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RESTRAINTSECLUSION&

2009

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Restraint and seclusion are emergency protective measures.

Our standards articulate the vision of: Eliminating and/or reducing use of these

restrictive measures. Application only in emergencies that pose an

immediate risk of harm. Responsibility to facilitate the discontinuation of

restraint or seclusion ASAP. Preserving the patient’s safety and dignity when

restraint or seclusion is used.

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Definition Restraint:

Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body, or head freely or restrict the patient’s freedom of movement and is not a standard treatment for patient’s condition.

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Definition Seclusion:

Involuntary confinement of the patient alone in a room or an area where the patient is physically prevented from leaving.

Does not include confinement on a locked unit where the patient is with others.

May only be used for the management of violent or self destructive behavior.

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Restraints Certain characteristics of patient are more

strongly associated with the use of physical restraints. Advanced age, disruptive behaviors, the

presence of invasive devices, and cognitive impairments are associated with greater use of restraints.

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Situations for Restraint? Interference with treatment

The use of restraints to prevent treatment interference has historically been based on the goal of protecting patients from harm associated with unskilled removal of a device.

Several studies have found that patients who self-extubate do so despite their being restrained. In addition, re-intubation is not required in 50%-89% of patients with unplanned extubation*

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Situations for Restraint? Fall Risk

Serious injuries from falls occur more commonly with restrained patients.

Behavior Restraints intensify behavioral symptoms,

making it extremely difficult to assess the true meaning of patient behavior.

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Risks of Restraint Significant injury risk with the use of

physical restraints are substantial and well documented.

Epidemiologic studies conducted over the span of many years establish that the likelihood of morbid results, including serious injurious falls, increases significantly with the continued use of physical restraints.

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RETHINK RESTRAINTS

“HEY! I THINK HE JUST MOVED! ADD ONE MORE!”

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Rethink Restraints Patients who are restrained do fall and may

sustain more serious injury because part of their body is tied to the bed or because they fall from a greater height after climbing up and over a side rail.

Patients have died as a result of being suspended from beds or chairs by straps or vest restraints, and by being entrapped in side rails.

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Rethink Restraints Injuries occur with regularity when patients

try to climb over side rails to get out of bed, strangle, and suffocate or otherwise lose bodily control. This may be due to improperly applied restraints or because staff neglected to monitor and adjust restraints as needed at specific timely intervals.

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Rethink Restraints The risk of patients injuring themselves,

sometimes fatally while becoming agitated and trying to escape from their restraints, is real.

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Rethink Restraints Restrained individuals often feel humiliated.

They may become depressed, withdrawn or agitated when freedom of movement is taken away from them.

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Rethink Restraints Restraints pose special risks

for people who are agitated, or who may fall while attempting to escape their restraints.

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FACTS

“ Restraints may be used to protect a patient from a greater risk of harm,

although evidence is lacking to support the effectiveness of using

physical restraints to prevent treatment interference.”

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FACTS Studies have repeatedly demonstrated that

there is no increase in serious injuries when physical restraints are replaced with other less restrictive safety measures based on the individual’s specific needs.

Studies have also demonstrated a dramatic decrease in behavior problems when restraints are removed.

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PROACTIVE STRATEGIES

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Least Restrictive Efforts must be made to use the

least restrictive available method of restraints and to restore each individual to his or her maximum possible level of independence.

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Identify alternatives Physiologic cares, such as attention to

comfort, pain relief, positioning, oral feedings in lieu of intravenous or enteral nutrition.

Close observation by staff (i.e. moving them to a room by the nurse’s station).

Environmental manipulation, such as increased light or presence of accessible call light or other means of communication.

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Identify alternatives Personal strengthening and

rehabilitation program. Use of “personal assistance”

devices such as hearing aids, visual aids and mobility device.

Use of positioning devices such as geri-chair, body and seat cushion.

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Identify alternatives Efforts to design a safer physical

environment, including the removal of obstacles that impede movement, placement of objects and furniture in familiar places, lower beds, use of bed alarms and adequate lighting.

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Types of Restraint Medical Restraint Behavioral Restraint

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MEDICAL RESTRAINT

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Medical Restraint: Indications Medical Restraint may be used for the following

indications when restrictive means would not be effective in protecting the patient: The patient is pulling tubes, lines or dressings. The confused patient is interfering with the provision of

care. The patient’s actions are endangering themselves. The patient’s diagnosis or condition is such that they

maybe unpredictably and suddenly awaken and harm themselves.

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Medical Restraint: Physician Order An order for restraint must be obtained from one of the

following : Attending Physician, Fellow, Medical Resident (except

first year) When physician is not available to issue such an order,

then restraint use may be initiated by a RN based on an appropriate assessment of the patient.

Physician order is required within 12 hours after initiating a restraint.

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Medical Restraint: Physician Order Telephone orders must be countersigned, dated

and timed within 24 hours of restraint initiation. Orders must be renewed if indicated after

assessing patient on each calendar day. PRN orders are not permitted.

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Medical Restraints: Safe Application Safe application of restraints

Ensure restraints are not too tight. Test to ensure two fingers can be inserted in between

restraint and skin. Note “front” and “back” of the vest restraint and apply

correctly. Pad any bony prominences. Use a knot that can be easily be released (half-bow). Secure restraints to the bed frame, never to bed rails or

mattresses.

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Medical Restraints: Risks Agitation Loss of Muscle tone Reduced Bone Mass Pressure Sores Decrease Mobility Stiffness

Falls Strangulation Frustration Loss of Dignity Incontinence Constipation

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Medical Restraints: Assessment The nurse must assess response every 2 hours

and PRN. The nurse should assess the patient’s clinical

condition every 2 hours, including skin integrity, skin color, and circulation.

If four-point restraints are applied, all above assessment should be made every 15 minutes.

If vest is used the nurse should assess the vest is non-restrictive of respiratory efforts.

The nurse should assess the need for restraint every 4 hours.

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Medical Restraints: Assessment Closely monitor restrained patients

Implement and document all appropriate interventions every two hours.

Visual / safety check Range of motion / Exercise and restraint release Repositioned with full ROM except during sleep

periods Offer bedpan / urinal Offer Nutrition / fluids if medically allowed

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Emergency Preparedness Staff are required to have a

current CPR card when caring for patient’s with restraints.

Be prepared to perform first aid techniques. In case of Emergency, Dial 3333 for Rapid

Response Team or Code Blue Team. Specify your exact location.

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Medical Restraints: Patient / Family Involvement

Efforts shall be made to discuss the issue of restraint, when practical, with the patient and the family around the time of use.

Document that the patient and patient’s family were informed about the use of restraint on the pink education form.

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Medical Restraints: Evaluate Need A trial “out of restraints” must be used once the

patient demonstrates appropriate behaviors (as defined in the physician orders). For example, the nurse may remove restraint as a trial,

during treatments, while the family is at bedside, or in situations where the patient’s safety may be assured using less restrictive means. Should these less restrictive interventions become ineffective or not applicable, restraints may be reapplied as long as the enabling restraint order remains in effect.

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Medical Restraints: Evaluate Need Early Release Criteria

Behaviors that led to the order of restraints are reduced.

Mental status / judgment improved.

A family member / sitter, available to be with the patient, is able to maintain the patient’s safety.

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BEHAVIORAL RESTRAINT

(VIOLENT / AGGRESSIVE BEHAVIOR)

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Behavioral Restraint Is the restriction of patient movement in response

to severely aggressive, destructive, violent or suicidal behaviors that place the patient or others in imminent danger.

Seclusion Involuntary confinement of the patient alone in a

room or an area where the patient is physically prevented from leaving.

Definition

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FACTS Medications that are designed to put a

person to sleep, and not treat the underlying condition, are considered chemical restraint.

Texas law forbids the use of “chemical restraints”.

Sedatives and psychotropic medications are used only if they are addressing a specific patient problem, not for restraint.

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Behavioral Management Prevention is always easier and more

effective. Careful patient assessment can identify risk

factors for violence, including trigger, previous restraint and seclusion history and trauma and abuse history.

Identify effective coping strategies used by the individual to safely manage behavior.

Involve patient in developing de-escalation or safety and support plan .

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Seclusion and Restraint: Reduction Plan Safety

Assure the individual’s physical and emotional well-being via interventions such as modifying the environment to reduce stimuli and induce a calming ambience.

Support Involves listening and talking in a supportive

way, offering comfort measures or whatever is needed to the individual, and using verbal de-escalation.

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Seclusion and Restraint: Reduction Plan

Structure technique Limit setting, convey behavioral expectations and

aid in constructive problem solving.

Symptom Management Aimed at specific symptoms including stress and

relaxation measures, diversionary activities, or medication.

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Behavioral Restraints The Joint Commission changed the

standard to align with Center for Medicare and Medicaid Services (CMS) rules that require the hospitals to evaluate violent or aggressive patient in-person, by a physician, within one hour of being restrained or secluded.

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Behavioral Restraints When a physician is not available to issue

such an order, the restraint use may be initiated by a Registered Nurse based on appropriate assessment of the patient but the physician must be consulted ASAP to obtain the order.

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Behavioral Restraints: Order Time Limits

The initial and all subsequent restraint orders shall expire in: 1 hour or less for patients 8 year or younger 2 hours for patients from 9 to 17 years 4 hours for patients 18 years of age or older

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Behavioral Restraints: Orders Orders Content

Describe the specific behaviors necessary for the individual to be removed from restraint.

Decision to continue the restraints must be documented at the end of each time-limited period.

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Behavioral Restraints: Orders Orders Content

Designate the specific procedure authorized. Specify the date, time, and maximum length of

time for which the procedure maybe used unless continuation is authorized. (no more than 4 hours for adults)

Specify the behaviors which resulted in the need of restraints.

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Behavioral Restraints: Renewal Renewal Orders

After the original order expires at the end of 4 hours, a nurse will perform a reassessment and if deems restraints should be continued for another 4 hours, obtain a renewal order from the physician.

The basis for the decision must be documented and signed by the nurse authorizing the continuation.

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Behavioral Restraints: Renewal Renewal Orders

The original order may be renewed for a maximum time period of 8 hours.

Restraints cannot be reordered and continued for more than 8 hours without a face-to-face evaluation by the physician for patients 18 years of age and every 4 hours for patients 17 and younger.

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Behavioral Restraints: Assessment The patient is assessed at the initiation of restraint and every

15 minutes thereafter. Assessment and documentation includes:

Appropriate type of restraints Signs of injury associated with the application of restraint Nutrition / Hydration Circulation and range of motion Vital Signs Hygiene and elimination Physical and psychological status and comfort Readiness for discontinuation of restraint

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RESTRAINTS

In conclusion…consider: Sentinel Event Reporting Death Report Requirement

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Sentinel Event Reporting Be aware of our

hospital’s processes to ensure that required reports of restraint-associated patient death are submitted in a timely fashion, as required by law.

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Death Report Requirement Hospital Staff must report a patient death to

CMS by telephone by the close of the next CMS business day if the death occurs under the following circumstances:

Patient dies while restrained or secluded. Patient dies within one hour of the removal of

restraint Patient dies within one week after restraint or

seclusion , when it is “ reasonable to assume the use of restraint or seclusion contributed to patient’s death”.

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Conclusion Restraints symbolize patient dependence

and caregiver power, so they must be used with discretion and prudence.

The burden of proof falls on caregivers proposing the use of restraints, rather than on those discouraging the interventions.