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Am Fam Physician. 2009;79(4):254-256

Author disclosure: Nothing to disclose.

In the mid-1900s, many acute and long-term care facilities began routine adoption of physical restraints and bed side rails in an effort to curtail patient falls and reduce liability concerns. This adoption came from a common-sense notion that physical restraints and side rails improved patient safety. Eventually, policies were developed to standardize their use.1,2

A physical restraint is any device that restricts a patient’s movement and cannot be removed easily by the patient. Examples of restraints include vest or wrist restraints, geriatric chairs with tables, and bed side rails. The prevalence of restraint use in nursing homes and acute care hospitals is estimated between 25 and 85 percent.3,4 Risk factors for being restrained include impaired cognition, low body weight, frailty, older age, and functional dependence.4,5 Restraints are most commonly used to prevent falls, wandering, and disruption of therapy.3,6

Over the past 20 years, it has become increasingly clear that routine adoption of physical restraints and bed side rails for patient safety preceded evidence of their effectiveness.7 Newer evidence suggests that using physical restraints and side rails to prevent falls is misguided and may pose a significant safety hazard to patients.8,9 Several studies have found that restrained patients were more likely to fall than those without restraint orders.4,10 In addition, studies show that restraints may actually increase the risk of serious injury from bed-related falls4,5,10 and are associated with a number of well-known complications (Table 11016).

Brachial plexus injuryJoint contractures
DeconditioningMuscle weakness
DeathPressure ulcers
ImmobilityPsychological distress
IncontinenceUrinary tract infections

In light of accumulated evidence, tradition alone is not adequate rationale for continued use of physical restraints or side rails. Federal regulations and practice guidelines are now consistent with the evidence, advising that restraints generally should not be used.1719 Restraints may, however, be temporarily required to control violent behavior or to prevent the removal of important equipment, such as endotracheal tubes, intra-arterial devices, and catheters.

Guidelines for restraint use suggest using the least restrictive device necessary, reassessing the patient’s response frequently, removing the restraint periodically, and renewing orders every 24 hours only after evaluation by a physician. Practice guidelines outline the need for care plan modification to compensate for restraint use, including frequent position changes and skin care, provision of adequate range of motion, and assistance with activities of daily living. Ongoing assessment of the underlying condition that prompted restraint use, early referral to a multidisciplinary team or geriatric specialist, and staff education are key to appropriate restraint use.20,21

Alternative strategies that may help reduce unnecessary and potentially hazardous physical restraint and side-rail use include fall prevention programs, new beds or bed modifications, and restraint-free environments, which employ a number of alternative measures for preventing and managing problematic behaviors (Table 220,2226). Fall prevention programs can include multifactorial interventions, such as staff education programs, gait training, review of appropriate use of assistive devices, and review and modification of medications. These have been shown to decrease the incidence of falls in long-term and assisted living settings.27 However, evidence is insufficient to make recommendations for or against multifactorial interventions in acute care settings.28

Design the physical environment so that staff may closely observe patients
Enhance exercise programs
Improve comfort in bed with pillows, cushions, and leg separator pads
Increase staff awareness of patients’ individual needs
Modify environment to improve lighting and eliminate fall hazards
Use patient positioning alarms to alert staff when a patient tries to exit the bed
Use personal assistance devices, including hearing, visual, and mobility aids

Several new products that may help address fall risk are available. Electric adjustable-height beds are expensive, but may be appropriate for those at greatest risk of falling or side-rail entrapment. Lowering bed height has been shown to facilitate standing and may reduce the incidence of serious injuries from bed-related falls.29,30 Bed modifications such as assist bars, bed handles, trapezes, or transfer poles can also provide mechanical support for transfers from bed.15 Additional research is needed to demonstrate the effectiveness of these modifications in preventing fall-related injury.

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