2008 Quick Reference Guidelines - UCLA Health



2010 Quick Reference Guidelines

Medical/Surgical vs. Behavioral Restraints

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IMPORTANT NEW Requirements (Changes in Restraint Policy #1321)

1. NEW LAW: Requires that the Hospital’s Director of Licensing and Accreditation report to the Centers for Medicare-Medical Services (CMS) knowledge of a patient’s death in the following situations:

a. Death that occurs while a patient is in restraint or seclusion.

b. Death that occurs within 24 hours after restraint is removed.

c. Death (known to the hospital) that occurs within 1 week if restraint contributed directly or indirectly to a patient’s death (e.g. death from asphyxiation or restriction of breathing related to restraints)

2. ROLE OF RN: If you believe that use of restraints have contributed directly or indirectly to a patient’s death (as above c), immediately notify your UD, CNS, or Educator and complete an event report under category - “Falls/Injuries Other than Falls”.

3. FREQUENCY OF DOCUMENTATION FOR MED/SURG RESTRAINTS:

• Document pt’s LOC, circulation, sensory, and motor Q2 hours.

• Document release, ROM, & reassessment of nutrition, skin, and hygiene needs Q2 hours.

• Assess/document more frequently as appropriate to patient condition & need.

4. TRANSPORTING PATIENTS To Procedures (Behavioral Restraints): Any patient in behavioral restraints must be accompanied and continuously monitored by a registered nurse. The patient must NEVER be left unattended.

5. “Tuff Cuffs” Replace “Hard/Leather” Behavioral Restraints in the inpatient areas: “Tuff Cuff” Quick Release restraints (which have the strength of leather and comfort of a soft restraint) will be used in the inpatient setting when behavioral restraints are required and soft restraints are not enough to ensure the patient and staff safety. Tuff Cuffs for the wrist (BLUE) and ankle (RED) restraints are available on the units or ordered through central supply. Replace ”lock w/key type” hard/leather restraints (used in the ER by security officers) with “Tuff Cuffs” when patients are admitted from ER to an inpatient nursing unit.

See attached “Protocol for Transporting Behavioral (Hard/Lock Type) Restraint Patients From ER to Inpatient Hospital Units”

MEDICAL/SURGICAL RESTRAINT REQUIREMENTS (Summarized)

• Initial MD Order is required (notify MD IMMEDIATELY if restraints initiated w/significant change in patient condition or behavior)

• Verbal Order MUST be obtained within 12 hours of restraint application – RN signs bottom of order form; MD must co-sign the order within 24 hours.

• Date and Time must be written at time of order

• NO PRN Orders (e.g. writing orders for future dates is not acceptable)

• Continuation Orders are required EACH CALENDAR DAY after MD examines patient

• Document least restrictive (alternative) methods as applicable.

• New orders required upon patient transfers to another unit or service.

• New orders also required if restraints are terminated and same behavior is demonstrated

• ESSENTRIS DOCUMENTATION (see attached examples):

✓ A (P) mark (Q2 hours on the “Treatments” section –1st line item) indicates the patient is observed and monitored for signs of injury, level of consciousness (LOC), circulation, sensory, and motor (observe and assess more frequently as appropriate)

✓ A (P) mark (Q2 hours on the “Treatments” section – 2nd line item) indicates release of restraints, range of motion; assessment of need for hygiene, elimination, hydration, nutrition, position change; and reassessment of need to continue restraints based on pt response to less restrictive interventions.

✓ For sleeping patients, use an (S) in place of Q2 hour assessments while a patient is sleeping. An (S) indicates that the sleeping patient's skin color and extremities are checked (observed) for tissue perfusion and adequate circulation, breathing is observed & respiratory rate is documented with routine vital signs.

✓ A “Restraints Plan of Care” is required under the NOTES section in Essentris charting reflecting goals and is driven by the Restraint Guidelines for Care (Nur-G1008)

✓ The patient’s response to interventions and less restricted measures used must be included in documentation.

BEHAVIORAL RESTRAINT REQUIREMENTS (Summarized)

• MD must evaluate patient (in-person) within 1 hour of BEHAVIORAL RESTRAINT application (Joint Commission/CMS - DHS requirement).

• Behavioral Restraint MD orders are “ Time limited” and require new orders at specific intervals

o Q4 hrs for adult patients

o Q2 hrs for 9-17 years

o Q 1 hr for < 9 years

• Orders are never written as PRN (MDs must NOT date or time orders ahead of time)

• IN-Person “Re-evaluation” by MD is required every 8 hours for 18 years old and older; every 4 hours for 17 and younger (TJC requirement)

• Use “Tuff Cuffs” when behavioral restraints are required and/or soft restraints are not enough to ensure the patient and staff safety (Hard/Leather Restraints used in the EMD are to be switched to “Tuff Cuffs” when patient is admitted to an inpatient setting.

• ESSENTRIS DOCUMENTATION: (see attached documentation)

✓ Continuous observation with q 15-minute documentation (PPPP) of patient’s safety, LOC and circulation, sensory, motor (CSM)

✓ Q2 hours (P) mark indicating release, ROM, reassessment, hygiene, elimination, hydration, nutrition, position change; and need to continue restraints (same as M/S restraints).

✓ Document Plan of Care in Notes Section

• As soon as patient de-escalates (Agitation less than +3), use least restrictive measures (e.g. change to "medical surgical" restraints or discontinue restraint use)

• Collaborate with patient and staff to help patient regain control & revise patient's treatment plan as needed

Med-Surg Restraints (Treatment Flowsheet)

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Behavioral Restraint (Treatment Flowsheet)

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Essentris - Plan of Care: - Be Sure to Activate Restraint Plan of Care

The Restraint Guideline for Care provides the structure and basis for the Plan of Care. It defines assessment parameters, interventions, and outcome criteria / goals. Individualized goals, specific to the patient are documented in the Essentris Plan of Care. Nursing interventions and patient progress toward the goals will be reflected in Essentris nursing documentation in the Notes, Treatments and other appropriate related Flowsheets. Care Plan Goals and interventions are to be reviewed and/or revised by the RN each shift.

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PROTOCOL FOR TRANSPORTING BEHAVIORAL (HARD/LEATHER) RESTRAINTS FROM THE ER TO INPATIENT HOSPITAL UNITS

PURPOSE: The following protocol is to outline the guidelines and process to ensure the safety and well being of the patient and the staff caring for patients in Hard/Leather Behavioral Restraints.

1. Locked hard restraints (requiring keys) used in the ED setting are NOT to be used in the Inpatient Care setting.

2. “Tuff Cuff” Quick Release restraints (which have the strength of leather and comfort of a soft restraint) will be used in the inpatient setting when behavioral restraints are required and soft restraints are not enough to ensure the patient and staff safety.

3. Security officers will be responsible for escorting all ER Patients in Behavioral Restraints (Locked Hard Restraints) to the Inpatient Nursing Units.

4. ER Staff will notify Security officer of a pending transfer of a behavioral restraint patient (in Locked/ Hard restraints) and approximate time of transfer.

5. ER Staff will notify the Inpatient Nursing unit that the transferring patient will be transported in locked/hard restraints.

6. Inpatient Nursing Unit is responsible for ordering the “Tuff Cuff” Restraints from CENTRAL SUPPLY prior to the patient’s admission to the inpatient nursing unit.

7. Both wrist (Blue) and ankle (Red) “Tuff Cuff” restraints must be available at bedside when Patient comes up from ER so the SWITCH from Buckle / Leather restraint to Tuff Cuff restraints can take place.

8. Security Officer(s) will accompany patient in Locked/Hard Behavioral Restraints to the nursing unit, and assist the RN in switching from “locked” hard restraints to the “Tuff Cuff” Wrist (blue) and Ankle (red) restraints.

9. Behavioral Restraints (Tuff Cuffs) shall be removed at the earliest opportunity. Replace with soft restraints and or use least restrictive measures possible.

“Tuff Cuffs” (Quick Release) – Order through Central Supply and Available on your CS carts SOON! USE ONLY for Behavioral Restraint Patients.

Wrist (Blue Color Coded) - “Restraint (Wrist) Tuff Cuff”

Ankle (Red Color Coded) - “Restraint (Ankle) Tuff Cuff”

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Restraint Alternative and

Fall Prevention Products

Restraint Alternatives: Order from Central Supply

Elbow Immobilizer Hand Control Mittens Activity Apron

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Falls or Entrapment Prevention Products:

Body Holder Device

Large /Body Holder (for bed) Medium Holder (for chairs) [pic] [pic]

Posey Sitter II Bed Alarm Device

(Fall Prevention –Device links to Nurse Call System)

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RESTRAINT "DEFINITIONS" AND SCENARIOS:

Agitation Scale

+ 3 Immediate threat to safety (Behavioral Restraint)

+ 2 Agitated, does not calm to verbal (Med/Surg Restraint)

+ 1 Agitated, calms to verbal (Med/Surg Restraint)

0. Calm, follows commands

Medical/Surgical Restraint - Patients with mild to moderate agitation (+1 to +2 on Agitation Scale) who are restrained to prevent injury due to accidental dislodgment of invasive/central lines, tubes, and drains.

Behavioral Restraint - Patients who exhibit violent, aggressive, unanticipated, and unexpected, behavior with sustained agitation (+3 on Agitation Scale). M.D. must see patient within 1 hour.

Read the following scenarios and indicate how you would describe the type of restraint (Behavioral versus Medical/Surgical) based upon the patient behaviors and level of agitation (agitation scale).

Indicate the type of restraint that you feel would be most appropriate: Behavioral Restraint versus Medical Surgical Restraint

Scenario 1:

1130. Patient agitated and trying to take out IV, kicking aggressively at the bed rail, screaming. Security called. Patient yelling out expletives, profanity, wants restraints off. Patient said he needed Motrin for pain. M.D. notified. 1600 Pulled out IV. Explained to patient that he was hurting himself - he said he didn't care. Security called to help restrain patient. Patient said he just gets angry sometimes and he has difficulty controlling angry. Said he was going to spit and urinate all over the place.

Circle appropriate type of restraint in this scenario:

• Behavioral Restraint

• Medical Surgical Restraint

Answer / Rationale: - Behavioral Restraint is appropriate due to violent, aggressive sustained +3 agitation. MD must see & assess patient within 1 hour. Complete the shaded areas of Restraint Order form. Continuation orders required Q4 hours adults (Q2 hours for children 9 to 17; Q1 hour for < 9 years).. Switch to Medical Surgical Restraints or D/C restraints as soon as patient de-escalates.

Scenario 2:

645. Received patient in a calm state. RN from NPI at bedside. Patient has pulled out several IVs. Mother and sister with patient. At 2130, patient began getting a little anxious - had a medical student talk with patient and family and patient calmed down. At 2420, patient became really anxious and confused. Ativan 4 mg. Given. MD came in to assess patient and wrote for stat blood and RUA. Patient wanted to get OOB, go to Las Vegas and gamble. At 0245 Ativan 2 mg given after MD made aware of patient anxiety. Patient would sleep a little and wake up and be anxious. No skin Breakdown, 2 point restraints. 0715 Patient sleeping without distress.

Circle appropriate type of restraint in this scenario:

• Behavioral Restraint

• Medical Surgical Restraint

Answer / Rationale: Medical Surgical Restraint is appropriate (agitation level is +1 to +2) Attempt use of alternative methods prior to restraints. Psychiatric Hold 5150 patients are not automatic "Behavioral restraints" unless the level of agitation warrants it. Restraint Orders should never be written as "PRN" Orders. A Continuation (Renewal) Order must be written by MDs EACH calendar day if restraints continue.

Scenario 3:

1030. Patient became very agitated, jumping out of his chair while watching T.V. and picked up chair and threw it in direction of nursing staff, yelling and pointing fingers. M.D. notified who came to assess patient at bedside. Haldol 2 mg. IM given in attempts to administer shot. Patient jumped up and began to yell and chase nurse out of room, reaching for nurse. M.D. and security called., 4-point Tuff Cuff restraints applied. Haldol 1 mg. IM given by charge nurse.

Circle appropriate type of restraint in this scenario:

• Behavioral Restraint

• Medical Surgical Restraint

Answer / Rationale: - Behavioral Restraint is appropriate due to violent, unexpected and aggressive sustained +3 agitation. MD must see & assess patient within 1 hour. Complete the shaded areas of Restraint Order form. Continuation orders required Q4 hours. Switch to Medical Surgical Restraints or D/C restraints as soon as patient de-escalates.

Scenario 4:

0800: 35 yo female patient with large cell lymphoma; hx smoking and alcohol, oriented to

person, occasionally disoriented, hallucinating; tachycardic, denies any chest pain or

SOB. Currently on Steroid therapy. Refuses IV access, MD aware; social/emotional

stated wanting to leave, tearful at times, reaching for something in the air; Constant

Observation Aide (Sitter) at beside. 1600 Ativan and Haldol PRN. Patient remains agitated

tries to get out of bed at times, confused. Vest (posey jacket) applied. Sitter and husband at

bedside trying to calm and reassure patient. Will continue to monitor.

Circle appropriate type of restraint in this scenario:

• Behavioral Restraint

• Medical Surgical Restraint

Answer / Rationale: Medical Surgical Restraint is appropriate (agitation level is +1 to +2) Attempt use of alternative methods prior to restraints. Restraint Orders should never be written as "PRN" Orders, and should NEVER be signed (pre-dated or signed) ahead of time. A continuation (renewal order) is required EACH calendar day. All orders must be dated and timed at time physician signs orders.

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Agitation Scale

+ 3 Immediate threat to safety (Violent, Aggressive, Sustained, Behavioral Restraints)

+ 2 Agitated, does not calm to verbal (Moderate Agitation, Medical / Surgical Restraints)

+ 1 Agitated, calms to verbal (Mild Agitation, Medical / Surgical Restraint)

0 Calm, follows commands

Medical/Surgical Restraint

Patients with mild to moderate agitation (+1 to +2 on Agitation Scale) who are restrained to prevent injury due to accidental dislodgment of invasive-central lines, tubes or drains, hypoxia, electrolyte/metabolic imbalance, dementia, encephalopathy, drug sensitivity, or sepsis.

•

Behavioral Restraint

Patients who exhibit violent, aggressive, unanticipated, AND unexpected behavior with sustained agitation (+3 on Agitation Scale.); imminent risk to staff or others.

M.D. must see & assess patient within 1 hour.

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