Restraint Use: Legal Requirements and Alternatives

Physical and chemical restraints restrict a patient's movement or behavior and carry significant risks of harm including asphyxiation, nerve damage, skin breakdown, increased agitation, rhabdomyolysis, aspiration, and psychological trauma. The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission have strict regulations governing restraint use based on the principle that restraints are a safety intervention of LAST resort, not a treatment modality. Restraint-related deaths occur through positional asphyxia when a restrained patient in a prone or compromised position cannot adequately expand the chest wall for respiration. Compression of the thorax or neck by restraint devices can obstruct the airway or restrict respiratory excursion. Metabolic complications include rhabdomyolysis from prolonged muscle contraction against restraints, which releases myoglobin that can cause acute kidney injury. The physiological stress response to restraint application causes catecholamine surge, increasing heart rate, blood pressure, and metabolic demands. Patients with delirium, dementia, or cognitive impairment are at highest risk for restraint-related injury because they continue to struggle against restraints without understanding their purpose, escalating rather than resolving the behavioral emergency.