SJ Use of Restraints

Summary:
Policy that defines the use of physical restraint for violent or self destructive behavior and non-violent behavior.
Effective Date: / 2/19/2001
Revision History: / 10/30/2013, 10/3/2013; 7/31/2013; 11/15/2011; 7/20/2011; 5/1/2011; 12/18/2010; 5/31/2010; 8/22/2007; 3/10/2007; 3/20/2006; 2/22/2006; 8/1/2005; 11/8/2004; 9/21/2004; 8/5/2004; 3/8/2004; 2/9/2003
Reviewed Date: / 10/30/2013
Facilities: / SJMC
Approved By: / SJMC CNO
Policy Impacts: / All Nursing Personnel

Scope

This policy applies to all staff members, physicians, physician assistants and licensed independent practitioners involved in ordering, applying, and monitoring, assessing, and providing care for any patient in a restraint.

Purpose

1.To protect the dignity and safety of inpatients, outpatients, staff, and visitors through safe

restraint processes.

2.To identify patients at risk for restraint and provide alternatives to restraint use.

3.To provide guidelines for use of least restrictive interventions to avoid restraint use. To define the procedure to be followed when all alternatives have been exhausted and proven ineffective, and restraints are necessary to maintain patient safety.

4.To define staff training requirements related to safe processes. See appendix A.

Responsibility

It is the responsibility of the hospital CNO or designee to disseminate this policy and its contents to all appropriate hospital employees and licensed independent practitioners and to ensure compliance.

Policy

1.This hospital strives to be a restraint free environment.

2.Seclusion will not be used at this hospital.

3.This hospital recognizes that all patients have the right to be free from physical or mental abuse, and corporal punishment.

4.Restraint use, of any form, will never be used as a means of coercion, discipline, convenience, or retaliation by staff.

5.Staff will ensure that patients are treated with dignity and privacy during periods of

restraint.

6.Staffing levels and assignments shall be set to minimize circumstances that give rise to restraint use and to maximize safety when restraints are used.

7.Restraint use will not be based on an individual’s restraint history or solely on a history of dangerous behavior.

8.Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others.

9.Restraint use will only be imposed upon receipt of appropriate physician orders, when needed to ensure the immediate physical safety of the patient, a staff member, or others and will be discontinued at the earliest time possible, regardless of the length of time identified in the order.

10.A protocol will not serve as a substitute for obtaining a physician’s or other Licensed Independent providers (LIP) order prior to initiating each episode of restraint.

11.Restraint use within the hospital is limited to those situations for acute medical and surgical care as a measure to prevent patient injury as well as to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.

12.The type or technique of restraint used will be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

13.Restraint orders will not be written or accepted as a PRN or standing order.

Procedure

1.Assessment for Risk for Restraint

The Registered Nurse (RN) performs an assessment when a patient exhibits behavior that may place the patient at risk for restraint. This risk assessment includes:

a.Does the patient have a medical device?

b.Does the patient understand the need to not remove the device?

c.Is the patient required to be immobile?

d. Does the patient understand the need to be immobile?

d.Is the patient exhibiting aggressive, combative, or destructive

behavior?

Does this behavior place the patient/staff/others in immediate

danger?

2. The assessment for the risk for restraint also includes:

a. Patients who arrive in restraints

b. Patients in restraint who have recovered from the effects of anesthesia

and are awaiting transfer to a bed.

1)Alternatives to Restraint:

a.Patients that are determined to be at risk for restraint will have alternatives initiated promptly. Appendix B contains a listing of alternatives to restraints.

Determination that alternatives to restraint have failed: The RN determines that alternatives to restraint have failed and that the patient will be safer in restraints than continuing without restraint.

Second Tier of Review: A member of nursing administration/management (e.g., Nursing Supervisor, Resource Nurse, manager/director) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint. The second tier or review will occur with the initial application of restraint. Renewals of restraint orders do not require a second tier of review. The review includes:
Alternatives attempted
Reason for restraint
Least restrictive type of restraint
Staff’s knowledge of the cause of patient behavior (physiological, psychological, environmental, medication)
Appropriate restraint for vulnerable patient populations
Staffing available for monitoring
Affirmation of partnering to meet the patient needs with safety and compassion. NOTE: In an emergency application of the restraint or seclusion, the above review will be done immediately after the application of restraint.

Order for Restraint:
An order for restraint must be obtained from a LIP/physician who is responsible for the care of the patient prior to the application of restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.
An order for restraint may not be written as a standing order, protocol or as a PRN or “as needed” order.
If a patient was recently released from restraint, and exhibits behavior that can only be handled through the reapplication of restraint, a new order is required.
If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.
When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competency may initiate restraint use based upon assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is initiated.

Order for Restraint With Non-Violent or Non-Self Destructive Behavior
Duration of order for restraint must not exceed twenty-four (24) hours for the initial order, and must specify clinical justification for the restraint, the date and time ordered, the duration of use, and they type of restraint and behavior-based criteria for release.
Twenty-four (24) hours is the maximum duration. The physician may order a shorter period of time.
Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.
To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint is necessary.
If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician

Order for Restraint with Violent or Self Destructive Behavior
Physician orders for restraint must be time limited, and must specify clinical justification for the restraint, the date and time ordered, the duration of restraint use, the type of restraint, and behavior-based criteria for release. Orders for restraint must not exceed:
4 hours for adults, aged 18 years or older
2 hours for children and adolescents aged 9 to 17 years
1 hour for children under 9 years
The time frames specified are maximums. The physician may order a shorter period of time
Staff assess, monitor and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.
To continue restraint beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order. Renewal orders for restraint may not exceed:
4 hours for adults, aged 18 years or older
2 hours for children and adolescents aged 9 to 17 years
1 hour for children under 9 years
Orders may be renewed according to time limits above for a maximum of 24 consecutive hours. Every 24 hours, a LIP/physician primarily responsible for the care of the patient, must see and evaluate the patient before writing a new order for restraints.

Application of Restraints:
Restraints are applied by staff with demonstrated competence in restraint application.
The patient is informed of the purpose of the restraint and the criteria for removal
The patient’s family is informed of restraint use, the purpose of the restraint and the criteria for removal

Patient monitoring: Monitoring the Patient in Restraints
Patients are assessed by an RN immediately after restraints are initiated to assure safe application of the restraint.
For patients in Non-Violent Restraints, the patient will be assessed by an RN at least every 2 hours. The assessment will include where appropriate:
Signs of injury associate with restraint including circulation of affected extremities
Respiratory and cardiac status
Psychological status including level of distress or agitation, mental status and cognitive functioning
Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met.
Hydration/nutritional needs are being met
Hygiene, toileting/elimination needs are being met
The patient’s rights, dignity, and safety are maintained
Patient’s understanding of reasons for restraint and criteria for release from restraint
Consideration of less restrictive alternatives to restraint
For patients in Violent Restraints, the patient will be continuously observed by an RN. Such monitoring will be documented every fifteen (15) minutes on the continuous observation flow sheet. A restraint assessment will also occur every 15 minutes and will be documented in the appropriate Meditech intervention. The assessment will include the following where appropriate:
Signs of injury associate with restraint including circulation of affected extremities
Respiratory and cardiac status
Psychological status including level of distress or agitation, mental status and cognitive functioning
Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met. (Q2 hours and prn)
Hydration/nutritional needs are being met (Q2 hours and prn)
Hygiene, toileting/elimination needs are being met (Q2 hours and prn)
The patient’s rights, dignity, and safety are maintained
Patient’s understanding of reasons for restraint and criteria for release from restraint
Consideration of less restrictive alternatives to restraint
More frequent monitoring and notification of the ordering LIP/physician occurs when
Patient’s medical and emotional needs and health status change
The type and design of the device or intervention poses increased risk
The level of patient agitation / distress at being placed in restraint as evidenced by an escalation of behavior.
Evidence of injury related to use of restraint.

Face-to-face assessment
A face-to-face assessment by a LIP/physician or RN with demonstrated competence must be done within one hour of restraint inititation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN will:
Work with staff and patient to identify ways to help the patient regain control
Evaluate the patient’s immediate situation
Evaluate the patient’s reaction to the intervention
Evaluate the patient’s medical and behavioral condition
Evaluate the need to continue or terminate the restraint or seclusion
Revise the plan of care, treatment and services as needed
NOTE: A telephone call does not constitute face-to-face assessment
When the 1-hour face-to-face is performed by an RN with demonstrated competence, the following must occur:
The RN must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1 hour face-to-face evaluation (“as soon as possible” is to be as soon as the attending physician/LIP is able to be reached by phone or in person). A consultation that is not conducted prior to renewal of the order would not be consistent with the requirement “as soon as possible”.
The consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face evaluation, the need for other treatments, and the need to continue or discontinue the use of restraint.
If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician/LIP arrives to perform the face-to-face assessment, the physician must still see the patient face-to-face to perform the assessment within 24 hours after the initiation of restraint.

Care of the Patient/Plan of Care:
The plan of care will clearly reflect a loop of assessment, intervention and evaluation for restraint and medications
Patients and/or families should be involved in care planning to the extent possible and made aware of changes to the plan of care

Discontinuation of Restraint:
The patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period
When an RN determines that the patient meets the criteria for release in the restraint order, restraints are discontinued by staff with demonstrated competence.
Once restraints are discontinued, a new order for restraint is required to reapply or reinitiate
A temporary release that occurs during patient care, e.g., toileting, feeding or range of motion, is not considered a discontinuation of restraint.
Documentation: The medical record contains documentation of:

1)Assessment for risk for restraint

2)The restraint alternatives employed Determination of effectiveness / ineffectiveness of restraint alternatives

3)Second tier review of need for restraint

4)Orders for restraint or any renewal orders for restraint

5)Restraint application / initiation

6)Family notification of restraint use

7)Patient and family education regarding restraint use

8)Assessment of the patient in restraints

9)Monitoring of the patient in restraints

10)Medical and behavioral evaluation for restraint management of violent or self-destructive behavior

11) Modifications of the plan of care Physician notification of changes in patient condition

12)Restraint removal/termination

13)Documentation requirements related to deaths of patient who were in or expired within 24 hours of being in restraint are located in appendix C. Documentation requirements are also located in Appendix C for patients who expired within one week of being in restraint and it is reasonable to assumen that the restraint contributed to the death.

APPROVAL SIGNATURES:

St. Joseph Medical Center, CNO

APPENDIX A: TRAINING REQUIREMENTS

A.Direct Care Staff

Staff will demonstrate competency in the application of restraints.

Training will be provided to all staff designated as having direct patient care responsibilities (the facility to list), including contract or agency personnel. In addition, if the hospital Public Safety Officers or other non-healthcare staff (the facility to list) assist direct care staff, when requested in the application of restraint or seclusion, the Public Safety Officers or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint. Training will occur:

1)Before performing restraint application, monitoring, assessment and providing care for a patient in restraint or seclusion,

2)As part of orientation, and

3)On an annual basis to ensure staff possess requisite knowledge and skills to safely care for restrained patients.

4)The results of skills and knowledge assessment, new equipment, or QAPI data may indicate a need for targeted training or more frequent or revised training.

B.Staff who conduct the one hour face-to-face evaluation

The purpose of the 1 hour face-to-face evaluation is to complete a comprehensive review

of the Patient’s condition and determine if other factors such as drug or medication

Interactions, electrolyte imbalances, hypoxia, sepsis etc. are contributing to the patient’s

violent or self-destructive behavior. Training for the RN or PA who conduct the 1 hour

face-to-face will include:

1)Application of restraints.

2)Monitoring, assessment and providing care for a patient in restraint; including:

The patient’s immediate situation
The patient’s reaction to the intervention
The patient’s medical and behavioral condition
The need to continue or terminate the restraint

C.Physicians and other LIPs authorized to order restraint

Physicians and other LIPs authorized to order restraint will have a working knowledge of this policy on the use of restraints.

D. Individuals providing training will be qualified as evidenced by education, training, and experience in techniques used to address patients’ behaviors for the populations served. In addition these individuals will demonstrate a high knowledge regarding all the requirements as set forth in this policy and procedure. There will be documentation to ensure that the individuals providing education and training have the appropriate qualification required.

Training Content

Restraint: All staff, including contract or agency personnel designated as having direct patient care responsibilities, will receive training in identifying patient and staff behaviors, events and environmental factors that may trigger circumstances that require the use of restraints. Education and training will be based on the specific needs of the patient populations served.
Nonphysical Interventional Skills: Staff will be trained on the use of nonphysical interventional skills. These alternative techniques include redirecting the patient, engaging the patient in constructive discussion or activity or otherwise assisting the patient to maintain self-control and to avert escalation. Training will address application of nonphysical interventions based on the assessment of the individual patient’s responses.
Least Restrictive Interventions: Staff will be trained on choosing the least restrictive intervention based on the individualized assessment of the patient’s medical or behavioral status or condition. Safe patient care requires looking at the patient as an individual and assessing the patient’s condition, needs, strengths, weaknesses, and preferences and tailoring interventions to individual patient’s needs after weighing factors such as the patient’s condition, behaviors, history and environmental factors.
Safe Application: Staff will be trained on the safe application of all types of restraint used in this facility including training to recognize and respond to signs of physicial and psychological distress
Necessity of Restraint: Staff will be trained and able to demonstrate competency in identification of specific behavioral changes that may indicate that restraint is no longer necessary and can safely be discontinued.
Monitoring: Staff will be trained and demonstrate competency in monitoring the physical and psychological well-being of a patient who is restreained. This training will include but will not be limited to: respiratory and circulatory status, skin integrity, and vital signs.
First Aid: Staff will be trained and able to demonstrate competency in first aid techniques for patients in restraint who are in distress or injured. The patient populations will be assessed to identify potential scenarios and develop training to address those scenarios. For example, for patients who are found hanging in restraints, or a restrained patient choking? Staff will be trained and certified in the use of CPR.

APPENDIX B: ALTERNATIVES TO RESTRAINT