Restraint Update 2016

For questions contact:Weddy Balmaceda, MSN, RN-BC, CCRN, CCDS

Professional DevelopmentExt. 5241

Source: RBMC policy and procedures

Objectives

• Review types of restraints• Review RBMC policy regarding use of restraints

& seclusion• Review documentation: Physician Order form,

Restraint flow sheet, Occurrence Screening form

RBMC Policy

• All patients have the right to be free from restraints or seclusion.

• Use of restraints or seclusion is an exceptional event, not a routine response to condition or behavior.

• Restraints or seclusion are initiated only after alternatives have been attempted and proven unsuccessful.

Indications for Use

• Non-Violent: Disruption of treatment

• Violent, Self-Destructive: Threat of violence or self-destructive behavior

Types of Restraints• Physical Restraint

• Drug Used as Restraint

• Therapeutic Hold

• Seclusion

Physical Restraint

Any manual method, physical device, material or equipment attached or adjacent to patient’s body, with or without the patient’s consent that: • Prevents free bodily movement to a position of choice• Restricts freedom to move arms, legs, body or head freely• Restricts normal access to his/her body• Patient cannot easily remove in the manner in which it was

appliedNote: Devices or practices that serve multiple purposes such as Geri Chair with locked tray or 4 raised side rails constitute a restraint when they restrict movement and cannot be removed by the patient.

Drug used as a Restraint

Drug/medication used to control behavior or restrict the patient’s freedom of movement that is not a standard treatment or dosage for the patient’s medical or psychiatric condition. Drugs are NEVER to be used as a restraint.

Therapeutic Hold

Holding a patient in a manner that restricts movement without the patient’s consent

Seclusion as a Restraint

Involuntary confinement of a patient alone in a room or area which the patient is physically prevented from leaving.• May only be used for the management of violent or

self-destructive behavior.• Can only be used in the Behavioral Units

Restraints and seclusion are not to be used simultaneously.

Exceptions

• Positioning or Securing Devices – used with patient’s consent to maintain position, temporarily immobilize during medical, dental, diagnostic or surgical procedures

• Age or developmentally appropriate safety devices –devices (stroller, safety belts, high chair lap belts, raised crib rails and crib covers) which a safety conscious childcare provider utilize to protect infant, toddler or preschool-aged child.

• Law enforcement restraint devices – i.e. handcuffs are not considered restraint.

Exceptions

• Four Side RailsUse of all 4 side rails would not be considered a

restraint in the following situations: - If a patient is not physically able to get out of bed

regardless of whether the side rails are raised or not.- A patient on seizure precautions- Infant or toddler in a crib with raised rails- A patient on a stretcher – increased risk of falling without

side rails raised.

Licensed Independent Practitioner

The following LIPs may initiate/discontinue restraint orders in accordance with policy:

• MD• DO• NP/CNS (as per hospital privileges• PA (as per hospital privileges)

Alternatives to Restraints

Providing companionship/supervisionChanging or eliminating treatments when feasibleModifying the environmentReality orientation and psychosocial interventionsDiversionary/physical or structured activitiesBehavior modification

Alternatives must be considered and documented as to effectiveness or lack thereof.

General Considerations• Restraints are contraindicated when precluded by patient’s clinical

condition• Restraints are not to be used as punishment, coercion, discipline,

retaliation or as a convenience to staff, or for forensic cases.• Progressive range of procedures must be used from the least

restrictive to the most restrictive.• Patient belongings are inspected for potentially dangerous objects

e.g. lighters, pocketknives prior to application of restraints.• Only LIP (or R.N. in an emergency) may initiate restraints or

seclusion, and must be present to monitor and evaluate the application.

• PCAs, security and other qualified clinical staff may participate in the application under the direction of the LIP or R.N.

Commonly Used Restraints

• Mitts (If pinned to bed or restrict free movement of hands and fingers)

• Soft limb restraints• Geri chair with locking tray• Full side rails• Leather limb restraints• Chest vest• Velcro (Behavioral Health Units only)

Application

• R.N. may initiate restraints in an emergency:- Following a clinical assessment- When alternatives and less restrictive interventionshave been tried and deemed ineffective.

• R.N. must notify LIP immediately to obtain order and for a face to face evaluation to be completed within one hour for violent/self destructive restraint application.

Orders• LIP shall utilize the Restraint Order Sheet.• Order must include:

1. Indication for use (Non-violent or Violent/Self-destructive)2. Type of restraint3. Number of extremities4. Length of time5. Criteria for removal6. Signature, date and time by physician or other LIP

• Orders must never be written as a standing order or as a PRN order

If ordered by another LIP, the attending physician must be notified as soon as possible, no later than 24 hr. of restraint use.

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Restraint Order: Time Limit

Non-Violent (Disruption of treatment): Every 24 hours

Violent, Self-destructive (Threat of violence or self-destructive behavior):

Every 4 hours for patients ages 18 years and overEvery 2 hours for patients ages 9-17 yearsEvery 1 hour for patients under 9 years of age

Criteria for Removal

• Agitation is decreased• Patient is able to verbalize behavior leading to

restraint/seclusion and expectation for release• Patient is in control of behavior; no longer harm to self

or others• Other, individualized criteria

Evaluation by LIP

• For Violent, Self-Destructive Restraints only• Face to face evaluation of patient by the LIP within one

hour of the order • Documentation includes: Description of patient’s behavior and immediate situation

that warranted use of restraint Alternatives or less restrictive interventions attempted Assessment of medical and behavioral condition Patient’s response to intervention used, and rationale for

continued use or termination of intervention.

Evaluation by LIP

• For both Violent, and Non-Violent Restraints• Face to face evaluation of patient by the LIP at least

once every 24 hrs. Changes in patients clinical status must be recorded.

• A new order must be obtained if use of restraints continues beyond the time limited order; however the face to face evaluation is only required every 24 hrs.

• If restraints are discontinued and patient has to be restrained again, a new order must be written. LIP must assess the patient within one hour if for violent, self-destructive behavior.

Nursing Care• Comprehensive patient assessment upon initiating restraints• Assessment and nursing interventions as follows:

Every 2 hours:Mental status, Cognitive functionCurrent behaviors indicating need for restraintsCirculation and skin assessmentRelease of restraints for skin care and range of motionComfort needs (fluids/nutrition offered, repositioning, toileting)Decision making with re-evaluation for continuing need for restraintsIf on chest vest: monitor every one hour from 10pm to 6am

Every 4 hours: Ambulation if clinically feasible Every 12 hours: Vital signs (More frequently if needed) Every 24 hours: Hygiene needs

Visual ObservationNon-violent: Based on nursing assessment, visual observation continuous or periodic. Document at a minimum every 2 hours.

Violent, Self-Destructive: Must be continuously monitored by assigned team member. Document every 15 minutes.

Plan of Care1. Modify the Interdisciplinary Plan of Care to reflect use of

restraints/seclusion.2. Debriefing of patients released from violent or self-destructive

behavior

Debriefing

• For patients released from restraints for violent or self-destructive behavior

• To be done as soon as possible but not more than 24 hours after the restraint/seclusion episode.

• Discussion include:Factors that led to the restraint/seclusionSteps to reduce the potential for future need of

restraint/seclusionClinical impact on patientWays the situation could have been handled differentlyDocument the debriefing meeting on the Restraint Flow

Sheet

Removal Guidelines• Restraints may be removed in accordance with the original order• Must be discontinued at the earliest time possible, regardless of

length of time identified in the order.• Time of removal and behavior that supports removal should be

documented in the Restraint Flow Sheet

Reapplication• If patient is recently released from restraints and exhibits behavior

that can only be handled by the reapplication of restraints, the R.N. may initiate restraints. This is considered a new episode and the LIP must be notified immediately to respond within one hour for a new order and face to face evaluation for violent, self-destructive restraint.

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Notifications

• Clinical leadership (Charge nurse, nurse manager, and/or nursing supervisor) is notified daily of patients in restraints.

• Security should be notified for any application/removal of behavioral restraints.

• If patient consents, the patient’s family, guardian or significant other will be notified of the need for use of restraints as soon as possible but not longer than 24 hours after application.

• Document the notification or refusal by patient on the flow sheet.

Documentation

Documentation will include, but not limited to:• Order• Face to face evaluation by Physician/LIP• Flow Sheet: All sections must be completed on an ongoing

basis• Plan of Care: Must be modified to reflect use of restraints

Violent, Self-Destructive Non-Violent Behavior

Order Parameter(Time Limit)

Adult: 4 hours9-17 y/o: 2 hours< 9 y/o: 1 hour

24 hours

Evaluation by LIP Face to face evaluation within1 hour of initiationDocument – Restraint Order form

Face to face evaluation not required

Visual Observation

Continuous monitoring At least every 2 hoursAt least every hr. 10pm-6am if wearing chest vest overnight

Documentation At least every 15 minutes At least every 2 hoursEvery hr. if on chest vest 10pm-6am

Debriefing To be done ASAP but no later than 24 hours after the restraint/seclusion episode

Not required

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Infection Control

• Universal precautions for all patients• Soiled restraints are to be changed promptly• Send leather restraints to Central Processing for cleaning.• In emergency situations, leather restraints may be cleaned

between patients following manufacturer’s recommendations, e.g. cleaned with soapy water and allowed to air dry.

• Velcro restraints will be cleaned following manufacturer’s recommendations.

• All other restraints will be discarded

Reporting Requirements

Any death associated with the use of seclusion or restraint is to be reported as soon as discovered to clinical leadership and to Risk Manager. Includes death that occurs: • While patient is restrained or in seclusion, or• Within 24 hours after the patient has been removed from

restraints or seclusion, or• Within one week of restraint removal where it is reasonable to

believe that the use of restraint contributed to the death

Administrative RequirementsOccurrence Screening Form: To be completed if a patient is in restraints for violent, self-destructive behavior for more than 12 hours or has 2 or more episodes within 12 hours. • Send form to Clinical Outcomes Department• Send copy to Director of Nursing Quality, Research and Resources.

Serious, preventable adverse events: Any patient death, loss of body part, disability, or loss of bodily function lasting more than 7 days or still present at discharge.

• Complete Incident Report and send to Risk Management• Must be reported to New Jersey Department of Health and Senior Service

within 5 days after the event is discovered.• The NJDHSS Report of Serious Preventable Adverse Events in a New

Jersey Health Care Facility form will be completed by Risk Management• Risk Management will coordinate Root Cause Analysis (RCA)• RCA must be completed within 45 days as per the NJ Dept. of Health and

Human Services Patient Safety Initiative

Administrative RequirementsReporting of Death: that occurs under the following circumstances must

be reported to CMS– While the patient is in restraints/seclusion– Within 24 hours after the patient has been removed from restraints or

seclusion– Known to the hospital that occurs within 7 days after restraints/seclusion

where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death. To be completed if a patient is in restraints for violent, self-destructive behavior for more than 12 hours or has 2 or more episodes within 12 hours.

• Immediately notify nurse manager &/or nursing supervisor.• Initiate the form “Report of Hospital Death Associated with Restraints or

Seclusion” prior to end of shift, and send to Risk Management.• Risk Management will:

– Contact CMS Regional Office no later than the close of business day following knowledge of death

– Complete the Hospital Death Report Worksheet & send information to CMS– Document in the medical record regarding the report of death to CMS,

including date and time reported to CMS