Physical restraint

Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance. Use the least restrictive intervention necessary to ensure the safety of the patient, staff and others.

Physical restraint is a restrictive practice, referring to physical immobilisation of a patient. Physical restraint should only be used as a last resort after all other evidence-based, person-centred and proactive strategies have been attempted, and reserved for patients whose:

• distress or behaviour poses an imminent risk of significant harm to self or others
• behavioural disturbance is persistent, escalating or recurrent despite other therapeutic interventions.

Restrictive practices are discouraged in all people, particularly children and older people, and people with developmental disability or cognitive impairment.

Temporary physical restraint may facilitate the administration of pharmacological therapy. Physical restraint must be proportionate to the risk of harm, and only be employed for the minimum duration that ensures the safety of the person or others; see here for more detailed information about restrictive practices in patients with a developmental disability. If physical restraint is required, document the rationale for its use, the type of restraint used, the patient’s response, whether consent was obtained, monitoring undertaken, the duration of restraint, and any adverse outcomes.

Physical restraint, especially in the prone position, has been associated with severe sequelae, including positional asphyxia, ventilatory depression, rhabdomyolysis, metabolic acidosis and cardiac arrest. If physical restraint is used, avoid prone restraint, and ensure the patient’s airway, breathing and circulation are not obstructed.

Physical restraint must only be implemented by a well-trained, practised and coordinated team following a local protocol or consensus state guideline. The safest physical restraint technique is to immobilise the patient’s limbs using a team approach. Ideally, 6 team members are required: one team member to immobilise each of the patient’s limbs by applying pressure to the patient’s main joints (eg shoulder and elbow; hip, knee and ankle), one to immobilise the patient’s head, and one to administer drugs if necessary. Apply a mask to the patient to prevent them from spitting at staff.

Continue to employ verbal de-escalation and psychological intervention techniques during physical restraint. Release the physical restraint as soon as it is safe to do so, or when the desired level of sedation is achieved—see the specific approach to Pharmacological management for acute behavioural disturbance in adults. Ensure documentation is completed each time a patient is physically restrained.