Physical restraint restricts a patient’s freedom. It should be used only when it is indispensable from a medical perspective for maintaining or protecting the patient’s life and body, and even then it must be performed with respect for the patient’s human rights and limited to the minimum necessary extent. Without readily justifying restraint, each staff member will understand the physical and psychological harm caused by restraint, maintain awareness toward minimizing restraint, and strive to provide medical and nursing care without physical restraint, except in emergency and unavoidable circumstances.

1) Definition of Physical Restraint

“The restriction of behavior by temporarily restraining the body of the relevant patient using clothing, padded belts, or similar means in order to suppress movement.”

Definition of physical restraint under Ministry of Health and Welfare Notification No. 129, April 8, 1988.

In the provision of medical care, the Ministry of Health, Labour and Welfare has indicated specific actions that constitute restrictions on the behavior of inpatients in the “Handbook for Zero Physical Restraint” issued in March 2001.

In March 2024, the Committee for the Promotion of Initiatives to Abolish and Prevent Physical Restraint presented the “Handbook for the Abolition and Prevention of Physical Restraint” for the realization of “preservation of dignity” and “support for independence.”

2) Specific Actions Subject to the Prohibition of Physical Restraint, etc.

“Handbook for Zero Physical Restraint,” March 2001, Ministry of Health, Labour and Welfare, Council for the Promotion of the Zero Physical Restraint Strategy.

① Tying the torso or limbs to a wheelchair, chair, or bed with straps or similar means to prevent wandering.

② Tying the torso or limbs to a bed with straps or similar means to prevent falling.

③ Enclosing the bed with rails (side rails) so that the patient cannot get out of bed by themselves.

④ Tying the limbs with straps or similar means to prevent the removal of intravenous drip, enteral nutrition, or other tubes.

⑤ Applying mitten-type gloves or similar devices that restrict finger function to prevent the removal of intravenous drip, enteral nutrition, or other tubes, or to prevent scratching of the skin.

⑥ Applying a Y-shaped restraint belt, waist belt, or wheelchair table to prevent the patient from sliding down from, or standing up from, a wheelchair or chair.

⑦ Using a chair that prevents a person who has the ability to stand up from standing.

⑧ Dressing the patient in care clothing (one-piece clothing) to restrict removal of clothing or diapers.

⑨ Tying the torso or limbs to a bed or similar place with straps or similar means to prevent behavior that may disturb others.

⑩ Administering excessive psychotropic medication to calm behavior.

⑪ Isolating the patient in a room or similar space that they cannot open of their own will.

3) Three Requirements for Emergency and Unavoidable Use of Physical Restraint to Protect the Patient’s Dignity

When all of the following three requirements are met in order to protect the life and body of the patient or other patients, physical restraint may be used to the minimum necessary extent after explaining the matter to the patient and family and obtaining consent.

① Imminence: There is an extremely high possibility that the life or body of the patient or another patient is at risk.

Examples include situations in which a tracheostomy tube, central venous catheter, or arterial catheter is in place.

② Non-substitutability: There is no alternative nursing or care method other than physical restraint or other behavioral restriction.

③ Temporariness: Physical restraint or other behavioral restriction is temporary.

4) Patient Conditions in Which Physical Restraint May Be Unavoidably Used

① The patient has impaired consciousness, senile dementia, delirium, or agitation, and is unable to recognize danger around them (cognitive impairment).

② The patient cannot maintain a medically necessary position and attempts to remove medical equipment such as a ventilator, tubes, or drains (examinations or treatment cannot proceed smoothly).

③ There is a risk that the patient may injure themselves, attempt suicide, or harm others (destructive or violent behavior).

④ Because the patient has temporarily or permanently lost the judgment necessary to maintain their own safety, there is a foreseeable risk of falls, fractures, head injury, or similar situations (risk of falls).

⑤ The patient has pruritus, pathological reflexes, or similar conditions and cannot suppress body movement by their own will (other cases).

⑥ There is a foreseeable possibility that the patient may leave the hospital or ward without permission (other cases).

5) Specific Actions Not Subject to the Prohibition of Physical Restraint

For patients with limb or trunk functional impairment, actions taken as a measure to maintain a stable posture so that remaining functions can be utilized may not be considered prohibited physical restraint. In such cases, physicians, head nurses, nurses, rehabilitation staff, and others will review the matter and clearly record the purpose, method, and other relevant details.

① Splint fixation or similar measures used for the treatment of orthopedic diseases.

② Use of four bed rails to prevent falls.

③ Splint fixation during intravenous infusion.

④ Use of a wheelchair belt when the patient cannot maintain a sitting position independently.

⑤ Accident-prevention measures to protect the patient from risks such as falls or leaving the hospital without using physical restraint.

・Bed-leaving sensors.

6) FY2024 Medical Fee Revision: “Criteria Related to the System for Minimizing Physical Restraint”

① Establishment of a Physical Restraint Minimization Committee.

In FY2025, activities were conducted under the name “Medical Care Team”; in FY2026, the name will be changed to “Physical Restraint Minimization Committee.”

② The committee shall have a chairperson (hospital director or deputy hospital director) who serves as the person responsible for the committee and for overall management of related issues.

The members shall be composed respectively of representatives from the medical staff, nursing department, clinical technology department, and administrative department.

Committee meetings shall be held approximately at least once every three months.

The current status of physical restraint shall be reported at the monthly hospital meeting.

③ Committee review items:

・Review of guidelines and related documents concerning minimization of physical restraint, etc.

・Understanding the implementation status of physical restraint, etc.

・Planning and implementation of education and training sessions for all staff, and other matters.

④ Records and dissemination:

・When the committee is held, minutes shall be prepared, circulated for approval, and stored by the vice chairperson.

・Approved minutes shall be used to disseminate information to staff.

⑤ If these criteria are not met, inpatient fees will be reduced by 40 points per day.

7) FY2026 Medical Fee Revision / Newly Established: “Criteria Related to Outcomes, etc. for Minimizing Physical Restraint”

If the criteria related to the system for physical restraint are met but the “criteria related to outcomes, etc.” are not met, inpatient fees will be reduced by 20 points per day.

A: The implementation rate of physical restraint is aggregated and is 15% or less.

B: All of the following initiatives are being continued toward the abolition of physical restraint in principle.

① The committee is held at least once every three months, and specific initiatives toward minimization are reviewed based on the implementation status.

② Specific reviews for discontinuation of restraint or introduction of alternatives are conducted by one of the following methods:

・The Physical Restraint Minimization Team makes rounds, and the team and ward staff collaborate in the review.

・Multiple ward staff members collaborate in the review.

8) Confirmation and Approval When Physical Restraint Is Unavoidably Used

① A physician, head nurse, responsible nurse, rehabilitation staff, and other members shall discuss the matter, and the physician shall make the decision. At night or on holidays, this shall be handled by the physician on duty and the responsible nurse.

② When issuing an order for physical restraint or discontinuing restraint, the physician must always record the matter in the medical record.

③ Physicians, nurses, and other staff shall strive to reduce the patient’s mental and physical distress and strengthen observation.

④ Physicians, nurses, and other staff shall explain the matter to the patient and family and obtain consent before implementing restraint.

Explanation to and Consent from the Patient and Family When Physical Restraint Is Used

① The physician shall explain physical restraint to the patient and family and obtain consent using the “Consent Form for Physical Restraint.”

② If the need for physical restraint arises urgently, consent shall be obtained by explaining the matter by telephone, and written consent shall be obtained at a later date. Details shall be recorded in the electronic medical record, including the physician’s progress notes and nursing records.

③ If consent cannot be obtained, the physician shall explain that it may not be possible to avoid danger and shall record the matter in the physician’s progress notes in the electronic medical record.

④ If the patient has no family member or key person, or if consent cannot be obtained from the patient, physicians, nurses, and other staff shall review the matter before implementing physical restraint, and the details shall be recorded in the physician’s progress notes and nursing records in the electronic medical record.

Training for minimizing physical restraint shall be provided to all staff.

The Physical Restraint Minimization Committee shall create and implement training programs.

1) Training shall be conducted once a year for staff other than ward staff.

2) Training shall be conducted at least twice a year for ward staff.

Quoted from Nagitsuji Hospital’s Guidelines for Minimizing Physical Restraint.