The application of physical restraints in healthcare settings is a critical practice, often considered necessary to safeguard patients from harm, especially during their hospital stay. However, it is paramount that such interventions are applied proportionally, effectively, safely, and with subsidiarity, as restraint use carries significant risks. These risks extend beyond physical complications like pressure ulcers, hematomas, hospital-acquired infections, decreased muscle strength (increasing fall risk), and entrapment, to include psychological harm such as increased agitation or anxiety. Furthermore, these complications can lead to delayed patient recovery and longer hospitalizations. Therefore, physical restraints should only be employed as a last resort and in strict adherence to established guidelines and regulations.
In the Netherlands, restraint is defined as “interventions that have restrictive consequences for the individual freedom of patients”. The Dutch healthcare system categorizes restraints into five distinct types, ranging from category 1 (least invasive), which includes bed sensors and room exit alarms, to category 5 (most restrictive), encompassing severe restraints like wrist/ankle restraints, abdominal restraints, and chair belts. The Professional Association of Nurses in the Netherlands (V&VN) has incorporated guidelines, titled “Restraint use in the hospital? No, unless…”, into hospital protocols, offering guidance on preventive and alternative interventions, conditions for restraint use, and their categorization. Despite the critical need for accurate documentation to gain transparent insight into restraint use and application, current documentation practices in Dutch hospitals often lack uniformity and are insufficient. This inconsistency makes data difficult to compare across institutions and limits a thorough understanding of their application.
This quality improvement project was specifically undertaken at Maastricht University Medical Center+ (MUMC+), a Dutch academic hospital, with the primary aim to improve the documentation of restraint use for adult patients on general nursing wards. The project sought to address the issue that, despite existing procedural agreements for reporting and recording restraint use in the Electronic Patient Record (EPR), the documentation option was underutilized by staff, leading to unreliable data and inconsistencies between the EPR and lending records. A preliminary improvement target was set to increase correct documentation from a baseline of 0% to 25% by March 2024, a goal deemed achievable within the study’s timeframe.
To achieve its objective, the study adopted a systematic approach, employing three Plan-Do-Study-Act (PDSA) cycles with follow-up measurements. The project team, multidisciplinary in nature and including patient participation, utilized the Lean Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) methodology. The initial baseline measurement, conducted through medical record reviews of forms from 2019 and 2022, revealed a 0% rate of correctly filled-out documentation forms for restraint use, indicating that all 48 analyzed forms were either inadequate or incomplete.
The interventions implemented across the PDSA cycles were designed to progressively enhance documentation:
- PDSA 1 involved the introduction of a new, updated documentation form on September 18, 2023. This form required documentation for each instance of restraint use, including indication, patient’s capacity to consent, and consent from the doctor and patient/legal representative.
- PDSA 2 focused on a multifaceted intervention aimed at improving knowledge and awareness among nursing and medical staff. This included a dedicated theme month, a new interdisciplinary protocol, QR codes on restraints providing step-by-step application instructions, training for healthcare workers, dissemination of information via posters and pocket cards, and an interactive escape room for practice.
- PDSA 3 involved providing additional feedback to all departments and medical professional groups, sharing hospital-level data to further emphasize documentation importance.
The accuracy and completeness of documentation were assessed by reviewing key aspects in the EPR, such as the indication for restraint, consultation with a second nurse and physician, patient and/or legal representative consent, and the specific restraint used. The primary outcome measure was the percentage of correctly filled-out documentation forms, while a secondary outcome measured the percentage of completed forms relative to issued restraints.
Ultimately, this project demonstrated a significant increase in the accuracy of documentation, with the percentage of correctly completed forms rising from 0% at baseline to 55.9% by the end of the study. Furthermore, the percentage of applied restraints that were documented, relative to those borrowed from the medical equipment department (MED), increased from 38.2% (PDSA 1) to 51% (PDSA 2), with a follow-up showing 43.5% of documented restraints fully and correctly completed. This improvement in documentation is considered a crucial initial step, not only for gaining better insight into restraint use but also for informing and developing future strategies aimed at reducing restraint use over time, particularly for higher category restraints. The study’s findings are expected to contribute significantly to national and international initiatives focused on standardizing definitions and improving documentation practices regarding restraint use.
APA Reference: de Boer, L., Scheepers, J., Vertommen, C., Klein, D. O., Rietbergen, T., & Bal, R. A. (2025). Improving accurate documentation for reducing restraint use: a quality improvement project in a Dutch academic hospital. BMJ Open Quality, 14(e003046). https://doi.org/10.1136/bmjoq-2024-003046.
