When someone is in the hospital, they may need extra care from doctors and nurses to keep themselves and others safe. This can happen during a mental health emergency, after a bad reaction to medication, or because of a medical condition that affects clear thinking or self-control.
In these situations, the standard of care requires doctors and nurses to use the least restrictive means to protect a patient.
Physical restraints such as wrist cuffs, vests, or belts are sometimes necessary, but they’re considered a last resort for managing agitated, combative, or disoriented patients. However, when misused or prolonged, restraints can transform from protective measures into sources of severe harm, including muscle breakdown conditions like rhabdomyolysis.
In Texas, where medical malpractice claims often highlight such issues, understanding the standards, risks, and potential for negligence is crucial for patients, families, and healthcare providers.
Standards Governing the Use of Restraints
Under Texas law, the standard of care is a national one, not localized. In many instances, hospital accrediting organizations like The Joint Commission have guidelines or documents that describe the standard of care.
In the case of restraints, The Joint Commission’s standards emphasize that restraints should only be applied when less restrictive alternatives have failed. Other techniques that nurses and physicians should try first include things like de-escalation techniques, one-on-one supervision, and medication adjustments.
When restraints are needed for patients exhibiting violent or self-destructive actions, they’re called behavioral restraints. Behavioral restraints require orders from a physician (or nurse practitioner or physician assistant), limited to four hours for adults, with mandatory face-to-face evaluations within one hour of initiation.
Additionally, nurses are required to continuously monitor patients with behavioral restraints, including checks every 15 minutes for vital signs, circulation, and psychological status, plus releases every two hours for hygiene, nutrition, and range-of-motion exercises.
Texas aligns with federal regulations under the Centers for Medicare & Medicaid Services (CMS), which prohibit restraints for convenience, coercion, or discipline.
Under accrediting guidelines, hospital personnel must document the justification for restraints, alternatives attempted, and ongoing reassessments to ensure that they’re discontinued at the earliest possible safe moment. Hospitals are also required to train their staff in restraint application and alternatives, with annual competency demonstrations. These standards aim to protect patient dignity while minimizing risks.
The Multifaceted Risks of Restraint Use
Despite these safeguards, restraints carry significant dangers. Physically, they can cause skin injuries, pressure ulcers, deep vein thrombosis (DVT), and aspiration pneumonia from immobility.
Studies show restrained patients face higher in-hospital death (mortality) rates and extended hospital stays.
The prolonged use of patient restraints can cause medical issues, leading to muscle atrophy, dehydration, and infections. They can also have psychological or mental health impacts, including causing delirium, agitation, and post-traumatic stress disorder (PTSD).
Patients report feelings of vulnerability, loss of dignity, and nightmares, which can erode trust in healthcare providers.
In psychiatric contexts, where restraints are more common, they may worsen underlying conditions like depression or schizophrenia, triggering cycles of increased sedation and further restraint.
One severe complication is rhabdomyolysis, a potentially life-threatening breakdown of muscle tissue.
This occurs when extended immobilization compresses muscles, reducing blood flow and causing cellular damage. Toxins from dying muscle fibers leak into the bloodstream, leading to kidney failure, electrolyte imbalances, and cardiac arrhythmias if untreated. In other words, excessive use of restraints can lead to failure of multiple organs.
Some patients have increased risk for developing rhabdomyolysis when they’re restrained. Risk factors include pre-existing conditions like dehydration or psychiatric medications, but restraint-induced pressure is a key trigger, especially in combative patients who fight or struggle against the restraints.
How Restraints Can Lead to Rhabdomyolysis
Rhabdomyolysis develops through a cascade of events tied to restraint use. Immobilization for hours or days restricts muscle movement, causing ischemia (reduced blood supply) and direct trauma from pressure points. When patients are agitated and forcefully resist restraints, there’s additional muscle strain. Plus, certain medications, like amitriptyline, can multiply the risk, because they already stress muscles.
These issues can often be spotted with lab work. Elevated creatine kinase (CK) levels signal muscle damage, often spiking dramatically in restrained cases.
Untreated, rhabdomyolysis progresses to acute kidney injury, with death rates up to 20% in severe cases.
This is why the standard of care requires last-resort use of restraints and careful preventative measures including frequent repositioning and early discontinuation. Lapses in proper monitoring can turn a safety tool into a fatal one.
Outlining Medical Negligence in Restraint Cases
When doctors and nurses resort to restraints without first trying alternatives, it can be medical malpractice. The same is true when health care providers fail to appropriately monitor and reassess patients who are restrained.
In one lawsuit, a hospital was held liable for not properly applying restraints, leading to patient injury.
Another family sued after a mother died following 24-hour restraint, alleging that the nurses and hospital staff ignored vital signs and nutritional deficits.
Texas hospitals can be held accountability for the negligence of their employees and nursing staff, but also for their direct liability for staff training gaps and policy violations.
Accountability and the Need for Safer Practices
While hospital restraints are sometimes necessary, they demand vigilant adherence to standards to avoid tragedy. Risks like rhabdomyolysis underscore the human cost of medical negligence, particularly in vulnerable populations.
In Texas, medical malpractice suits can hold hospitals, doctors, and nurses accountable when restraints are misused and cause serious injury or death.
