Physical restraints are defined as ‘any manual method or physical or mechanical device, material or equipment attached or adjacent to the individual’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body’.24 Examples of physical restraints include chest/vest, pelvic, combination of wrist, mitt or ankle, and also geriatric chairs with fixed tray tables and cushion tables in wheelchairs. These devices are generally not easily removed by the older adult.25

Restraint use in NHs varies widely among countries and institutions. Restraint practice patterns are attributed to cultural backgrounds and ethical views.26 In general, the restraint use in Denmark, Iceland and Japan is low with less than 9% of NH residents restrained at any time.26 Between 15 and 17% of residents were restrained in France, Italy and Sweden. Spain demonstrated almost 40% of residents restrained. Similarly, Germany reported restraint use at 26%27 and Switzerland at 40%.28 Another study found that 24% of older adults are restrained in Sweden29 and at least 52% of residents in Dutch NHs are restrained.30

Combined with the research and heavy regulatory oversight in the USA, the prevalence of restraint use among NH residents dropped from 9.7% in 2001 to 5.5% in 2007.31 However, restraint use continues to vary widely throughout the USA,32 with some regions reporting almost 20% usage33 while others continue with even higher usage.34

Spurred by the practice shift in the NH setting, in American hospitals, the prevalence varies from 3.4 to 24.3% in non-intensive and intensive care settings, respectively.35 The past two decades have shown an overall decrease in physical restraint use in acute care and a change in practice patterns.36, 37 In hospitals, restraint use is more often employed to prevent treatment interference than to avert falls, thus arm/limb restraints prevail over chest/vest restraints.38–40 A chair that prevents rising is the most common form of restraint while limb restraints are the least commonly used.41 Trunk restraints are more prevalent in Sweden and the USA than other restraint types.26 In The Netherlands, Germany and Switzerland, siderails are reported as being the most commonly used form of restraint.42 In addition to decreased restraint usage over the past 30 years, restraints are now ‘less restrictive’ compared with previous decades; wheelchair cushions and seat belts are more often used than the more restrictive vest restraints.

Siderails, also referred to as bed rails, cotsides, guardrails, safety rails or sideboards, are adjustable metal or rigid plastic bars that attach to the bed and come in a variety of sizes.25 Beds include bilateral, full-length siderails or four ‘half’ or ‘split’ siderails, allowing diverse combinations of rails from one upper rail to both upper and lower rails.43 Siderails are defined as restraints or ‘restrictive’ devices when used to impede a patient’s ability to get out of bed voluntarily.44 Since the use of restraints in bed has been drastically reduced in both NHs and hospitals, siderails have become the most frequently used restraint to prevent older adults from independent or accidental egress from bed.45–47

Similarly to physical restraints, siderail use varies among countries and institutions. A study conducted in a British hospital reported that 8.4% of patients had full-length siderails raised and a multisite study in English and Welsh hospitals showed full-length siderail use varying between 12.2 and 38.9%.48 There are no national statistics available for siderail prevalence in American NHs and hospitals;25 however, several studies report rates of restrictive siderail use ranging from 18 to 64%.46, 49–51 The Royal College of Nursing issued guidelines aimed at further reduction of restraints, and bedrails are listed as the most likely form of restraint.

The continued use of both restraint and siderail usage is based on embedded practices of healthcare providers who for decades have linked these devices to patient safety and protection.52, 53 As a result, efforts to reduce their use have occurred through regulatory oversight and guideline development for the assessment of risk. For example, the US Food and Drug Administration (FDA) has issued several guidelines, including the most recent ‘A Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment’.54 The United States Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) has guidelines to NHs that classify siderails as restraints when they prevent voluntary egress.55 These guidelines emphasize that restraints are defined according to their functional application as any device, material or equipment that inhibits mobility or change in position and are not easily removed by the person.56 Similarly, the 1999 CMS Hospital Conditions of Participation and 2001 JCAHO standards redefined siderail use as restraints for hospitals using this functional definition.57 Since then, the FDA Hospital Bed Workgroup has created guidelines that describe assessment techniques for implementing siderails, and also developed the Bed Safety Tool Kit, which includes information and tools aimed at reducing the rate of entrapment in siderails.58 Based on the American guidelines, Canada issued ‘Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching Reliability and Other Hazards’ in 2008, which provides similar recommendations.59

Use of restrictive devices depends on three factors: patient characteristics, organizational attributes and healthcare providers’ justification. Prevalence of restrictive devices varies with age, functional status and cognition.60 Greater age, worsened physical health, a previous fall and the presence of depression or other psychiatric disorders have been associated with restraint use.49, 61, 62

Impaired cognition is the most significant patient factor associated with restraint and siderail use.33, 45, 53, 63, 64 Among ambulatory NH residents, a restraint prevalence of 37% was reported in confused residents, whereas non-confused residents were virtually never restrained.64 Confused older adults and elders are also the most likely to be restrained in hospitals.65, 66

Castle et al. reported that organizational attributes, rather than patient factors, were more predictive of restraint use.67 These include high nursing aide–patient ratios, reduced occupancy rates and prospective Medicaid reimbursement. Similarly, in hospitals, high utilization of licensed practical nurses rather than registered nurses and nurse staffing patterns on weekend shifts are strongly associated with restraint use.66 The American statistics are in direct contrast, however, to a recent European study that revealed job characteristics (i.e. high workload) and ward characteristics (i.e. low percentage of nurses) were less significant in predicting restraint use than resident factors.42 High risk of self-harm or injury to staff is a common reason cited for patient restraint.68 Other reasons include paradigms that restraint use is generally appropriate and that siderails are only moderately restrictive.42

Justification for restraints is also based on the healthcare providers’ view that these devices prevent vulnerable older adults from injury secondary to falls, behavioural symptoms or treatment interference. The most common reason cited for restraint and siderail use is prevention of falls,25 and other common reasons include mobility aid and prevention of wandering.48 There is no empirical evidence, however, to support the use of these devices to prevent falls.

Numerous studies demonstrate a significant incidence of falls and injury among restrained confused patients in both NH and hospital settings.64, 69–72 In addition, another study examining the relationship between restraint use and falls among NH residents found that restraints were not associated with a significantly lower risk of falls or fall-related injuries.64

There is also no evidence to support the use of restrictive siderails to prevent falls. One NH study examined resident outcomes associated with consistent restrictive siderail status when compared with residents with no or non-restrictive siderail use for 1 year.46 Controlling for cognition, functional and behavioural status, the study found no indication of a decreased risk of falls or recurrent falls with restrictive siderail use. Similarly, a retrospective hospital-based study found that the incidence of falls from bed with siderails elevated was equal to or higher than the outcome when siderails were not elevated. Those patients with impaired cognition status were found to be the most likely to fall from bed when the siderails were elevated.47

Another major reason that healthcare providers choose restrictive devices is to reduce or control behavioural symptoms. Interestingly, although restraints are employed to ‘treat’ these symptoms, the use of these devices is strongly correlated with physical or verbal aggression, especially among those with dementia.73–76 Delirium has also been found to be highly correlated with restraint use in several large-scale studies.77–79 The usage of restrictive devices to manage behavioural symptoms in NHs or medical/surgical (non-psychiatric) care settings is strongly prohibited.

Behavioural symptoms, such as anxiety, agitation, physical aggression and delirium, may result in patient interference with medical treatments. Treatment interference refers to both removal and manipulation of a monitoring or treatment device (e.g. feeding tubes, urinary catheters, intravenous lines, oxygen therapy).80–83 This can be especially dangerous when the treatment or device fulfils a life-saving or life-maintaining function such as mechanical ventilatory support. Hand restraints may not prevent unplanned extubations in agitated patients.84 Since many of those with unplanned extubations do not require reintubation,84, 85 restraints may be a marker of insufficient sedation that requires more attention to implementation of evidence-based guidelines for sedation of intubated patients.86, 87 The lack of evidence to support routine restrictive device usage to prevent falls and treatment interference or reduce behavioural symptoms is thus compounded by the numerous complications associated with use of these devices.

The use of restrictive devices is not without risk. In the 1980s and 1990s, research describing the negative physical and psychological sequelae associated with restrictive devices was the major impetus for changing the practice in hospitals and NHs.88 Psychologically, restrained older adults experience anger, humiliation, depression and low self-esteem.89–91 Additionally, the use of restraints may convey feelings of punishment, emotional harm and patient suffering.68

As described earlier in this chapter, the most common physical consequence of prolonged restraint or siderail use is immobility.10, 19, 21, 22, 33 Other harmful medical outcomes associated with restraint include hyperthermia,92 rhabdomyolysis,93 brachial plexus injury,94 axillary vein thrombosis,95 compressive neuropathy,96 Hess’s sign97 and stress-induced cardiac arrhythmias.98 Furthermore, siderails have been identified as a vector for nosocomial infections. Microbes cultured from siderails have been associated with subsequent integumentary and respiratory ailments.99–104

Although less common, restrictive devices have also been associated with fatal outcomes such as thromboembolic disease105 and strangulation and asphyxiation.98, 106, 107 Strangulation can occur due to improper application of a vest restraint or when an older adult with a vest restraint slips between two half rails. Asphyxiation results from gravitational chest compression when an older adult is suspended by a vest or belt restraint in a bed or chair.108, 109 Asphyxiation can also occur if a person is entrapped within siderails or when patients become entrapped between theapeutic overlay air mattresses and siderails.110

Entrapments occur through the siderail bars, through the space between split siderails, between the siderail and mattress or between the head or footboard, siderail and mattress.111 Persons at high risk for entrapment include older adults with pre-existing conditions such as altered mental status (dementia or delirium), restlessness, lack of muscle control or a combination of these factors.112, 113 More recently, cases of asphyxiation deaths due to patients becoming trapped between therapeutic overlay air mattresses and siderails have been reported.110 These negative consequences associated with restraint use have served as an impetus for research aimed at identifying alternative ‘best practices’ to restrictive devices.

Several studies have described the relationship between restraint reduction and fall/injury rates. In all of these studies, significant reduction in restraints and siderails occurred without increases in falls or fall-related injuries.50, 70, 114–118 Although none of the studies represent a randomized clinical trial, no significant differences were found in the number of patients falling prior to or following the reduction of physical restraint use. Further, the studies demonstrated no statistically significant difference in falls compared with historical controls when restrictive siderails are removed.119

Fall-related injuries are rarely examined statistically, since the number of subjects required is often cost prohibitive for most research studies. Fall-related minor injury in older persons, however, has significant implications for morbidity and mortality.120 Capezuti et al. reported that continued restraint use (versus restraint removal) was the only characteristic to increase significantly the risk of fall-related minor injury (bruises, abrasions, certain sprains and other soft tissue injuries that do not result in hospitalization or bed rest).70 In summary, results from studies of restrictive device reduction efforts have demonstrated that they can be removed without negative consequences.

The positive outcomes associated with restrictive device reduction may represent not only the safe removal of these devices, but also the effectiveness of interventions aimed at decreasing the likelihood of falling and injuries. Both individual alternatives and the most effective strategies used to implement these interventions have been evaluated in NH and hospital settings.

Optimal resolution requires multiple interventions that rely on coordination via interdisciplinary dialogue and action.121 Comprehensive assessment, coordinated care management and individualized intervention plans targeting identified risk factors have been found to be the most successful strategies to reduce restrictive devices.

‘Best practice’ approaches to restrictive device reduction are described in the literature or by professional associations as clinical practice guidelines for use in the NH and acute-care hospital.47, 58, 108, 122–124 Professional standards and governmental and accreditation regulations emphasize that a decision to use physical restraints and/or siderails should only be made after clinical evaluation and interdisciplinary care planning determines the purpose for the intervention. Further, alternatives to restrictive devices should be implemented and evaluated prior to initiating restraints. Thus, a thorough assessment is necessary in the following situations: in patients who are at high risk for application of physical restraints or siderails, prior to and during restraint reduction efforts, or in situations where the provider is assessing the continued need for restrictive devices.

Multidisciplinary collaboration is an important part of any evaluation regarding the use of restraints and siderails. There is also an indication that, due to the differences in staff opinions regarding restraint use, cultural sensitivity is necessary in designing interventions to reduce the use of physical restraints.42 The following sections describe clinical approaches that reduce the likelihood of restrictive device use.

Promote Mobility

Maintaining physical activity in hospitalized elders and NH residents is crucial to preventing the harmful effects of immobility. Careful consideration is warranted when ordering bed rest. The ability to move around in bed and to transfer and ambulate safely is also important to prevent falls and injuries.125 The assessment should include the patient’s ability to perform the skills necessary for safe mobility and transfer, including the need for assistance and assistive devices (e.g. walkers, canes). If there are problems, then a physical or occupational therapist should be consulted. Rehabilitation therapists may suggest transfer devices to enable or assist in safe transfer and promote stability when standing, which may include a trapeze, transfer pole or bar or raised one-quarter or half length siderail directly attached to or adjacent to the top of the bed. These may also serve as assistive bed mobility devices.

Certain activities by nursing staff promote mobility, such as encouraging or assisting patients with changing position in bed, transferring out of bed to chair and ambulating.126