical-legal risk can also be mitigated by following guidelines on the use of restraints; complying with laws, rules, regulations, and accreditation standards; and having appropriate staff training and protocols for observation and treatment.3,4,5 Best practices on restraints generally emphasize that institutions should strive to be restraint free. Restraints should be considered extraordinary measures and only used when alternate interventions fail. When considered necessary, they should be tracked and employed for the shortest time possible, and the restraint order should be regularly revisited. Some institutions mandate a debriefing shortly after a patient has been restrained. In addition, Accreditation Canada requires that institutions being surveyed provide information about their restraint policies and practices.
By considering expert testimony in CMPA’s medical-legal cases and current best practices, and by complying with applicable laws, policies, and standards, the risks and adverse effects from restraints should be minimized.
Risk management considerations
When using restraints physicians should consider the following risk management measures, which are based on the experts’ opinions in the analyzed CMPA cases:
- Attempt to de-escalate the situation using other methods.
- Obtain an adequate history, including medications and co-morbidities.
- Conduct an appropriate physical examination.
- Explain the plan for the use of restraints calmly and clearly to patients or substitute decision-makers.
- Document the rationale for using restraints and use the least restrictive means necessary.
- Ensure clear and readily available policies and procedures for monitoring restrained patients and ensure appropriate training of staff.
- Adhere to applicable regulations, laws, and accreditation standards.
- Rakhmatullina, M., Taub, A., Jacob, T., “Morbidity and mortality associated with the utilization of restraints: a review of literature,” Psychiatric Quarterly (2013) Vol. 84 No. 4, p.499-512.
- Government of Québec, An Act Respecting Health Services and Social Services, S -4.2. Retrieved on March 4, 2015 from: http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/S_4_2/S4_2_A.html.
- Emanuel, L.L., Taylor, L., Hain, A., Combes, J.R., Hatlie, M.J., Karsh, B., Lau, D.T., Shalowitz, J., Shaw, T., Walton, M., eds., “PSEP - Canada Module 13d: Mental Health Care: Seclusion and restraints, When all else fails,” The Patient Safety Education Program - Canada (PSEP - Canada) Curriculum. © PSEP-Canada Project, 2010. Accessed February 2, 2016 from: http://http://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/MentalHealthModules/Pages/Mental-Health-Care-Seclusion-and-Restraint.aspx.
- Registered Nurses’ Association of Ontario , “Promoting Safety: Alternative Approaches to the Use of Restraints,” 2012, Clinical Best Practice Guidelines. Accessed February 2, 2016 from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf.
- American College of Emergency Physicians, “Use of patient restraints,” Clinical and Practice Management, April 2014. Accessed February 2, 2016 from: http://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints.