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Four-Point Restraint



Four-point restraints may be required for patients with psychiatric illnesses or altered mental status who become violent and dangerous in the emergency department. The use of physical restraints may be necessary for their own protection and the protection of others. Professionals must understand the indications and contraindications for the use of physical restraints. Knowing the proper application of physical restraints is crucial for minimizing the risk of harm to the patient and the treatment team.

Agitation and violent behavior are frequently seen in acute care settings, such as emergency departments and inpatient psychiatric facilities.
Approximately 10% of psychiatric patients in the emergency department will have violent behavior and possibly require some form of restraint.
Studies show that nurses and mental health workers are at an increased risk of work-related violence.
Psychiatry residents have a 40–50% chance of being physically assaulted by a patient during their residency,
and emergency physicians also have an increased risk of being physically assaulted by a patient at some point during their practice.
Physical restraints are therefore a necessary safety measure in certain circumstances.

Professionals must be aware of the potential negative physical and psychological consequences of restraints. Measures should be taken to preserve the patient’s dignity and rights. The act of physically restraining a patient has both ethical and medicolegal implications, including the potential violation of a patient’s rights.
One study that compares legal and medical opinions suggests that emergency physicians are inclined to use restraints more frequenctly than juris doctors given the same scenario.
Therefore, the use of four-point restraints should be a last resort after attempts to deescalate the situation have failed and less restrictive measures were ineffective.
The decision to physically restrain a patient must be given serious consideration.


For the patient’s own protection and the protection of others, a health care professional may deem it necessary to place a patient in four-point restraints. The Centers for Medicare & Medicaid Services established some basic principles for the use of restraints (see C.F.R. 482.13).

Restraint and seclusion can only be used in emergency situations if needed to ensure physical safety and if less restrictive interventions have been determined to be ineffective. There is a degree of ambiguity concerning what situations constitute a true emergency and physicians must sound clinical judgment and carefully document their reasoning.
In addition, the patient has the right to be free from restraint and seclusion, in any form, imposed as a means of coercion, discipline, or retaliation by staff. Restraints should not be used for convenience.

Keeping these principles in mind, there are certain indications that may prompt the use of four-point restraints:

When the patient is physically combative

When the patient is a clear and immediate danger to self or others

When less restrictive alternatives have been attempted without success

When it reasonably appears that delay in restraint would subject the patient and others to risk of serious harm

Attempts at deescalation that should be considered before the use of four-point restraints include the following:

Verbally requesting cooperation while maintaining a nonaggressive posture and tone of voice

Having an adequate security force nearby that is visible to the patient

Redirecting and/or diverting the patient’s emotions

Separating the patient from others

Offering appropriate medications


Contraindications to four-point restraints include the following:

When the patient is competent and refusing care

When the patient is not a danger to self or others

When less restrictive alternatives have not been considered or attempted

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