When to use mitten restraints? A Comprehensive Guide to Patient Safety

According to the Centers for Medicare & Medicaid Services (CMS), a device is considered a restraint only if a patient cannot remove it easily. This distinction is crucial for healthcare professionals and caregivers who need to understand exactly when to use mitten restraints as a measure of last resort for patient safety. This guide explores the appropriate medical justifications, risks, and alternatives associated with their use.

Quick Summary

Mitten restraints are used to protect patients from self-harm or interfering with medical treatments after less restrictive alternatives have failed. They are considered a last-resort intervention for confused or agitated patients who may pull out tubes or scratch wounds. Policies dictate careful monitoring, regular assessment, and documented necessity for use.

Key Points

• Last Resort Intervention: Mitten restraints should only be used when less restrictive options have failed to ensure patient safety.

• Protecting Medical Equipment: The primary use is to prevent patients from pulling out essential tubes, lines, and catheters.

• Preventing Self-Injury: They protect patients from unconsciously scratching or picking at wounds, dressings, or medical sites.

• Least Restrictive Option: Mitten restraints are considered less restrictive than other physical restraints because they allow for some arm movement.

• Strict Protocols Required: Proper application, frequent monitoring, and thorough documentation are mandatory to prevent patient injury and ensure safety.

• Careful Application: When applying mitten restraints, ensure they are not too tight, which could compromise circulation.

• Prioritize Alternatives: Before applying restraints, nurses should attempt strategies like distraction, environmental changes, or increased supervision.

• Regular Assessment: The need for the restraint must be continuously evaluated, with a plan for removal as soon as it's safe to do so.

Mitten Restraints: Indications and Ethical Considerations

Mitten restraints, or hand mitts, are soft gloves that prevent a patient from using their fingers to grasp objects, while still allowing for some hand and arm movement. Unlike more restrictive physical restraints that immobilize limbs, mitts are typically considered a less invasive option for patient protection. Their use is governed by strict medical and ethical guidelines, emphasizing that they are only to be applied after all other less restrictive alternatives have been exhausted.

When is it Medically Justified to Use Mitten Restraints?

The primary justification for using mitten restraints is to ensure patient safety and prevent the disruption of medical treatment. Common scenarios include:

• Prevention of Self-Extubation or Dislodgement of Vital Lines: Patients who are confused, disoriented, or delirious may attempt to pull out life-sustaining medical devices, such as endotracheal tubes, intravenous (IV) catheters, or feeding tubes. Mittens prevent the patient from gripping these devices, protecting them from harm.
• Protection of Wounds and Surgical Sites: Patients with skin conditions, surgical incisions, or open wounds may unconsciously scratch, pick, or peel at the site, compromising wound integrity and increasing the risk of infection. Mitten restraints protect the area from patient interference.
• Mitigation of Self-Harm Behaviors: In specific, well-documented cases involving chronic, repetitive self-injurious behavior related to severe medical or psychiatric conditions, mitten restraints may be ordered by a physician. This is a rare circumstance, and such orders must be constantly reassessed.

Comparison of Restraint Types

Feature	Mitten Restraints	Soft Limb Restraints	Vest Restraints
Restrictiveness	Least restrictive; prevents grasping but allows arm mobility.	More restrictive; limits joint movement and secures limbs.	Most restrictive; prevents unassisted bed/chair exit.
Purpose	Protects IVs, drains, and wounds from picking or pulling.	Prevents patient from pulling tubes and lines from a specific body part.	Prevents falls or patient from leaving bed or chair.
Patient Population	Used for confused, disoriented, or delirious patients.	Used for patients who may disrupt life-saving treatment.	Used for patients at risk of falling or unassisted exit.
Risks	Agitation, loss of dignity, potential for circulatory issues if too tight.	Skin breakdown, nerve damage, agitation, circulatory issues.	Physical deconditioning, serious injury, suffocation.

Alternatives to Mitten Restraints

Federal regulations require that restraints be used only as a last resort, after all less restrictive interventions have failed. Alternatives to consider include:

• Frequent Assessment and Monitoring: Consistent rounding by nurses can help anticipate patient needs and address agitation before it escalates. A one-on-one sitter or continuous video monitoring can provide enhanced observation.
• Environmental Adjustments: Ensuring a calm, comfortable, and well-lit environment can reduce patient confusion. Lowering the bed to reduce fall risk is another strategy.
• Distraction and Redirection: Engaging the patient with activities or conversation can divert their attention from tubes, lines, or wounds. For tactile stimulation, special fidget blankets or weighted items can be used.
• Camouflaging Medical Equipment: Covering IV sites with sleeves or creative dressing techniques can make tubes and lines less obvious to a confused patient.
• Pain and Medication Management: A thorough assessment of the patient's medication regimen can reveal potential side effects or a need for different pain management strategies that may be contributing to agitation.

Proper Application and Monitoring

If mitten restraints are deemed necessary, proper application and monitoring are essential for patient safety.

• Application: Place the patient's hand inside the mitt, ensuring the fingers are in a natural position. Secure the wrist strap snugly but not so tightly that it restricts blood circulation. A flat finger should fit comfortably between the restraint and the patient's wrist.
• Monitoring: Follow your facility's policy for regular monitoring, which typically involves checking the restrained limb every 15 minutes and releasing the restraint every hour for skin assessment and range of motion exercises.
• Documentation: Detailed documentation is required, including the reason for the restraint, alternatives attempted, the type applied, the patient's response, and the monitoring schedule.

Conclusion

Mitten restraints are a serious intervention used for the safety of patients who are at risk of harming themselves or disrupting critical medical treatments. They are never to be used for staff convenience or as a form of punishment. The decision to use mitten restraints must follow a thorough assessment of the patient's needs and the exhaustion of all less restrictive alternatives. By prioritizing patient dignity and safety, and adhering to strict protocols, healthcare providers can ensure that mitten restraints are used appropriately and only for the shortest duration necessary.

Visit the Centers for Medicare & Medicaid Services website for guidelines on patient restraints.

Frequently Asked Questions

What is the primary purpose of mitten restraints?

The primary purpose of mitten restraints is to prevent patients from injuring themselves or interfering with medical treatment, such as pulling out IV lines or disrupting wound dressings.

Can mitten restraints be used for staff convenience?

No, mitten restraints can never be used for staff convenience, punishment, or as a substitute for proper care and supervision.

What are some alternatives to using mitten restraints?

Alternatives include distraction techniques, increased patient supervision (including a sitter or video monitoring), adjusting the environment, or camouflaging medical lines and tubes.

Are mitten restraints considered a less restrictive option than other restraints?

Yes, because they prevent grasping while still allowing for some arm mobility, mitten restraints are generally considered a less restrictive option than other physical restraints like wrist or vest restraints.

How often should a patient in mitten restraints be monitored?

A patient in mitten restraints should be monitored frequently, with best practices recommending checks every 15 minutes and release for skin and range of motion assessments every hour, according to facility policy.

What are the risks associated with using mitten restraints?

Risks include increased patient agitation, psychological distress, potential for compromised circulation if applied too tightly, and skin irritation.

Is a physician's order required to use mitten restraints?

Yes, in most healthcare settings, a physician's order is required to apply mitten restraints. The order must be based on a documented medical necessity and is time-limited.

What documentation is required for the use of mitten restraints?

Documentation should include the reason for the restraint, alternatives tried and failed, the type of restraint used, the patient's behavior and response, and the monitoring schedule.