The Mandated Standard: Removal at Least Every Two Hours
For any patient in a physical restraint, whether a vest, mitts, or soft ties, the nursing assistant plays a vital role in adhering to patient safety protocols. The universally accepted standard in most care settings, governed by regulations from bodies like the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, is that physical restraints must be removed and released at least every two hours.
This is not merely a suggestion but a mandatory procedure that is documented meticulously in the patient's care plan. The two-hour interval is essential for several reasons related to patient health and dignity, which will be explored in detail in the following sections. Compliance with this rule prevents a host of potential medical complications and psychological distress.
The Critical Rationale Behind Regular Removal
Regularly removing restraints serves several crucial purposes beyond simple protocol adherence. The two-hour release period provides an opportunity to perform critical care tasks that maintain the patient's well-being and prevent serious harm.
- Circulation Checks: Prolonged, uninterrupted restraint can restrict blood flow to the restrained limbs, potentially leading to nerve damage, tissue death, and blood clots. The two-hour release allows the nursing assistant to check for signs of compromised circulation, such as coldness, numbness, or a bluish tint in the skin.
- Skin Integrity and Pressure Ulcers: Constant pressure from restraints can quickly lead to skin breakdown and the development of painful pressure ulcers (bedsores). During removal, the nursing assistant can reposition the patient and inspect the skin for redness, irritation, or other signs of injury, a critical step in prevention.
- Range of Motion and Muscle Atrophy: Inactivity caused by restraints can lead to joint stiffness (contractures) and muscle wasting (atrophy). Releasing the restraint allows the nursing assistant to perform passive or active range-of-motion exercises, helping to maintain mobility and physical function.
- Meeting Basic Needs: The two-hour release also provides an opportunity to offer the patient toileting, fluids, and nourishment. It addresses basic human needs that cannot be met while restrained, upholding the patient's dignity and comfort.
The Nursing Assistant's Protocol for Monitoring and Removal
While the two-hour mark is for complete release, the nursing assistant's responsibility for a restrained patient is ongoing. There are two different frequencies to keep in mind: monitoring and removal.
Monitoring While Restrained
In addition to the two-hour removal schedule, the restrained patient must be monitored more frequently, typically every 15 minutes. This involves visually checking on the patient to observe their immediate condition and behavior. This frequent observation is particularly important for patients restrained for violent or self-destructive behaviors, and in all cases, helps ensure the patient is not in immediate distress or attempting to escape the restraint in a manner that could cause harm.
The Safe and Ethical Removal Procedure
When the two-hour removal is due, a nursing assistant should follow a clear, safe, and ethical procedure. If the patient is agitated, another staff member should assist to ensure safety. The steps include:
- Release: Untie the quick-release knot used to secure the restraint straps to a non-movable part of the bed or chair frame. Never tie a standard knot.
- Assessment: Inspect the restrained area for signs of redness, swelling, or breakdown. Assess the patient's comfort level and check for numbness or tingling.
- Repositioning: Help the patient change position to alleviate pressure points and improve circulation. Assist with range of motion exercises for the restrained limbs.
- Basic Care: Offer fluids, toileting, and attend to any hygiene needs. Use this time to engage with the patient and reassess their mental state.
- Reapplication or Discontinuation: Reapply the restraint if the physician's order is still in effect and the need persists. However, the best practice is to always reassess whether the restraint is still the least restrictive option required. If the situation is resolved, the restraint should be discontinued and the nurse notified.
Risks of Non-Compliance and Prolonged Use
Failing to follow the strict guidelines for restraint removal can have severe consequences for the patient and legal repercussions for the facility and its staff. The risks associated with improper or prolonged restraint use are well-documented and include:
- Physical Injury: Pressure ulcers, nerve damage, circulation impairment, and even strangulation or death can occur from improper restraint application or neglect.
- Emotional and Psychological Trauma: Being restrained can be a frightening and humiliating experience, leading to feelings of helplessness, anxiety, depression, and increased agitation or aggression.
- False Imprisonment: Using restraints without a valid medical reason or proper authorization is a violation of a patient's rights and can constitute false imprisonment.
- Increased Fall Risk: Counterintuitively, studies have shown that restraints do not prevent falls and can actually increase the risk of serious injury if a patient attempts to escape while restrained.
The Shift to Restraint-Free Care and Alternatives
The gold standard in modern healthcare is a restraint-free environment, emphasizing patient dignity and safety through alternative interventions. Healthcare facilities are actively working to reduce and, whenever possible, eliminate restraint use. A nursing assistant should be trained and encouraged to utilize alternatives first.
One authoritative source on this topic is the Health Resources and Services Administration (HRSA), which provides comprehensive resources on patient safety and the ethical use of restraints. You can find more information about these guidelines and alternatives on their website.
Comparison Table: Restraint Monitoring vs. Removal
| Feature | Patient Monitoring | Restraint Removal and Release |
|---|---|---|
| Frequency | At least every 15 minutes | At least every 2 hours |
| Purpose | Observe patient's behavior, comfort, and safety | Assess skin, check circulation, provide basic needs, perform ROM |
| Action | Visual check, verbal communication | Full release, repositioning, care tasks |
| Duration | Brief | Sufficient time to perform care (e.g., 10-15 minutes) |
| Personnel | Nursing Assistant | Nursing Assistant |
| Documentation | Required, noting observations | Required, noting care provided and assessment |
Conclusion
The responsibility of a nursing assistant regarding patient restraints is two-fold: continuous monitoring and routine removal. While constant vigilance is necessary for the patient's immediate safety, the mandated two-hour removal protocol is essential for preventing serious complications associated with prolonged immobilization. By diligently following these protocols and prioritizing the use of less restrictive alternatives, nursing assistants provide a high standard of compassionate, person-centered care that honors patient dignity and safety above all else.
