Purpose:



POLICY AND PROCEDURE DIRECTIVE

Subject: Restraint & Seclusion

Date: 5/09

I. This memorandum rescinds any other publication covering the same material.

(P_GN_PC_10, and P_GN_PC_21).

II. Purpose:

A. This facility creates an environment that helps hospital staff focus on the patient’s well being. This requires planning, thoughtful education, quality improvement, and possibly new or reallocated resources. Our goal is an organization wide approach to restraints that protects the patient’s health and safety and preserves his or her dignity, rights, and well-being.

B. This facility ensures that restraint and seclusion interventions are safely and appropriately used. Because of the associated risks and consequences of use, this facility is continually exploring ways to decrease restraint use through effective preventive strategies or the use of alternatives to restraint. Policies and procedures for the use of restraint and seclusion are developed through an interdisciplinary process and approved by medical staff and administration. Staff roles and responsibilities in the use of restraints and seclusions are identified for all appropriate disciplines. Requirements for documenting the justification and use of these interventions are defined.

III. Definitions:

A. Restraint

The definition of physical restraint is any manual method or physical or mechanical device that restricts freedom of movement, physical activity or normal access to one's body, material, or equipment, attached or adjacent to the patient's body that he or she cannot easily remove. A restraint can be a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is NOT a standard treatment or dosage for the patient’s condition.

B. Seclusion: Confining a patient to an area when the patient is physically prevented from leaving the area or when staff gives the impression that physical intervention will occur if he/she attempts to leave. The patient is not allowed to leave the area or the room and is physically prevented from leaving.

IV. Situations In Which Restraint Standards Do Not Apply:

A. Standard practices that include limitation of mobility or temporary immobilization

related to medical, dental, diagnostic, or surgical procedures and the related post-

procedure care processes. These include but are not limited to:

1. surgical positioning

2. arm-board during intravenous administration

3. radiotherapy procedures

4. protection of surgical and treatment sites in pediatric patients

5. post-op / post-anesthetic care

B. Adaptive Support

Mechanisms intended to permit a patient to achieve normative bodily functioning. These mechanisms include orthopedic appliances, braces, tabletop chairs, or other appliances or devices used to give postural support to the patient.

C. Age or Developmentally Appropriate Protective Safety Interventions

Age or developmentally appropriate protective safety interventions that a safety- conscious child care provider outside a health care setting would utilize to protect an infant, toddler, or preschool-age child would not be considered restraint or seclusion. Example of these would be strollers, safety belts, swing safety belts, high chair lap belts, raised crib rails, and crib covers. Protective devices such as helmets are also not considered a restraint.

D. Forensic and Correction Restrictions

The use of restrictive devices, such as handcuffs, applied and monitored by law enforcement officials are not governed by restraint guidelines. However, restraint use related to clinical care for individuals under forensic or correction restrictions will follow these restraint guidelines. The forensic patient is the prisoner of the law enforcement officer, but the individual is the patient of the hospital; therefore, the hospital is responsible for the provision of safe and appropriate care.

E. Temporary Holds

Temporary holding for a procedure or test is not considered a restraint as long as the

patient’s right to refuse the treatment is being honored.

F. Protective Devices:

Protective devices or mechanisms intended to compensate for a specific physical deficit or prevent safety incidents not related to cognitive dysfunction. These include but are not limited to:

1. Helmets

2. Geri-Chairs (the patient has the skill/ ability to easily remove)

3. Side-rails (2 of 4)

4. Mittens applied to hands for scratching or pulling and are not secure to the

5. Bed frame.

G. Drugs / Medications

Drugs / medications used as a standard of treatment are not considered a restraint if the medication is used within FDA guidelines (including dosing), follows national practice standards and is based on the patient’s symptoms and overall condition. Medications used to enable (improve the patient’s ability to effectively or appropriately interact with the world) and not disable the patient are not considered a restraint.

H. Confinement on a licensed locked unit

I. Cribs / Canopies

Age appropriate cribs or canopies are not considered a restraint.

J. Devices with Multiple Purposes

Devices, which serve multiple purposes, such as a Geri-chair or side rails, when the result of the use is to restrict movement and cannot be easily removed by the patient, must be considered restraints.

K. Use of Side Rails

If the side-rails are raised and restrict the patient’s freedom to exit the bed, and the

patient cannot remove or release the side-rail, then the side-rails are considered a

restraint. Stretcher side-rails, because the side-rails are a safety intervention, are not

considered a restraint.

V. Patient Rights:

A. Each patient has the right to be free from restraints that are not medically necessary when alternative methods are sufficient to protect the patient or others from harm. Restraints shall be used only when alternative methods are not sufficient to protect the patient or others from injury. The least restrictive form of restraint will be used. Restraint or seclusion shall be ended at the earliest possible time.

B. The application or initiation of seclusion or restraint respects the patient as an individual. The decision to apply restraints is based on identified individual patient needs. Consideration is given to the impact on the individual’s rights, safety, dignity and well- being, which must be preserved during use of seclusion or restraint.

C. Restraint procedures are performed by competent staff following established guidelines, in accordance with safe and appropriate restraining techniques.

D. Each patient (and/or his or her representative) has the right to participate in the development and implementation of his or her plan of care.

E. Use of restraint or seclusion may never act as a barrier to the provision of safe and appropriate care, treatments, and other interventions to meet the needs of the patient. The patient must be able to continue his/her care and participate in care processes.

F. Each patient has the right to personal privacy, which includes at a minimum, that patients have privacy during personal hygiene activities (e.g., toileting, bathing, dressing) and during medical/nursing treatments. A patient’s right to privacy may be limited in situations where a person must be continuously observed, such as when restrained or in seclusion when immediate and serious risk to harm self or others exists.

G. Restraint procedures will be conducted in a manner to ensure the preservation of the individual’s modesty and prevent visibility to others

H. Each patient has the right to receive care in a safe setting, which provides protection for the patient’s emotional health and safety as well as his/her physical safety. Respect, dignity and comfort would be components of an emotionally safe environment. (e.g., the environment is kept safe and clean; a comfortable body temperature is maintained, etc.).

I. Care and treatment will demonstrate respect for the patient as an individual.

J. Contraindications to restraint/seclusion will be assessed and considered prior to use of restraint. Examples of contraindications to restraint use are sexual abuse history, frailty in the elderly, etc.

K. Patients, families, and/or significant others have the right to understand the rationales for restraints and the hospital philosophy regarding restraints.

L. Each patient has the right to be free from restraints of any form that are not medically necessary. Neither restraint nor seclusion shall be used for purposes such as coercion, discipline, convenience, or retaliation by staff. Any such use is explicitly prohibited.

VI. Types Of Restraints:

There are two types of restraint. A restraint is either Medical/ Surgical restraint

(Non-violent, Non-self-destructive) or Violent/ Self-Destructive Behavioral restraint. It is important to note that the requirements for each type of restraint is not specific to any treatment setting, but to the situation why the restraint is being used. Further, the decision to use a restraint is driven by the comprehensive individual assessment for the patient that concludes, that at that time, the use of less intrusive measures pose a greater risk that the risk of using a restraint, not by the diagnosis. Behavioral reasons for the use of restraints are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder with violent or self-destructive behavior. Restraint AND Seclusion used at the same time is only permitted if the patient is continually monitored by trained staff via audio AND video monitoring equipment.

|Violent/ Self-Destructive |Acute Medical and Surgical |

|Behavior |Restraint |

|In the case of a patient with cognitive impairment, such as Alzheimer’s Disease, which restraint standard (Violent/Self-Destructive Behavior |

|Standards or Acute Medical and Surgical) would apply? Two examples are offered for the sake of clarification. |

| | |

|Example1: A patient with Alzheimer’s Disease has a catastrophic |Example 2: A patient diagnosed with Alzheimer’s Disease has surgery for|

|reaction where he/she becomes so agitated and aggressive that he/she |a fractured hip. Staff determines that it is necessary to immobilize |

|physically attacks a staff member. He/ she cannot be calmed by other |the hip to prevent re-injury. The uses of less restrictive alternative |

|mechanisms, and his/her behavior presents a danger to themselves and |have been evaluated or were unsuccessful. |

|the other patients. | |

| | |

|The use of restraint or seclusion in this situation is governed by the |The use of restraint or seclusion in this situation is governed by the |

|Violent/Self Destructive Behavior Standard. |Acute Medical and Surgical Care Standard. |

VII. Procedures:

A . Staff Training and Competence:

Our facility ensures staff is trained and competent to minimize the use of restraint and

seclusion, and to use them safely when the use is indicated. Our facility assures the staff

providing training is qualified as evidenced by education, training, and experience in

techniques to address patients’ behaviors. Our facility leadership team assesses the

competence of staff in minimizing the use of restraint and seclusion prior to participation

in any use of restraint of seclusion, as part of orientation and on a periodic basis in orders

to use them safely, including:

1. The basic underlying causes of threatening behaviors exhibited by the patients

serve.

2. Aggressive behavior that is related to a patient’s medical condition and not

related to his/ her emotional condition, for example, threatening behavior that

may result from delirium in fevers or from hypoglycemia.

3. How their own behavior can affect the behavior of the patients they serve.

4. The use of alternative and/ or nonphysical interventions.

5. The initiation, safe application, and removal of restraints to include monitoring and

reassessment.

6. Recognizing signs of physical and psychological distress in patients who are

restrained or secluded.

7. Clinical identification of behavioral changes that indicate restraint or seclusion is no

longer necessary.

8. Monitoring of the physical and psychological well-being of a patient in restraint or

seclusion including respiratory and circulatory status, skin integrity, vital signs and

special requirement for the face-to-face evaluation

9. Documentation requirements

10. Physicians authorized to order restraint and seclusion should have a

working knowledge of hospital policies regarding restraint and seclusion.

11. The employee’s HR file must contain competency validation for safely

applying, monitoring and removing restraints before the employee

participates in any use of restraint or seclusion. A list of restraints that are

approved for use in this facility is developed as guidance for this competency

validation.

B. Assessment of Risk Factors:

A. A comprehensive assessment of the patient must determine that the risks associated with the use of restraint outweigh the risk of not using it. The use of an anatomical, physiological and psychological assessment for risk factors by the RN and / or the

Physician facilitates the limited, justified use of restraint/ seclusion. Planning for being proactive rather than reacting to the patient’s behavior protects the patient’s health and safety and allows for the implementation of preventive strategies that would be of the greatest benefit to the patient. Factors to consider as part of the assessment include, but are not limited to:

1. Degree of orientation to person, time and place.

2. Memory disturbances.

3. Fluctuating levels of awareness.

4. Alteration in sleep/ wake cycle.

5. Perceptual disturbance.

6. Pain or other discomfort.

7. Types and/or combination of medications which may be contributing to the behavior.

8. Types and/or combination of treatment modalities.

9. Physiological changes, such as oxygen perfusion, blood glucose changes, blood chemistry, etc., which may be causing or contributing to the altered behavior patterns.

10. Techniques, methods, or tools that would assist the patient control his/ her behavior.

11. Risks associated with vulnerable patient populations, such as emergency, pediatric, and cognitively or physically limited patients.

Restraint or seclusion use is limited to a situation in which there is imminent risk

of a

Patient physically harming him or herself, staff or others, and nonphysical interventions would not be effective.

Situations in which restraints/ seclusion are clinically justified include:

1. Harmful to self or others, major property destruction, and alternative measures have been attempted.

2. Threatens placement and/or potency of necessary therapeutic lines/tubes, interfering with necessary medical treatment and alternative measures have been attempted.

3. Patient is unable to follow directions to avoid self-injury and protective, alternative measures have been attempted.

C. Limiting the Use of Restraint or Seclusion

Our facility believes nonphysical techniques are the preferred intervention in the

management of behavior. Attempts should be made to evaluate and use interventions/

alternatives when possible and in response to the patient’s assessed needs:

1. Monitoring

a. Companionship; staff or family to stay with patient

b. Room near to or visible from the nursing station

c. Close, frequent observation, one-to-one when necessary

2. Environmental Measures

a. Decrease stimulation; quiet surrounding, appropriate lighting, relaxing

music

b. Call bell accessible at all times

c. Orientation / reorientation of patient to surroundings

d. Bed in low position with brakes locked

e. Rooms/ halls clear of obstacles and excess equipment

f. Use of bed alarm system

g. Availability of bedside commode

h. Familiar possessions/ photographs

i. Briefs over Foley

3. Comfort Measures

a. Address pain management or other source of discomfort

b. Comfortable positioning and clothing, keeping patient clean and dry

c. Reduce noise; avoid waking up patient during periods of sleep, if possible

d. Gentle touch, soothing voice

4. Interpersonal Skills

a. Pleasant, consistent interaction with patient and family

b. Actively listening to patient; calm reassurance

5. Staffing

a. Consider assessed patient needs/ behavior as well as patient / staff

safety when making assignments

b. Flexibility to allow for assignment changes as per patient needs/ behavior

c. Consistency in staffing (i.e. assigning staff familiar to patient as often as possible)

6. Regular Toileting

a. establish consistent toileting schedule; every two hours while awake, one to two times at night

b. encourage patient to ask for assistance at first feeling of toileting need;

respond to patient’s needs promptly and positively

c. check for constipation / full bladder as indicated

7. Education

a. Educate patient/ family/ significant other to patient deficits and have a

consistent plan of approach; re-educate/ remind them of goals/ potentials on an ongoing basis

b. Solicit patient/ family/ significant other for alternative measures

c. Provide patient/ family/ significant other with opportunities for control;

other choices

8. Diversion Activities

a. Distract patient with videos, TV, reading material; engage in conversation

b. Purposeful activities such as puzzles

c. Provide alternative activity for hands (i.e. Rubber ball, squeezing devices)

d. Sensory aids

e. Be sure patient has and is using eyeglasses, hearing aids

f. Provide alternative system for sensory deficits if needed

9. Medication / Nutrition

a. Assist in adjustment of treatment to stabilize physiological changes by

notifying physician

b. Discontinue all lines that may be no longer medically necessary and

initiate oral as appropriate from IV or NG

10. Reality Orientation and Psychological Intervention

a. Involve the patient in conversation . Do not talk over him/ her.

b. Explain procedures to reduce fear and convey a sense of calm

c. Provide reality links when appropriate (calendar, clock, etc)

d. Use relaxation techniques (warm bath, warm drink, etc)

e. Attempt to verbally redirect behavior

11. Interdepartmental Communication / Consultation

a. Occupation/ Physical/ Activities Therapy may be consulted by

staff to assist with activities planning to redirect behavior

b. Pharmacy may be consulted to review medication regimen

c. Respiratory Therapist may be consulted to review oxygenation

D. Notification of the Patient’s Family

Efforts are made to discuss the issue of restraint, when practical, with the patient and

family at the time that the restraint or seclusion is applied. In cases where the patient,

or surrogate decision maker, has consented to have the family kept informed regarding his or her care, and the family has agreed to be notified, staff attempts to contact the family promptly to inform them of the restraint or seclusion episode.

E. Orders for Restraint

Written or verbal orders for initial and continuing use of restraint and seclusion are

time limited.

1. The physician or on-call physician responsible for the care of the patient is authorized to order a restraint. Physicians authorized to order restraint and seclusion must have a working knowledge of hospital policy regarding restraint and seclusion.

a. Be for each use of the restraints and related to a specific episode of the

patient’s behavior and not for an unspecified future time or episode.

b. Contain a starting and ending time.

c. All verbal or telephone orders must be countersigned within 24 hours.

VIII. Behavioral Use Of Restraints: (Violent or Self Destructive Behavior)

These standards apply to any use of restraint or seclusion for behavioral health care reasons, regardless of location or setting within the hospital.

Behavioral health care reasons for the use of restraint or seclusion are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder. An emergency or crisis situation exists if the patient’s behavior becomes aggressive or violent and presents an immediate and serious danger to his/her safety or that of others and the least restrictive measure that will ensure the patient’s or other’s safety is restraint or seclusion. The use of restraint and seclusion poses an inherent risk to the physical safety and psychological well-being of the patient and staff. Therefore, restraint and/or seclusion are used only in an emergency, when there is an imminent risk of a patient physically harming him/her or others, including staff, and non-physical interventions would not be effective. Non-physical interventions are the first choice as an intervention, unless safety demands an immediate physical response.

A. Procedure/Methodology:

1. If the patient’s behavior meets the criteria of being a threat to hurt themselves or others, then restraints are required to protect the patient. The type of physical intervention selected must consider the information learned from the patient’s initial assessment. This should be verified and documented in the physician’s order using the Physician Order Sheet for Restraints or Seclusion.

2. If indicated, apply restraints according to hospital policy.

3. Document the physician’s order for restraint on the Physician’s Order Sheet for Restraint or Seclusion following the guidelines in Section B. below.

4. Once the patient is under control and safe, begin documentation on the Behavioral Restraint and Seclusion Flow sheet.

5. As early as feasible in the restraint or seclusion process, make the patient aware of the rationale for the intervention and the behavioral criteria for its discontinuation.

6. RN assessments are documented on the Behavioral Restraint and Seclusion Flow sheet following the Observation and Monitoring guidelines in Section C. below.

7. Once the patient meets the criteria for release as documented in the physician’s order, the restraint or seclusion is discontinued. The decision to discontinue the intervention must include a determination that the patient’s behavior is no longer a threat to himself/herself or others.

8. When seclusion or restraint is implemented, the patient’s plan of care must be modified to reflect this change.

9. Document in the patient’s medical record any injuries that occur during the restraint or seclusion episode, as well as the treatment provided for those injuries.

B. Authorization and Ordering of Seclusion or Restraint:

1. The physician, or another licensed independent practitioner as defined in Section 1.A. above, orders restraint or seclusion only when less restrictive measures have been found to be ineffective to protect the patient or others from harm.

2. In an emergency situation, this hospital authorizes a registered nurse trained in the use of seclusion/restraints to initiate the seclusion/restraint. As soon as possible after the initiation of restraint or seclusion, an order must be secured from a physician. The R.N. shall at this time consult with the physician regarding the patient’s physical and psychological status and in identifying ways to help the patient regain control so that restraint or seclusion may be discontinued.

In some emergency situations, the need for a restraint intervention may occur so quickly that an appropriate order cannot be obtained prior to the application of restraints. In these emergency situations the order must be obtained either during the emergency application of the restraint or immediately (without time interval) after the restraint has been applied.

3. A physician or specially trained registered nurse must see and evaluate the patient in-person within one (1) hour of the initiation of seclusion or restraints. A telephone call is not adequate. If the patient is released from seclusion or restraint in less than one hour, the face-to-face assessment must still be performed within the one-hour time frame. The physician or specially trained registered nurse should:

a. Assess the patient’s physical and psychological condition

b. Assess whether the restraint is still needed

c. Assess the cause of the incident

d. Assess if the restraint was appropriate to address the behavior

e. Work with the staff on ways to help the patient regain control

f. Revise the care plan as necessary

g. Documents his/her assessment of and plan of care for the patient

4. If the seclusion or restraint is ordered by a physician, coverage physician, etc. other than the treating physician (the physician who is responsible for the management and care of the patient), that physician should consult with the treating physician as soon as possible. This will allow the treating physician to impart any information from the patient’s history that may impact the seclusion or restraint episode (i.e., the patient having a history of being physically abused where seclusion or restraint may actually escalate their behavior).

5. "PRN" or "standing" orders for seclusion or restraint are unacceptable and will not be utilized to authorize the use of seclusion or restraint. Each episode of

restraint or seclusion must be initiated in accordance with the order of a physician. However, a temporary release that occurs for the purpose of caring for a patient’s needs, i.e., toileting, feeding, and range of motion, is not considered a discontinuation of the intervention.

6. Written and verbal orders for seclusion or restraint are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time but cannot exceed:

4 hours for adults 19 years or older;

2 hours for children and adolescents ages 9 to 17; or

1 hour for children under age 9.

7. After the original order expires (referring to the 4 hour - 2 hour - 1 hour order outlined in A. above), the physician or specially trained registered nurse is encouraged to perform a face-to-face reassessment of the patient. However, when the order is about to expire, the R.N. can telephone the physician, report the results of his/her most recent assessment (i.e. that the patient is still in crisis), and request that the original order be renewed for another period of time (not to exceed the established time limits). The original order may only be renewed in accordance with these limits for up to a total of 8 hours for ages 19 and over and 4 hours for patient ages of seventeen and under.

8. The physician conducts an in-person reevaluation at least every 8 hours for patients ages 19 years and older and every 4 hours for patients ages 17 and younger. Once a patient is placed in restraint or seclusion, a physician must see them face to face within 8 hours for patients 19 and older and within 4 hours for patients under 18. If a patient is released from seclusion or restraint, and then requires to be placed in seclusion or restraint again, a new order must be obtained.

9. A Registered Nurse ensures that seclusion and/or restraint is ended at the earliest possible time, using the behavioral criteria for release from seclusion/restraint defined for each individual patient.

Examples of behavioral criteria include, but are not limited to: Patient is no longer physically aggressive; Patient is no longer a safety threat to self or others; the patient’s behavior is no longer a threat to him/her 0self or others.

10. Contents of a seclusion or restraint order will include:

a. The type of restraint, device or seclusion employed

b. The maximum length of time restraint or seclusion may be utilized

c. The specific behaviors that present a danger to the patient or others which require the use of seclusion or restraint

d. The specific measurable behaviors, which must be exhibited by the patient in order for the seclusion or restraint to be discontinued.

C. Observation/Monitoring of the Patient in Restraint or Seclusion

1. The intent of monitoring the patient is twofold. First, monitoring evaluates the well being of the patient and the continued protection of their rights and dignity. Examples would include monitoring whether the patient is comfortable, too warm or cold, needs fluids, and whether his/her circulation is constricted. Second, monitoring evaluates the behaviors that precipitated the use of seclusion/restraint to determine whether the behavior is still present. This evaluation is used to decide whether restraint or seclusion is still required to protect the patient or others or whether the behavior has subsided and early release or a less restrictive method is now appropriate.

2. A patient in restraint or seclusion is monitored through continuous, uninterrupted in-person observation by an assigned staff member who is competent and trained to do so. In this hospital all Mental Health Associates are trained to do so. In other words, a staff member will be assigned to perform one to one, face to face observation of the patient. For a patient in restraint, this observation must be done in-person as long as the individual is in restraint. After the first hour, a patient in seclusion (without restraint) may be continuously monitored using simultaneous video and audio equipment, if consistent with the patient’s condition or wishes. For example, it may be more helpful and less disruptive to the patient if staff is not monitoring him or her by physically sitting in the seclusion room or watching through the window into the seclusion room. If monitors are used, there must be a staff member assigned to constantly view the video monitors with the audio engaged.

3. A staff member who is trained and competent assesses the patient at the initiation of restraint or seclusion and every 15 minutes thereafter. In this hospital, Mental Health Associates can perform this assessment. This assessment includes, as appropriate to the clinical needs of the patient and the type of restraint or seclusion, the following:

a. Signs of any injury associated with the application of restraint or seclusion

b. Nutrition/Hydration

c. Circulation and range of motion in the extremities

d. Skin integrity

e. Vital signs, respiratory and cardiac status

f. Hygiene and elimination

g. Physical and psychological status and comfort (including pain)

h. Readiness for discontinuation of restraint or seclusion

Patients are continually monitored but documentation is performed every 15

minutes. Some physical assessment of the patient must be conducted immediately

after restraint or seclusion is initiated, and as appropriate to the patient’s

condition, needs, and the type of seclusion or restraint.

4. The patient in restraint or seclusion must be offered frequent opportunities for fluids and nourishment, toileting and elimination, range of motion and exercise of limbs.

5. If a patient is in a physical hold, a second staff member must be assigned to observe the patient.

6. Staff provides assistance to the patient to meet behavioral criteria for discontinuing restraint or seclusion.

D. Additional Requirements:

1. Staff who have direct patient contact will have ongoing education and training in the proper and safe use of seclusion and restraint, as well as techniques and alternatives to handle the symptoms, behaviors, and situations that have traditionally been treated through the use of restraint or seclusion.

2. If the patient has consented to have his/her family kept informed about his/her care, treatment, and services, and the family has agreed to be notified, staff must attempt to contact the family promptly to notify them of the restraint or seclusion episode.

3. The patient and staff must participate in a debriefing about the restraint or seclusion episode as soon as possible and appropriate, but no longer than 24 hours after the episode. The patient and, if appropriate, the patient’s family participate, with staff members who were involved in the episode and who are available, in the debriefing about each episode of restraint or seclusion. The debriefing is used to do the following:

a. Identify what led to the incident and what could have been handled differently

b. Ascertain that the patient’s physical well-being, psychological comfort, and right to privacy were addressed

c. Counsel the patient for any trauma that may have resulted from the incident

d. When indicated, modify the patient’s plan for care, treatment, and services

4. In the event of patient injury or death that may be reasonably assumed to be related to restraint or seclusion, refer to the “Sentinel Event Response and Reporting Policy” for direction.

5. Any patient who expires while in restraints or was in restraints in the seven days prior to death should be reported to the Patient Safety Hotline at ext. 5309.

IV. Medical Use Of Restraints (Non Violent)

Restraint may only be used when clinically necessary to improve the patient’s well-being and when other less restrictive measures have been found to be ineffective to protect the patient from harm. Restraint must be implemented in the least restrictive manner possible. A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint outweigh the risk of not using the restraint. Evaluation of whether devices should be used as restraints must include how they benefit the patient, and whether a less restrictive device/intervention could offer the same benefit at less risk.

A. Assessment of the Patient :

1. Initial assessment is conducted to identify potentially harmful behavior

2. History of behavior

3. Current behavior

4. Physical and cognitive status

5. Circumstances that led to consideration of restraint or seclusion use.

6. Current Risk Factors associated with observed behavior

7. Risk of restraint use versus benefits of the restraint to the patient

8. Patient / Family concepts / Feelings about restraints

9. Determination of least restrictive intervention and rationale for selection

10. Consideration of less restrictive alternatives tried and/or failed in the past, including failure of non-physical interventions

11. Physical status related to restraint use:

a. Vital signs for relevance to the physical safety of the use of restraint

b. Nutritional and hydration needs

c. Circulation status

d. Range of motion status

e. Hygiene needs

f. Elimination needs

B. Authorizing and Ordering :

1. Restraint orders be dated and timed when signed by the physician and should include the

type of restraint used, reason for restraint, criteria for release, and specifies the duration

of the restraint order.

2. If the restraint continues to be clinically justified, continued use of restraint beyond the

first 24 hours must be authorized by the physician. Restraint orders must be renewed each

calendar day. A face to face examination by the physician at least every 24 hours

determines the clinical justification for the continued use of restraint.

3. If the ordering physician is not the attending physician, the attending physician must be

consulted as soon as possible. The attending physician may have information regarding

the patient’s history significantly impacts the use or selection of restraint.

4. Restraint orders are never written on an “as needed” basis, PRN orders, standing orders,

protocols.

5. Trial releases are not permitted and are to be considered discontinuation of the restraint.

C. Monitoring:

When restraint is used, there is an increased need for patient monitoring to assure patient

safety that the least restrictive methods are used, and use is discontinued as soon as possible.

Restraint is initiated only with the order of a physician. The order is time limited

not to exceed 24 hours and includes the specific reason for the restraint(s).

In emergent situations, and when a physician is not readily available, a Registered Nurse competent in medical restraint use may initiate restraint based on an appropriate assessment of

patient needs. This comprehensive assessment shall include a physical assessment to identify medical problems that may be causing a change in the patient’s behavior. If the restraint is applied in an emergent situation, the order must be obtained either during the emergency application of the restraint or immediately after the restraint has been applied.

1. Immediately after restraints are applied, a qualified registered nurse makes an

assessment to ensure restraints were properly and safely applied, and applied

in a manner so as not to cause harm or pain.

2. A qualified Registered Nurse must assess the patient at established timeframes.

Assessment, as appropriate to the type of restraint includes:

a. Signs of injury associated with the application of restraint(s)

b. Nutrition / hydration

c. Circulation and range of motion in the extremities

d. Vital signs

e. Hygiene and elimination

f. Physical and psychological status and comfort

g. Cognitive functioning

h. Readiness for discontinuation of restraint

3. Ongoing monitoring is performed. Monitoring includes, but is not limited to:

a. That the patient’s rights, dignity and safety are maintained

b. That the least restrictive method possible is used

c. Changes in the patient’s behavior or clinical condition needed to initiate

d. Restraint removal

e. The appropriate application, removal, or reapplication of the restraint

4. Care is provided at least every 2 hours to include:

a. Offer of fluids / nourishment

b. Hygiene care as required

c. Toileting as required

d. Release of extremities and provision of range of motion exercises

D. Documentation:

All actions taken regarding restraint and/or seclusion must be documented in the patient’s medical record.

1. Documentation in the patient’s medical record should indicate a clear progression in

techniques are implemented with less intrusive restrictive interventions attempted (or considered prior to the introduction of more restrictive measures) for each episode of restraint.

a. Patient assessment prior to the implementation of restraints.

b. Rationale for the use of restraint or seclusion

c. Behavior that met criteria for implementing or discontinuing the use of restraint

d. Evidence that alternative or least restrictive methods have failed, or the patient’s behavior clearly indicates alternative methods would not provide for the safety of the patient, other patients, or staff.

e. Type of intervention used, including assurance that method of restraint chosen is the least restrictive device according to individual needs.

f. Physician notification immediately of any significant change in condition.

g. Results of patient monitoring.

h. Patient’s response to the use of restraint.

i. Restraints should be ended at the earliest possible time. The documentation should include the end time, patient response, and any action taken.

j. Reassessment and documentation of ongoing need for restraint prior to obtaining a new order for restraint.

k. Discontinuation of the restraint for more than range of motion or personal care will be considered a discontinuation of the restraint and will require a new order for restraint.

l. Patient assessment and patient care interventions provided should be documented no more than every 2 hours.

The use of restraints should be included in the patient’s daily plan of care and include interventions and actions necessary to decrease or discontinue the restraint.

E. Patient Needs:

1. Restraint may not act as barrier to the provision of safe and appropriate care, treatments and other interventions to meet the needs of the patient.

2. The plan of care will not be compromised by the use of restraints and shall include:

a. Provision of nutritional needs

b. Provision of hydration needs

c. Provision of elimination needs

d. Provision of hygiene needs

e. Provision of exercise and range of motion

f. Provision of patient safety and comfort

g. Discuss restraint, when practical, with patient and family at the time of

use.

F. Reporting of Restraint Related Death

1. Any patient who expires while in restraints or within 7 days of having been in restraints must be reported.

a. Staff RN will report to Clinical Coordinator or Charge Nurse.

b. Charge nurse or Clinical Coordinator will report the death to the Patient

Safety line. (5309).

Section Five: Performance Improvement And Competency

A. Performance Improvement:

1. The Governing Board, Medical Staff and hospital leadership are responsible and accountable for ensuring that quality and performance improvement efforts address the priority for improved care and safety. This hospital has established a priority for performance improvement activities that focuses on the high risk area of restraint and seclusion. The hospital collects data that measure the performance of potentially high-risk processes such as restraint and seclusion.

Example: CNO or designee reviews daily all use of restraints and reports his/her analysis through the hospital’s performance improvement processes, including reports to Medical Staff and Governing Board.

2. Medical Staff Roles and Responsibilities include the continuous assessment and improvement of the quality of care and treatment. Physicians participate in measuring and assessing the use of restraint and seclusion for all patients in the hospital.

3. The hospital must ensure that each patient’s right to be from restraints is protected and must take actions to comply with requirements through its Quality and Performance Improvement activities. Hospital leadership will assess and monitor the use of restraint and seclusion, implement actions to ensure only medically necessary restraints are used. One suggested methodology is to maintain a restraint and seclusion log.

4. Non-behavioral restraints

a. Data regarding use of non-behavioral restraints is collected to assist the facility in measuring and assessing restraint use to identify opportunities to introduce preventive strategies, alternatives to use, and process improvements that reduce the risks associated with restraint use. [Refer to Performance Improvement Plan for Restraint Reduction.

b. Data on all non-behavioral restraint episodes are collected from and classified for all settings/units/locations by the following

1. Patient identifier (e.g., name, record number, account number)

2. Shift

3. Staff who initiated the process

4. Date and time each episode was initiated

5. Day of the week each episode was initiated

6. Length of episode of restraint

7. Type of restraint use

8. Whether injuries were sustained by the patient or staff

9. Age of the patient

10. Gender of the patient

5. Behavioral restraint or seclusion

a. Data regarding use of behavioral restraint or seclusion is collected to monitor and improve its performance of processes that involve risks. Data is used to do the following:

1. Ascertain that restraint and seclusion are used only as emergency intervention

2. Identify opportunities for incrementally reducing the rate and increasing the safety of restraint and seclusion use

3. Identify any need to redesign care processes.

b. Data on all behavioral restraint and seclusion episodes are collected from and classified for all settings/units/locations by the following:

1. Patient identifier (e.g., (e.g., name, record number, account number)

2. Shift

3. Staff who initiated the process

4. Length of each episode

5. Date and time each episode was initiated

6. Day of the week each episode was initiated

7. Type of restraint used

8. Whether injuries were sustained by the patient or staff

9. Age of the patient

10. Gender of the patient

c. Information obtained and documented from debriefings shall be used in performance improvement activities.

d. Particular attention shall be paid to the following:

1. Multiple instances of behavioral restraint or seclusion experienced by a patient within a 12-hour time frame

2. Number of episodes per patient

3. Instances of restraint or seclusion that extend beyond 12 consecutive hours

4. Use of psychoactive medications as an alternative for or to enable discontinuation of restraint or seclusion

References:



• HAS Patient Care Standards: Restraint and Seclusion

• Frequently Asked Questions: Restraint and Seclusion

.gov

• Hospital Conditions of Participation 482.13 (e) & (f)

• Skilled Nursing Conditions of Participation



• “Learning from each other: Success Stories and Ideas for Reducing Restraint and Seclusion in Behavioral Health.”

Special Considerations Associated with Special/Vulnerable Populations

1. There are risks involved in any physical intervention. Therefore, the risks should always be considered when the danger presented by the patient’s behavior outweighs the risks of physical intervention.

2. The initial assessment of each patient upon admission assists in obtaining information about the patient that could help minimize the use of restraint or seclusion as well as reduce the inherent risk to the physical safety and psychological well-being of the patient.

3. Patients with pre-disposing risk factors include, but are not limited to, patients with the following:

a. Pregnancy

b. Asthma

c. Smoker

d. Head or spinal injury

e. History of fracture

f. History of surgery

g. Deformity

h. Seizure disorder

i. Obesity

j. Geriatric

k. Children

l. Abuse – physical, emotional, sexual, rape

4. Restraining a patient in a supine position may predispose the patient to aspiration.

a. If the patient must be restrained in the supine position, ensure that the head is free to rotate to the side, and when possible, the head of the bed is elevated to minimize the risk of aspiration.

b. Have suction equipment accessible and ready for immediate use.

5. Restraining a patient in a room that is not under continuous observation by qualified staff increases the risk of injury to the patient.

6. Equipment related factors may increase the risk of injury to patient:

a. Use of split side-rails without side-rail protectors

b. Use of a high-neck vest

c. Incorrect application of a restraining device

d. Monitor or alarm not working or not being used when appropriate.

7. Risk of bed-rail entrapment is increased for patients with any of the following:

a. Confusion or other cognitive impairment

b. Sedation

c. Restlessness

d. Lack of muscle control

e. Small physical size

8. Restraint related positional asphyxia occurs when the person being restrained is placed in a position in which he/she cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart.

a. Face down (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breath are extremely dangerous and should be avoided at all times.

b. This includes a seated or kneeling position in which the person is being restrained is bent over at the waist and any face down position on a bed or mat.

9. Geriatric Patients

a. Increased risk of strangulation in vest restraints. This facility does not allow the use of vest restraints for this reason.

b. Increased risk of bed-rail entrapment.

c. Ensure airway is unobstructed at all times. Ensure there are no loose items around the patient’s head such as bed linens, towels or any type of plastic linen protection.

d. Special consideration must be given to bowel and bladder function, skin integrity, and risk of falls.

10. Patients at Risk for Self Harm or Suicide

a. Complete suicide risk assessment upon admission, and as defined in suicide risk assessment policy.

b. Patients with identified suicide risk will and unable to contract for safety, actively trying to harm self will be under direct observation.

c. Ensure safe care environment by detecting and securing contraband such as sharps, matches, drugs, etc.

11. Cognitive Impairment

a. Because of increased risk of injury related to bed-rail entrapment and strangulation, it is recommended that patients with significant cognitive impairment be constantly monitored while in restraint.

12. Pediatric Patients

a. Ensure correct type and size of restraint is used specific to the size, weight, and developmental age of the patient.

13. Drug Overdose (Drug Abuse)

a. Ensure safe care environment by detecting and securing contraband such as drugs, alcohol matches, etc., including access from family and friends.

b. At risk for asphyxia due to sedation.

c. At risk for aspiration or strangulation due to vomiting.

Patients with deformities, fractures, injury or physical limitations that preclude proper application of restraining devices.

a. Assessment will include physical variances that could impact the proper application of restraint device

b. If the physical variances do not allow for the safe application of the restraint device, other less restrictive interventions must be implemented to ensure the safety of the patient.

c. High vest and waist restraints will Not be used

14. Smokers

a. Ensure that all smoking materials are removed from patient’s access, including access from family and friends.

b. Patient / family education regarding the risk associated with smoking while in restraints.

15. Obesity

a. Excessive weight increases risk of asphyxiation in either the prone or supine position.

References:

▪ JCAHO Sentinel Event Alert: Preventing Restraint Deaths, Nov. 18, 1998

▪ Learning From Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health; APNA/APA/NAPHS

▪ Non-Violent Crisis Intervention Training Program, Crisis Prevention Institute, Inc.

▪ JCAHO Sentinel Event Alert: Bed rail entrapment deaths, Sept. 6, 2002

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download