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. [1, 2, 3]
Agitation and violent behavior are frequently seen in acute care settings, such as emergency departments and inpatient psychiatric facilities. [4, 5, 6] 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. [8, 9] 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
Equipment for four-point restraint includes the following:
Disposable gloves (latex-free if the patient has a known latex allergy)
Soft nylon or leather restraints (see the image below)Nylon restraints.
Manufacturer-specific instructions for the type of restraints used (see the image below)Example of manufacturer instructions.
A hospital bed or sturdy stretcher
Padding for any concerning pressure points
Chemical restraints on standby (eg, haloperidol 5 mg IM, lorazepam 2 mg IM, benztropine 1 mg IM)
Note that leather restraints are typically reserved for combative and violent patients.
While anesthetics are generally not necessary, chemical restraints may be used in conjunction with physical restraints or as an alternative to physical restraints. Haloperidol, lorazepam, and ziprasidone are examples of medications commonly used in the setting of acute agitation.
Some patients may become more violent and agitated after physical restraints are applied, so the use of these medications in conjunction with physical restraints may be necessary to achieve safe control of the situation. Additionally, the use of haloperidol may be combined with an anticholinergic such as benztropine to reduce the possibility of extrapyramidal effects.
Positioning the patient in the supine position is the preferred option. The head of the bed should be elevated approximately 30 degrees to decrease the risk of aspiration. See the image below.
Positioning the patient in the prone position increases the risk of suffocation and should only be used as a secondary option. Do not use any pillows under the patient's head in this position.
The complication rate associated with use of physical restraints is 6.7%.  Half of the complications are associated with escape from restraints. Therefore, it should be ensured that the restraints are applied securely and as specified by their manufacturer.
The most commonly cited complications are abrasions and bruises.  Injuries to the patient's extremities may include dislocation, contusion, numbness, tingling, fracture, or muscle strain. These injuries tend to occur during the application of restraints with a violent patient.
Positioning the patient prone increases the risk of suffocation. This is further increased if the patient is positioned prone with a pillow. This position should be avoided if possible.
Positioning the patient supine without elevating the head of bed increases the risk of aspiration and subsequent respiratory problems that may develop.
Studies on the use of physical and chemical restraints with elderly patients are limited; however, the use of both forms of restraint appears to be safe if done correctly. 
If a patient is not chemically sedated while physically restrained, prolonged struggling may lead to hyperthermia, lactic acidosis, and elevated creatinine kinase levels.  Laboratory studies should be obtained if this is suspected, as it may change a patient's disposition from psychiatric service to medical admission.
Exposure to blood or bodily fluids while restraining violent patients puts law enforcement officers and health care workers at an increased risk of infection. Therefore, team members should take appropriate precautions before attempting restraint. 
Proper technique starts with having a sufficient number of personnel. Ideally, there should be a five-member team, with one leader and one member for each extremity.
Hospital security and police should be called to help subdue a violent patient. Violent patients should be isolated, derobed, searched for weapons, and gowned. This can prevent harm to hospital staff members who are not adequately trained.
Any staff members attempting to physically restrain a patient should be educated and equipped with skills to protect themselves and minimize harm to the patient.
Approach to Four-Point Restraint
Clearly explain to the patient and the patient's family what you are doing as the restraints are being applied and explain why you are applying the restraints.
Have each member apply a restraint to an extremity as specified by the manufacturer instructions, and then secure the restraint to the base of the bed or stretcher. Do not apply the restraints to bed rails.
Restraints may need to be applied one at a time while the other extremities are held down. Providers should be aware of how to apply the specific types of restraints used by their hospital and also be familiar with how to tie quick-release knots.
After the restraints are secured, their integrity should be tested and the patient's extremities should be examined for any signs of circulatory compromise.
Offer the patient medication, but if necessary administer medication or chemical restraints involuntarily.
The patient should be continually assessed, monitored, and reevaluated. The frequency and types of reassessments vary among institutions.
If physical restraints are initiated because of a patient's behavior, a physician or licensed independent practitioner must see the patient and evaluate the need for restraints within 1 hour of the restraints being placed. 
Orders for behavioral restraints must be limited to the following:
4 hours maximum for adults
2 hours maximum for children and adolescents
1 hour maximum for children younger than 9 years
It is the duty of the health care professional to discontinue the use of four-point restraints as soon as possible once it is deemed safe to do so. If the decision is made to remove the restraints, remove one at a time while carefully monitoring the patient to ensure safety.
Rules for Four-Point Restraint
The following is a list of rules for restraint and seclusion set forth by the Centers for Medicare & Medicaid Services as part of the Condition for Participation for Hospitals (see C.F.R. 482.13). This list provides a summary of points to remember when the use of restraints is being considered.
Restraint and seclusion are safety interventions of last resort, to be used only when an individual poses an imminent danger to someone’s safety. As a Joint Commission requirement, every institution should have a protocol for the use of restraints. 
Restraint and seclusion may be ordered only by a physician or a licensed independent practitioner (eg, a physician’s assistant or nurse practitioner who is licensed to deliver medical services without oversight).
Orders must be time-limited as follows:
4 hours for adults
2 hours for children and adolescents ages 9-17
1 hour for patients younger than 9 years
The intervention must be ended as soon as it is safe to do so.
Certain risky practices, such as “basket holds” and applying back pressure to a person who is prone, are prohibited.
A physician or licensed independent practitioner must conduct a face-to-face assessment of the individual as soon as possible, which cannot exceed one hour after restraint.
Appropriately trained staff must continually assess, monitor, and reevaluate individuals who are restrained or secluded. Thorough documentation is imperative. 
Debriefings with the individual and staff must occur as soon as possible after each use of restraint or seclusion.
Staff must receive extensive and appropriate training, including all aspects of deescalation.
Deaths and serious injuries resulting from restraint or seclusion must be reported to governmental authorities.