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Restraints

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The use of restraints at WCMC increased significantly over the previous year. Restraints are primarily used in the CCU and are only applied after alternative methods have been tried or considered. Only trained staff can apply restraints and they must be documented thoroughly. Alternative methods and guidelines for different types of restraints are also outlined.

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Restraints WCMC is continually trying to minimize the use of restraints. The number of restrained patients increased 49% this year and the number of restraint episodes increased 34%! The majority of restraints occurred in CCU. Every effort is made to maintain patient safety by first using methods other than restraints. Restraints are used only when other methods have been tried and found to be ineffective. In an emergency situation alternative methods do not always need to be tried but should at least be considered prior to the use of restraints. Only competent trained associates may apply – release – and reapply restraints.
Restraints(continued)  Always notify the Nursing Supervisor ASAP when restraints are initiated.  Address the use of restraints at home in the Initial Interview in the Social Services section “Signs of Abuse/Social Deprivation. If restraints are used at home order a Social Services consult.  Leave the Restraint sticker on the front of the patient’s chart, through all levels of care, until discharge from the hospital system.  Immediately report any patient death that occurs while in restraints OR that occurs within 1 week of being in restraints to Quality/Risk Management at 1062. Complete and fax the CMS form to Quality Management at 1065 immediately.
Alternatives to Restraints  Ask the family for assistance in  “Low” bed management of at-risk behavior  Adequate sedation  Evaluation of meds/status  Room close to desk  Close monitoring by staff/family  Wrap around/Seat belt  Progressive ambulation plan  Reorient often  Offer snacks  Age-appropriate activities  Frequent bed checks/bed alarm  Place in wheelchair at station  Relaxing music  Allow uninterrupted rest periods  Address the 3 P’s at regular  Redirection intervals  Verbal mediation  Limit excess noise  Escort from area  Offer choices  1:1 monitoring  Time out
Restraints (Definition) Any method or device that restricts a patient’s freedom of movement, physical activity, or normal access to his/her body to ensure his/her safety. Does not include • Legal or forensic devices – handcuffs, shackles. Legal personnel are required to continually monitor patients who are prisoners or wards of the legal system. • Devices applied only for a procedure-such as insertion of CVL or CT, dressing change • Devices used for positioning in OR/PACU
Restraints (Types) PHYSICAL Any manual method or mechanical device that immobilizes or reduces the ability of a patient to move his/her extremities, body or head freely and which he/she cannot easily remove. Never restrain a patient in the prone position (to avoid positional asphyxia). The majority of restrained patient deaths have occurred with the patient restrained in the prone position. If a patient is “taken down” in the prone position in a physical hold during a Stat 13 or a emergency situation, immediately turn the patient supine to avoid any injury.
Restraints(types) CHEMICAL Any medication used to restrict a patient’s freedom of movement or used for the emergency control of behavior and is not a standard treatment or dosage for the patient’s medical or psychiatric condition. “Standard treatment” would enable the patient to function more effectively than would be possible without the medication. This would not be a chemical restraint. Medications, including PRN, medications that are part of the regular medical regimen for a known medical or psychiatric condition (such as drug/ alcohol withdrawal, schizophrenia, etc.) are not considered restraint even if their purpose is for violent behavior. For this reason it is wise when writing an order for one time or PRN order for any sedative or psychotropic medication to include the reason for the medication, such as “Geodon 20mg IM now for violent behavior r/t schizophrenia”. This would not be a chemical restraint.
Restraints (Physical) Mittens Limb – • cloth • non-locking hard • non-locking leather Tabletop Chair-if the patient cannot remove the tabletop Freedom splints Net enclosed bed-do not use! Cloth Vest-more injuries occur with the vest. Use with caution . Physical hold
Restraints (documentation)  All documentation is completed by licensed nurses  A physician order is required. Restraints may be applied by an RN in an emergency situation before calling the doctor.  Obtain a Restraint packet from CCU. Always complete the pre- printed Restraint Orders, Restraint Tool and Restraint Flowsheet.  Place the Restraint sticker on the front of the patient’s chart and complete when restraints are initiated and discontinued.  Always inform the patient, even if they may not understand, and family about the risks of restraint use/non- use
Restraints (documentation) Approximately every 2 hours • Release restraints on a temporary basis during care • Consider/attempt less restrictive restraints or alternative measures • Assess if the need or reason for restraint is still present • Perform neurovascular checks/skin integrity assessment • Assess/meet the patient’s physical/emotional needs • Provide toileting, hydration, and positioning as well Every 4 hours Assess & document the specific reason/need for restraint. Every shift • RN addresses patient behavior in the plan of care/problem list (Refer to CCU-Potential for injury r/t use of restraints or Potential for injury
Restraints (documentation) Observe/assess the patient on an ongoing basis for readiness for discontinuation of restraints Discontinue ASAP or as ordered by the physician Complete the restraint sticker on the chart front Discard the restraints - Do NOT send home with the patient If behavior recurs after restraints are discontinued start at the beginning of the process Discontinuation is considered any time restraints are removed for >1 hour – excluding for patient care, meals, treatments, tests, or therapy If a restrained patient is sent to another area (i.e. X-ray or dialysis), a restraint competent nursing associate must be in attendance
Restraints (Non-violent behavior) Two major purposes for restraints: • Non-violent/non self-destructive behavior • Violent/self-destructive behavior Majority of restraints are applied for non-violent behavior which includes any of the following reasons: • To protect the integrity of essential lines, tubes, and/or dressings required for medical treatment • To protect the patient from injury while in the bed or chair • To protect the patient from injury due to wandering in an unsafe manner
Restraints (Non-violent behavior)  Physician orders are limited to one calendar day (midnight to midnight)  Place a new Restraint Order on the chart at midnight if restraints are still needed  Complete the following on the Restraint Orders; • Reason for restraint • Type of restraint • Length of time of restraint (including the date) • Place a “sign here” sticker on the MD order Prompt the MD to sign order when rounding that day
Restraints (Violent behavior) For the emergency management of aggressive, combative or violent behavior that places the patient or others in imminent danger of injury or harm • Used most often in the ED, CCU and the psychiatric units Notify physician ASAP after restraints are applied • MD is required to assess the patient within 1 hour • Exception: Restraints that are applied in ED or the psychiatric units. A MD is always present in the ED to assess the patient. On the psychiatric units a trained RN is permitted to complete the 1 hour assessment.
Restraints (Violent behavior) Orders are time-limited according to age • 4 hours for patients 18 years or older • RN calls the MD every 4 hours for a new order if restraints are still required • Check and/or observe the patient about every 15 minutes • Constant observation is required for any patients in leather or locking restraints Debriefing is no longer required when restraints are discontinued. However it is still therapeutic to discuss the episode of restraint with the patient.
Physical Hold PHYSICAL HOLD  Any type of manual hold that the patient cannot easily release himself from. It is intended to be as brief as possible until a safer form of restraint can be initiated  A physical hold is most used during a Stat 13 situation, for a patient on 72 hour hold or to give a medication against a patient’s will in an emergency situation for violent behavior  It is only used for violent behavior  A physician order to give a medication against a patient’s will must be obtained before giving the medication
Physical Hold (continued)  If a patient is in a physical hold only for <15 minutes complete only the Restraint Orders and Restraint Tool.  On the Restraint Tool in the “Type of Restraint” section check Physical Hold.  Document “Used for <15 minutes for injection of medication.” Include in the Reason for Discontinuation of Restraint section “Released after medication given. No patient injury noted.”  If a patient is in a physical hold for <15 minutes and then placed in restraints complete the Restraint Orders.  On the Restraint Tool document after Physical Hold “Used for <15 minutes until 4 points restraints applied”.  Also complete the Restraint Flowsheet as usual regarding the 4 point restraints.
Restraints/Seclusion  Time out is the voluntary restriction of a patient to a designated area from which the patient is not physically prevented from leaving and is used when a patient is out-of- control and needs to be removed from the general patient area  Seclusion is the involuntary confinement of a patient alone in a room or area where the patient is physically prevented from leaving  Seclusion is used only for patients with violent behavior or self- destructive behavior  Seclusion is used only in the psychiatric units on WCMC South- each have a special locked room that is used for seclusion  Seclusion does not apply when patients have been placed on 72 hour hold and are restricted to their room

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Restraints

  • 1. Restraints WCMC is continually trying to minimize the use of restraints. The number of restrained patients increased 49% this year and the number of restraint episodes increased 34%! The majority of restraints occurred in CCU. Every effort is made to maintain patient safety by first using methods other than restraints. Restraints are used only when other methods have been tried and found to be ineffective. In an emergency situation alternative methods do not always need to be tried but should at least be considered prior to the use of restraints. Only competent trained associates may apply – release – and reapply restraints.
  • 2. Restraints(continued)  Always notify the Nursing Supervisor ASAP when restraints are initiated.  Address the use of restraints at home in the Initial Interview in the Social Services section “Signs of Abuse/Social Deprivation. If restraints are used at home order a Social Services consult.  Leave the Restraint sticker on the front of the patient’s chart, through all levels of care, until discharge from the hospital system.  Immediately report any patient death that occurs while in restraints OR that occurs within 1 week of being in restraints to Quality/Risk Management at 1062. Complete and fax the CMS form to Quality Management at 1065 immediately.
  • 3. Alternatives to Restraints  Ask the family for assistance in  “Low” bed management of at-risk behavior  Adequate sedation  Evaluation of meds/status  Room close to desk  Close monitoring by staff/family  Wrap around/Seat belt  Progressive ambulation plan  Reorient often  Offer snacks  Age-appropriate activities  Frequent bed checks/bed alarm  Place in wheelchair at station  Relaxing music  Allow uninterrupted rest periods  Address the 3 P’s at regular  Redirection intervals  Verbal mediation  Limit excess noise  Escort from area  Offer choices  1:1 monitoring  Time out
  • 4. Restraints (Definition) Any method or device that restricts a patient’s freedom of movement, physical activity, or normal access to his/her body to ensure his/her safety. Does not include • Legal or forensic devices – handcuffs, shackles. Legal personnel are required to continually monitor patients who are prisoners or wards of the legal system. • Devices applied only for a procedure-such as insertion of CVL or CT, dressing change • Devices used for positioning in OR/PACU
  • 5. Restraints (Types) PHYSICAL Any manual method or mechanical device that immobilizes or reduces the ability of a patient to move his/her extremities, body or head freely and which he/she cannot easily remove. Never restrain a patient in the prone position (to avoid positional asphyxia). The majority of restrained patient deaths have occurred with the patient restrained in the prone position. If a patient is “taken down” in the prone position in a physical hold during a Stat 13 or a emergency situation, immediately turn the patient supine to avoid any injury.
  • 6. Restraints(types) CHEMICAL Any medication used to restrict a patient’s freedom of movement or used for the emergency control of behavior and is not a standard treatment or dosage for the patient’s medical or psychiatric condition. “Standard treatment” would enable the patient to function more effectively than would be possible without the medication. This would not be a chemical restraint. Medications, including PRN, medications that are part of the regular medical regimen for a known medical or psychiatric condition (such as drug/ alcohol withdrawal, schizophrenia, etc.) are not considered restraint even if their purpose is for violent behavior. For this reason it is wise when writing an order for one time or PRN order for any sedative or psychotropic medication to include the reason for the medication, such as “Geodon 20mg IM now for violent behavior r/t schizophrenia”. This would not be a chemical restraint.
  • 7. Restraints (Physical) Mittens Limb – • cloth • non-locking hard • non-locking leather Tabletop Chair-if the patient cannot remove the tabletop Freedom splints Net enclosed bed-do not use! Cloth Vest-more injuries occur with the vest. Use with caution . Physical hold
  • 8. Restraints (documentation)  All documentation is completed by licensed nurses  A physician order is required. Restraints may be applied by an RN in an emergency situation before calling the doctor.  Obtain a Restraint packet from CCU. Always complete the pre- printed Restraint Orders, Restraint Tool and Restraint Flowsheet.  Place the Restraint sticker on the front of the patient’s chart and complete when restraints are initiated and discontinued.  Always inform the patient, even if they may not understand, and family about the risks of restraint use/non- use
  • 9. Restraints (documentation) Approximately every 2 hours • Release restraints on a temporary basis during care • Consider/attempt less restrictive restraints or alternative measures • Assess if the need or reason for restraint is still present • Perform neurovascular checks/skin integrity assessment • Assess/meet the patient’s physical/emotional needs • Provide toileting, hydration, and positioning as well Every 4 hours Assess & document the specific reason/need for restraint. Every shift • RN addresses patient behavior in the plan of care/problem list (Refer to CCU-Potential for injury r/t use of restraints or Potential for injury
  • 10. Restraints (documentation) Observe/assess the patient on an ongoing basis for readiness for discontinuation of restraints Discontinue ASAP or as ordered by the physician Complete the restraint sticker on the chart front Discard the restraints - Do NOT send home with the patient If behavior recurs after restraints are discontinued start at the beginning of the process Discontinuation is considered any time restraints are removed for >1 hour – excluding for patient care, meals, treatments, tests, or therapy If a restrained patient is sent to another area (i.e. X-ray or dialysis), a restraint competent nursing associate must be in attendance
  • 11. Restraints (Non-violent behavior) Two major purposes for restraints: • Non-violent/non self-destructive behavior • Violent/self-destructive behavior Majority of restraints are applied for non-violent behavior which includes any of the following reasons: • To protect the integrity of essential lines, tubes, and/or dressings required for medical treatment • To protect the patient from injury while in the bed or chair • To protect the patient from injury due to wandering in an unsafe manner
  • 12. Restraints (Non-violent behavior)  Physician orders are limited to one calendar day (midnight to midnight)  Place a new Restraint Order on the chart at midnight if restraints are still needed  Complete the following on the Restraint Orders; • Reason for restraint • Type of restraint • Length of time of restraint (including the date) • Place a “sign here” sticker on the MD order Prompt the MD to sign order when rounding that day
  • 13. Restraints (Violent behavior) For the emergency management of aggressive, combative or violent behavior that places the patient or others in imminent danger of injury or harm • Used most often in the ED, CCU and the psychiatric units Notify physician ASAP after restraints are applied • MD is required to assess the patient within 1 hour • Exception: Restraints that are applied in ED or the psychiatric units. A MD is always present in the ED to assess the patient. On the psychiatric units a trained RN is permitted to complete the 1 hour assessment.
  • 14. Restraints (Violent behavior) Orders are time-limited according to age • 4 hours for patients 18 years or older • RN calls the MD every 4 hours for a new order if restraints are still required • Check and/or observe the patient about every 15 minutes • Constant observation is required for any patients in leather or locking restraints Debriefing is no longer required when restraints are discontinued. However it is still therapeutic to discuss the episode of restraint with the patient.
  • 15. Physical Hold PHYSICAL HOLD  Any type of manual hold that the patient cannot easily release himself from. It is intended to be as brief as possible until a safer form of restraint can be initiated  A physical hold is most used during a Stat 13 situation, for a patient on 72 hour hold or to give a medication against a patient’s will in an emergency situation for violent behavior  It is only used for violent behavior  A physician order to give a medication against a patient’s will must be obtained before giving the medication
  • 16. Physical Hold (continued)  If a patient is in a physical hold only for <15 minutes complete only the Restraint Orders and Restraint Tool.  On the Restraint Tool in the “Type of Restraint” section check Physical Hold.  Document “Used for <15 minutes for injection of medication.” Include in the Reason for Discontinuation of Restraint section “Released after medication given. No patient injury noted.”  If a patient is in a physical hold for <15 minutes and then placed in restraints complete the Restraint Orders.  On the Restraint Tool document after Physical Hold “Used for <15 minutes until 4 points restraints applied”.  Also complete the Restraint Flowsheet as usual regarding the 4 point restraints.
  • 17. Restraints/Seclusion  Time out is the voluntary restriction of a patient to a designated area from which the patient is not physically prevented from leaving and is used when a patient is out-of- control and needs to be removed from the general patient area  Seclusion is the involuntary confinement of a patient alone in a room or area where the patient is physically prevented from leaving  Seclusion is used only for patients with violent behavior or self- destructive behavior  Seclusion is used only in the psychiatric units on WCMC South- each have a special locked room that is used for seclusion  Seclusion does not apply when patients have been placed on 72 hour hold and are restricted to their room