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.

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  Table 1.

  Types of restraints and specific risks to individuals

• 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

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

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).