Title: Restraint Use for Non-Violent and Violent Situations Number 701, Version 8 Original Date: 07/18/2017 Effective: 01/17/2019 Last Review/Revision Date: 01/17/2019 Next Review Date: 01/17/2022 Author: System Restraint Team Approved by: BH System Practice Oversight Team, Chief Nursing Officers, PolicyTech Administrators, 01/17/2019
Discrete Operating Unit/Facility: Ambulatory Services Banner Baywood Medical Center B--UMCS Child and Adolescent Clinic (Beh. Health) Banner Behavioral Health Hospital Banner Boswell Medical Center Banner Casa Grande Medical Center Banner Churchill Community Hospital Banner Del E Webb Medical Center Banner Desert Medical Center Banner Estrella Medical Center Banner Fort Collins Medical Center Banner Gateway Medical Center Banner Goldfield Medical Center Banner Heart Hospital Banner Ironwood Medical Center Banner Lassen Medical Center Banner Ocotillo Medical Center Banner Payson Medical Center Banner Thunderbird Medical Center Banner--University Medical Center Phoenix Banner--University Medical Center South Banner--University Medical Center Tucson East Morgan County Hospital McKee Medical Center North Colorado Medical Center Ogallala Community Hospital Page Hospital Platte County Memorial Hospital Sterling Regional MedCenter Torrington Community Hospital Washakie Medical Center
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Table of Contents
Introduction 3 Purpose 3 Applicability 3 Definitions 3 Policy 5 Patient Rights and Safety 5 Use of Restraint or Seclusion 5 Restraint/Seclusion Orders 6 Restraint Availability 6 Seclusion 7 Quiet Room 8 Education 8 Staff 8 Providers 9 Patient and Family/Care Partner 9 Quality 9 Quality Activities 9 Reducing Restraint Risks 10 Risks 10 Procedures for Restraints and Seclusion 10 Assessment and Alternative Interventions 10 Procedures for Behavioral Restraints / Seclusion 11 Initiating Restraint or Seclusion 11 Care of the Patient in Restraints or Seclusion 13 Discontinuing Restraint or Seclusion 14 Documentation 14 Procedures for Medical Restraints 15 Application of Restraints 15 Discontinuing Restraints 17 Documentation 17 Other Information 17 References 17 Other Related Policies 18 Keywords 18 Appendix List 18 Appendix A: Alternatives to Restraints 19 Appendix B: When Side Rails are, or are not, Restraints 22 Appendix C: Exceptions – PRN Orders per CMS Rules 24 Appendix D: 1:1 Observation Form 25 Appendix E: Quick Reference on Medical and Behavioral Restraint/Seclusion 26 Appendix F: Enclosure Beds 30
Page 2 of 29 Title: Restraint Use for Non-Violent and Violent Situations Number: 701, Version: 8
Introduction
Purpose / 1. Purpose: Population Use of Restraint or Seclusion may be required in emergency situations to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.
This policy ensures that the use of Restraint or Seclusion promotes patient safety, rights, dignity and well-being in accordance with applicable federal and state regulations.
To reduce the use of Restraint.
2. Population: All Employees
Applicability This policy does not apply to:
Treatment immobilization (i.e., during a medical/diagnostic or surgical procedure, arm board for IV administration) Postural support devices used for proper body position and balance (i.e. prosthetic devices) Any device that can be readily removed by the patient (e.g. self-releasing lap belt) Age appropriate protective safety interventions Use of drugs, such as sedatives or psychotropic medications, within standard dosing parameters and accepted treatment protocols for the patient’s medical condition Patients with forensic correctional restrictions
Definitions Adaptive Support: Orthopedic appliances, braces, wheelchairs, or other devices used for postural support of the patient to assist in obtaining and maintaining normative bodily functioning, or performing activities of everyday living.
Alternative Interventions: Preventive strategies and innovative actions that are intended to meet the patient’s unmet needs and eliminate the cause of behaviors that put the patient at risk for restraint use, such as being fall-prone, wandering or interfering with medical treatment devices. (See Appendix A for Alternatives to Restraints)
Behavioral/Violent Restraint: Restraint or Seclusion used to manage violent or self-destructive behavior; i.e. danger to self (DTS) or danger to others (DTO) that poses an imminent danger to the physical safety of the patient, staff or others, regardless of the patient’s location.
Chemical Restraints: Medication used to manage the patient’s behavior or restrict movement and is not a standard treatment or dosage for the patient’s condition or symptoms Continued on next page
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Introduction, Continued
Definitions, Medical/Nonviolent Restraint: A physical or mechanical device, material, or (continued) equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Adaptive Support items are not considered to be restraints.
Restraints: For purposes of this policy, Restraints refers to Medical Restraints, Behavioral Restraints and Chemical Restraints.
Code Gray: The hospital code to assist with communication of a violent situation involving threatening or violent behavior and summoning available staff or an identified team on duty.
De-escalation Techniques: Non-physical interventions designed to reduce maladaptive and threatening behavior.
Emergency Situations: Unanticipated patient behavior that places the patient or others at serious threat of violence or injury if no intervention occurs and that calls for the use of restraint or seclusion as an immediate response. (42 CFR 483.352 Definitions).
Imminent Danger: Immediate harm to the patient or other(s) is likely to occur if no action is taken.
Involuntary Hold: Emergency detention to hold a patient who is considered a danger to self or others pending a psychiatric or approved behavioral health professional evaluation.
Licensed Independent Practitioner (LIP): for the purposes of this policy - a physician, nurse practitioner, physician assistant, or other individual permitted by law and by the organization to provide care, treatment, and services without direct supervision. A LIP operates within the scope of their license.
Quiet Room: A room where a patient may choose to go voluntarily as a means of reducing stress or anxiety.
Seclusion: Involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. May only be used for management of violent or self-destructive behavior.
Self-destructive Behavior: Behavior that may cause self-inflicted injury. This does not include pulling out lines, tubes, etc. due to delirium, confusion, or discomfort.
Validated Staff: Staff that has completed the requirements for Restraint education and are determined to be competent to restrain patients.
Violent Behavior: Behavior that may cause harm to self or others, such as kicking, flailing, or punching. ______Continued on next page
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Policy
Patient rights Staff shall promote the safety, rights, dignity and well-being of patients and shall use and safety preventive strategies and alternative interventions whenever possible.
All appropriate alternative measures shall be used prior to use of Restraints or Seclusion. Restraints and Seclusion are interventions of last resort to prevent interference with medical treatment, self-harm or physical harm to others. Restraints and Seclusion are used in the least restrictive manner possible. Restraints and Seclusion are discontinued as soon as possible.
Use of restraint 1. Staff shall promote the safety, rights, dignity and well-being of the patients or seclusion through:
Early recognition of maladaptive behaviors. Early recognition of pain responses. Application of knowledge of the symptomatic behaviors and other manifestations of various crisis situations that may escalate violence. Use of appropriate alternative interventions needed to decrease escalating behavior before using Restraints.
2. The Restraint or Seclusion is proportionate and appropriate to the severity of the patient’s behavior and the patient’s:
Chronological and developmental age Size Gender Physical condition Medical condition Psychiatric condition Personal history, including any history of physical or sexual abuse
3. If Seclusion rooms are available in behavioral health units or emergency departments, persons who are an imminent danger to others are placed in Seclusion only. Patients who are an imminent danger to self are placed in Restraints in the Seclusion room under direct observation by staff member.
4. “PRN” orders for Restraint or Seclusion shall not be used.
5. Mechanical Restraints are always applied in a supine position.
Exception: pregnant patients are always placed on their side.
6. Only Validated Staff may apply the use of Restraint or Seclusion and monitor the patient.
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Policy, continued
Use of restraint 7. Banner Health (BH) does not use time-out or a time-out room. Quiet Rooms are or seclusion, available for patients that choose to utilize a low-stimulation area to decrease continued stress and anxiety. (See Quiet Room in the Seclusion topic section)
Restraint / A physician/LIP order is required prior to the initiation of Restraints or Seclusion. seclusion orders Exception: In emergency situations, Restraints and Seclusion may be applied prior to the Registered Nurse (RN) obtaining the order; however, an order must be obtained during or immediately after the application of Restraints.
Restraint 1. Restraint devices are available to the health care professional through the supply availability chain or security, dependent upon the type of restraint needed to manage the patient’s behavior. The type of restraint does not determine the reason for Restraint, but rather this is determined through assessment of the patient and the identification of the behavior being demonstrated which has been unresponsive to less restrictive measures initiated by the nurse. The following is a list of types of restraint, but may not be all-inclusive:
Soft limb restraints, Mittens that are tethered to immobilize the arm or hand, Bed side rails, Freedom Splints (where available) Enclosed beds (where available) Limb restraints with hook and loop fasteners Lap belts (5-point restraint), and Locking or non-locking (non-leather) restraints
o Information: Non-locking restraints are closed with buckles rather than locks o Note: See Appendix B: When Side Rails Are, or Are Not, Restraints
2. Not all restraints are available in all facilities.
3. Spit hoods may be available for use.
4. Body nets are not to be used at BH.
5. Each facility determines the mechanism for controlling the availability of restraints and has a mechanism in place to identify and monitor restraint use.
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Policy, continued
Seclusion 1. Seclusion interventions when used on non-behavioral health units include:
Private or semi-private rooms where the person is prevented from leaving their room due to an unrelated medical isolation protocol; 1:1 staff person for the person’s safety related to self-harm/violent behaviors as ordered by the physician; and Involuntarily holding the patient in the room and preventing them from leaving.
2. Seclusion on Behavioral Health (BeH) Units and Units with Designated Seclusion Rooms
Is designated to be used for Seclusion when the patient is determined to be danger to others (DTO) or when the patient is restrained for self-harming behaviors. Requires that the seclusion room door be locked for DTO behavior. Open door seclusion for DTO behavior on BeH units is prohibited. Will not be conducted in a patient’s bedroom or a sleeping area; Allows staff members full view of the patient in all areas of the room and the Seclusion Room must be free of safety hazards; Requires at least 60 square feet of floor space; Requires a non-adjustable bed that:
o Consists of a mattress on a solid platform; o Is constructed of a durable, non-hazardous material; o Is raised off of the floor; o Does not have wire springs or a storage drawer; and o Is securely anchored in place.
Requires that if a room used for Seclusion does not contain a non-adjustable bed, an alternate piece of equipment is available for use in the room used for seclusion that:
o Is commercially manufactured to safely and humanely restrain a patient’s body; o Provides support to the trunk and head of a patient’s body; o Provides restraint to the trunk of a patient’s body; o Is able to restrict movement of a patient’s arms, legs, trunk, and head; o Allows a patient’s body to recline; o Does not inflict harm on a patient’s body; and o Is described in documentation of the manufacturer’s specifications for the piece of equipment and that documentation is maintained.
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Policy, continued
Quiet room 1. When a Quiet Room is used:
Patients will be allowed to bring items approved by the RN (e.g., book, paper, writing instrument, portable music device) during this time. Assigned personnel will document every 15 minute patient observation as per the rounding protocol, or more frequently as determined by the RN or physician. The RN will document in a progress note that the QUIET ROOM was used with the initial and discontinued time, date, and patient response to the intervention or situation.
2. If a seclusion room is used as a Quiet Room:
The designated sign “QUIET ROOM” is placed on the outside of the door: If restraints are on the bed, they are removed before the room is utilized as a Quiet room.
3. When the QUIET ROOM, is used as a Seclusion room, the QUIET ROOM SIGN is removed, the room is inspected for safety and any potentially dangerous objects are removed immediately.
Education
Staff 1. A comprehensive training program educates staff in conducting behavioral assessment and innovative alternatives to meet the patient’s needs. Validated Staff are those who have successfully completed this training program and demonstrated their ability to conduct a behavioral assessment and apply Restraints.
2. The comprehensive training program is designed to allow staff to gain knowledge, skill and demonstrate competence in:
Behavioral assessment (Conducted by the RN) Preventive strategies; Alternative interventions, including de-escalation and deflection techniques; Proper application of restraints; The monitoring and care of patients in restraints, including supporting documentation; First aid, including identification of the need for and care of patients who are injured or in distress; and Cardiopulmonary Resuscitation.
3. Additional training is provided to a select group of RNs that is designed to equip them with the skills and competencies to perform the face-to-face evaluation of patients, in accordance with applicable state and federal regulations.
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Education, continued
Providers BH educates all physicians and LIPs responsible for ordering Restraints on hospital restraint policies during orientation to the facility and following adoption of any changes to the policy that impact providers.
Patient and 1. Staff educates patients and their families/significant others, as HIPAA allows, family / care about the reason for Restraint use as appropriate, and alternatives to eliminate partner Restraints.
2. Educational materials will be provided to educate and help reduce Restraint use.
Quality
Quality Quality improvement activities performed by designated personnel related to the use activities of Restraint or Seclusion:
Document all episodes of Restraint. Conduct a review of Restraint use monthly to evaluate the effectiveness of the Restraint process and compliance with applicable policies, rules and regulations. Implement corrective actions if additional training is required or process improvement is warranted. Report
o Restraint trends via facility quality reporting structure. o Potential Restraint-related adverse events and/or deaths using the incident reporting system.
Maintain a Restraint log/audit tool. Report to CMS per CMS guidelines
o Each death that occurs while patient is Restrained or within 24 hours of restraint removal.
NOTE: BH has an established procedure for review of a patient’s record and notification to the appropriate authorities when a patient dies while in Restraint.
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Reducing Restraint Risks
Risks 1. Restraints can cause injury and even death. In 1998, the Joint Commission issued a sentinel event alert on preventing Restraint deaths, which identified the following risks:
Placing a restrained patient in a supine position could increase aspiration risk. Placing a restrained patient in a prone position could increase suffocation risk. Using an above-the-neck vest that is not secured properly may increase strangulation risk if the patient slips through side rails. A restraint may cause further psychological trauma or resurfacing of traumatic memories.
2. To help reduce these risks:
A Medical or Behavioral Restraint will be applied safely and appropriately. Monitoring and assessment of the patient must be completed as per policy. Gentle reassurance, support, and frequent contact will be provided to the patient to relieve their fear of the Restraint. Vital signs (pulse, respiration, blood pressure, and oxygen saturation) will be monitored to determine how the patient is responding to the Restraint.
Procedures for Restraints and Seclusion
Assessment and alternative interventions
Step Action 1 Notify LIP immediately of a significant change in patient behavior.
Information: There may be a physiological change that requires immediate intervention. 2 Medical: Identify behaviors that interfere with medical treatment or place the patient at risk of harm.
Behavioral or Chemical: Identify risk factors that might be causing escalating behavior, including:
history of behavioral conditions substance abuse prior physical injury to self or others physical or sexual abuse or stimulus ______Continued on next page
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Procedures for Restraints and Seclusion, continued
Assessment and alternative interventions, continued
Step Action 3 Investigate triggers or contributing factors that may be reasons for the behavior, including:
physical, physiological, psychological and environmental factors 4 Implement preventive strategies and alternative interventions to meet the patient’s needs and eliminate the cause of behaviors that put the patient at risk for restraint/seclusion use.
Note: Several different measures may be required. See Appendix A: Alternative Interventions and Lippincott Procedures (links below).
Restraint Use for a Patient on a Psychiatric Unit
Restraint Use for Assaultive and Violent Behavior
5 Medical: When possible, notify family regarding patient condition and discuss alternatives being considered to reduce necessity for Restraint. 6 Medical: Consider services of a patient care companion (where applicable). 7 Consult with patient’s physician if nursing interventions, de-escalation techniques and/or other alternative interventions are not effective.
Information: Contributing factors such as pain or anxiety, or withdrawal from substances may require medication orders. 8 If additional staff are needed, initiate a Code or the identified response team.(i.e. Swift Response Team, Bert) 9 Document the assessment and alternative interventions that have been implemented and the results. ______
Procedures for Behavioral Restraints / Seclusion ______
Initiating 1. Only Validated Staff will apply Restraints and transport patients to Seclusion. restraint or seclusion 2. Each order for Restraint or Seclusion in violent situations must state the maximum duration of the Restraint or Seclusion according to the following limits.
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Procedures for Behavioral Restraints / Seclusion, continued ______
Initiating Age related time limitations for orders: restraint or seclusion, o Every four hours for patients age 18 and older continued o Every two hours for patients ages 9 through 17 o Every one hour for patients less than age 9
B--UMCS ONLY: o Every three hours for patients who are 18 years old and over o Every two hours for patients who are 12-17 years old o Every hour for patients who are 11 and younger
Orders may be renewed if necessary up to a total of 24 hours in increments stated above.
Face-to-face requirements:
o Evaluation consists of: . 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 or Seclusion o A face-to-face must be completed by Physician, LIP, specially trained RN, or Physician Assistant within one hour of initiating restraints and again with each NEW order (at least every 24 hours). o A face-to-face is not required with each subsequent restraint RENEWAL order. . Exception: In the Arizona Behavioral Health Units and Behavioral Health Hospitals a face-to-face must be completed within one hour of each initiation and renewal order.
Step Action 1 Obtain a written or documented verbal order prior to initiation of Restraint or Seclusion.
Caution: If the need for Restraint or Seclusion arises so quickly that an order cannot be obtained prior to the application of the Restraint or Seclusion, Restraint or Seclusion may be initiated by an RN. The order must be obtained by an RN either during the emergency application of the Restraint or Seclusion or immediately after (within a few minutes) of the application of the Restraint or Seclusion. 2 Notify the attending physician as soon as possible if the attending physician did not order the Restraint. 3 Perform a face-to-face evaluation of the patient as soon as possible, but no later than 1 hour after the initiation of Behavioral/Violent Restraint or Seclusion.
Reminder: If the use of Restraint or Seclusion is discontinued in less than one hour, a face-to-face evaluation must still take place. ______Continued on next page
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Procedures for Behavioral Restraints / Seclusion, continued ______
Care of the 1. Monitoring is performed by Validated Staff. patient in restraints or 2. Monitor the patient for seclusion appropriateness and necessity of Restraints or Seclusion, restraint safely applied, risks associated with the intervention, level of distress or agitation, cognitive status and vital signs if able to obtain IF… THEN The patient is in Behavioral Monitor the patient a minimum of Restraint OR Seclusion every 15 minutes, more frequent or continuously depending on assessment of patient. The patient is in Behavioral Monitor the patient continuously. Restraint AND Seclusion
Information: Continuous monitoring and documentation per above of the following, includes but is not limited to:
Cognitive status Type of intervention used Circulation and range of motion in restrained extremities, Nutrition Hydration Hygiene Elimination Comfort Psychological status
3. Notify Family regarding initiation of Restraint or Seclusion if release obtained from patient.
Note: Minor patient’s parents must be notified within 1 hour after initiation of Restraint or Seclusion.
4. Provide education materials to patient and/or family.
Note: Include criteria for release of Restraint or Seclusion. ______Continued on next page
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Procedures for Behavioral Restraints / Seclusion, continued ______
Discontinuing 1. Discontinue Behavioral Restraint or Seclusion at the earliest possible time, Restraint or regardless of the length of time specified in the order. Seclusion Note: Have a minimum of two staff members release locked/buckled restraints.
Reminder: Once Restraint or Seclusion is discontinued, further use constitutes a new episode and the procedure must start at the beginning including obtaining a new order.
Exception: A Restraint is NOT considered to be discontinued in the following situations:
A temporary, directly-supervised release that occurs for the purpose of caring for a patient's needs (e.g., toileting, feeding, or range of motion exercises) is not considered a discontinuation of the Restraint or Seclusion intervention as long as the patient remains under direct staff supervision. (See Appendix F for enclosure beds)
Documentation Document the following related to Restraints and/or Seclusion:
1. A medical staff member or clinical staff documents the following information in a patient’s medical record before the end of the shift in which the patient is placed in Restraint or Seclusion or, if the patient’s Restraint or Seclusion does not end during the shift in which it began, during the shift in which the patient’s Restraint or Seclusion ends:
Physician/LIP’s order for each episode of Restraint or Seclusion. Initial assessment, including
o Description of behavior that necessitated initiation of Restraint or Seclusion alternative interventions used prior to initiation of Restraint or Seclusion and the effectiveness of alternatives.
Modify, in writing, the patient’s plan of care addressing the use of Restraint or Seclusion. 15 minute checks to include circulation checks (within the scope of the observer), general status, patient comfort, offer of: nutrition/hydration, elimination; VS as ordered; hygiene as needed Findings of the face-to-face evaluation of the patient, including:
o The patient’s current situation; o The patient’s reaction to the intervention;
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Procedures for Behavioral Restraints / Seclusion, continued ______
Documentation, The patient’s medical and behavioral condition; and, (continued) The need to continue or terminate the restraint or seclusion. Hourly assessment to include general condition, continued need for restraint, and patient response. Results of patient monitoring. Reassessment of readiness for discontinuation of Restraint or Seclusion Significant changes in patient condition The names of the medical staff members and personnel members with direct patient contact while the patient was in the Restraint or Seclusion.
2. A staff debriefing shall be completed after each behavioral restraint to identify opportunities for alternatives interventions that may have been more successful.
NOTE: In the event of a death: CMS must be contacted by telephone no later than the close of business the next business day following knowledge of the patient's death. Document in the patient’s medical record the date and time of CMS mandatory reporting and to whom the report was made.
Procedures for Medical Restraints (Non-Violent Restraints)
Application of 1. Unit Manager / Designee: restraints Ensure staffing levels and assignments needed to minimize circumstances that might give rise to Restraint use and to maximize safety when there is an episode of restraint use.
2. Lippincott Procedures: Restraint Application, Limb
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Procedures for Medical Restraints (Non-Violent Restraints), Continued
Application of restraints, Step Action (continued) 1 Obtain an order for Medical/Nonviolent Restraint from the physician or other LIP prior to application of restraints or immediately after application of Restraint t.
Reminders:
The attending physician must be consulted as soon as possible if the attending physician did not order the Restraint.. Use of a “PRN” order for restraint use is not acceptable. 2 Apply Restraint under the direction of a RN, physician, or other licensed independent practitioner (LIP) 3 Obtain an order with each new episode of Restraint and daily if patient restrained greater than 24 hours. 4 Re-assess the patient every 2 hours or more frequently based on the individual needs of the patient.
Note:
Take into consideration o Patient’s condition, o Cognitive status o Risks associated with the chosen intervention, o Type of intervention used
Include in the assessment o Circulation and range of motion in restrained extremities, o Nutrition, o Hydration, o Hygiene, o Elimination, o Comfort, o Physical/psychological status and o Readiness for discontinuation of restraints. 5 Inform patient, patient’s family or authorized representative about reasons for Restraint use. 6 Provide written educational information to patient or family as appropriate. 7 Update the patient’s plan of care.
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Procedures for Medical Restraints (Non-Violent Restraints), Continued
Discontinuing Discontinue Restraint under the supervision of an RN when the condition requiring restraints the Restraint t no longer exists.
Reminder: Once Restraint discontinued, further use constitutes a new episode and the procedure must start at the beginning including requiring a new order.
Exception: A Restraint is NOT considered to be discontinued in the following situations:
A temporary, directly-supervised release that occurs for the purpose of caring for a patient's needs (e.g., toileting, feeding, or range of motion exercises) is not considered a discontinuation of the Restraint. As long as the patient remains under direct staff supervision, the restraint is not considered to be discontinued because the staff member is present and is serving the same purpose as the Restraint.
Documentation 1. Document the following:
Physician or LIP’s order for Medical Restraint (non-Violent Restraint) use. Initial assessment, including
o Description of behavior that necessitated initiation of Restraint use, o Alternative interventions used prior to initiation of restraints and o The effectiveness of the alternatives.
Reassessment of patient every two hours, at minimum, including readiness for discontinuation of restraints. Significant changes in patient condition Modification to the patient’s plan of care addressing the use of Restraint.
Other Information
References American Psychiatric Nurses Association. Seclusion & Restraint Standards of Practice. May 2000; Revised May 2007; revised April 2014. California Chapter: 20152016 AB1194 Section 1. (Amends) - Chaptered (Stats.2015 Ch.570) California Health and Safety Code
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Other Information, Continued
References, Centers for Medicare and Medicaid Services. (2008). State operations manual: (continued) Appendix A: Interpretive guidelines. Retrieved November 12, 2009 from http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf Federal Register/ Vol. 71, No. 236/ December 8, 2006/Rules and Regulations. Department of Health and Human Services, 42 CFR Part 482 Medicare & Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights; Final Rule. Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH). (2016). Standards PC.03.03.01 through PC.03.05.19. Park, M. and Tang, JH. Evidence-Based Guideline: Changing the Practice of Physical Restraint Use in Acute Care. (2007). J of Gerontol Nursing; 33(2): 9- 16. Powe, M. (2017). CMS Clarifies PA Ordering of Restraint and Seclusion. Retrieved September 29, 2017 from https://www.aapa.org/career-central/practice- resources/cms-clarifies-pa-ordering-restraint-seclusion/
Other related Safety Precautions: Suicide, Danger to Self, and Danger to Others in Non- policies Behavioral Health Settings for Adults, Children, and Adolescents
Behavioral Health Nursing Standards of Care
Keywords Alternatives Behavioral Restraints Enclosed Beds Freedom Splint Locked Restraints Medical Restraint Non-emergent Non-violent Behavior Non-violent Restraints Restraint Alternatives Restraints Seclusion Soft Restraints Violent Behavior Violent Restraints
Appendix Appendix A: Alternatives to Restraints Appendix B: When Side Rails are, or are not, Restraints Appendix C: Exception – PRN Orders per CMS Rules Appendix D: Quick reference on Medical and Behavioral Restraint/Seclusion Appendix E: Enclosure Beds
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APPENDIX A: Alternatives to Restraints
Physical Approaches to reduce restraint use through physical modification. modification
Alternative Examples Modify environment Increase/decrease lighting establish wandering paths disguise exits room or bed change If applicable: take outside Adapt wheelchairs Wedge pillow Lap buddy. Provide body props / postural Wedge pillow enhancer Lap buddy Install alarm/safety devices Bed or chair alarm. Reduce unnecessary visual or Eliminate buzzers auditory stimuli Bells Intercoms Television Shut doors If applicable: Use of the “Quiet Room” Personalize rooms Use secured unit Behavioral Health Units
Activities Activity related approaches to reduce restraint use.
Activity Example Consider PT/OT/RT consult. If applicable: Pet therapy, increase contact with RT staff Structure daily activities Utilize orientation boards in rooms. Increase staff 1:1 time with patient Permit or encourage wandering/pacing Provide physical exercise Ambulation, Stretches
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APPENDIX A: Alternatives to Restraints, Continued
Activities, (continued)
Activity Example Provide appropriate assistive Cane devices Walker Wheelchair Slide board On BeH: units ensure appropriate devices are allowed Provide appropriate Radio, TV, Video stimulation/socialization Headphones, hand held games
Physiological Physiological and nursing care approaches to reduce Restraint use that would be and nursing appropriate for the type of setting may include: care Evaluate underlying physical or psychological problems. Relieve fear and remind the patient they are safe; allow a safe object for comfort Evaluate sleep patterns; Schedule daily nap. Relieve pain, anxiety Relieve hunger; provide snacks Relieve boredom; play cards, games, increase engagement through scheduled 1:1 contact (“I will be back to talk to you at 2:00”) Provide frequent reminders and choices to avoid a specific behavior Provide repeated reassurances or limits as needed Use appropriate footwear such as slipper socks, supportive shoes Use eyeglasses, hearing aids, or dentures Adequate hydration (consider consult with Clinical Dietitian). Relocate near nursing station for increased engagement Institute toileting schedule. Implement repositioning techniques. Reevaluate drug use/medications Take out of room as appropriate. Provide diversion/recreation (e.g. busy box, book, journal writing, contacting a friend). All personal items within reach
o Water, Hearing aide, glasses, dentures, Kleenex, call light, Urinal.
Provide bath/shower/massage
o Back rub, foot rub.
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APPENDIX A: Alternatives to Restraints, Continued
Psychological Physiological approaches to reduce Restraint use include: approaches Consider Social Services/Case Management consult Actively listen / explore feelings and perceptions of patient. Encourage independence in other aspects of care. Provide reality orientation (e.g. orientation boards, clocks). Accept patient’s perceptions of their reality and relieve distress if possible Provide additional engagement
o Family and friends to sit with patient. o Phone Calls to support persons
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APPENDIX B: When Side Rails Are, or Are Not, Restraints
The risk of 1. When deciding whether or not to use side rails remember that the risk using side presented by side rail use should be weighed against the risk presented rails by the patient's behavior.
2. Risks of using side rails:
Frail elderly patients may be at risk for entrapment or entanglement between the mattress or bed frame and the side rail.
Disoriented patients may
o View a raised side rail as a barrier to climb over, o Slide between raised, segmented side rails, o Scoot to the end of the bed to get around a raised side rail and exit the bed.
Falls from the greater height posed by the raised side rail
o Possibility for sustaining greater injury or death than if the patient had fallen from the height of a lowered bed without raised side rails.
Determining whether or Side rails ARE a Restraint if Side rails ARE NOT a Restraint if not side rails The purpose of the side rails is to The purpose of the side rails is to are a restrict the patient’s freedom to exit the prevent the patient from falling out of Restraint bed. the bed.
Example: Examples include when the patient is:
The patient does not remain in bed On a stretcher,
in spite of repeated reminders to Recovering from anesthesia,
stay on bed rest, so the staff raises Sedated, all side rails. Experiencing involuntary o In this case, the patient is movement, restricted from freely moving his On certain types of therapeutic body. In this case, the side rails beds, are a restraint. Not physically able to get out of bed regardless of whether the side rails are raised or not.
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APPENDIX B: When Side Rails Are, or Are Not, Restraints, Continued
The number of side rails IF THEN 1 The bed has 4 segmented side The side rails are considered a restraint rails, and all 4 side rails are raised because the patient’s movement is to keep the patient in bed restricted, and an order is required 2 The bed has 2 long side rails and The side rails are considered a restraint both side rails are raised to keep because the patient’s movement is the patient in bed restricted, and an order is required 3 The bed has 4 segmented side The side rails are not considered a rails, and 3 or less are raised restraint because the patient can freely
move to get out of bed. No order is required. 4 The bed has 2 long side rails and The side rails are not considered a only 1 is raised restraint because the patient can freely move to get out of bed. No order is required. 5 The patient is sedated due to pain The side rails are not a restraint, medication and all side rails are because they are up for patient safety raised. 6 The patient is on a stretcher in the The side rails are not a restraint, ED or other area where narrow because the narrowness of the stretchers are used stretcher impacts patient safety. The side rails help the patient move on the
stretcher and prevent falls.
7 A patient is on a bed that constantly The raised side rails are a safety moves to improve circulation or intervention to prevent the patient from prevents skin breakdown, falling out of bed and are not viewed as restraint. 8 A patient is placed on seizure The use of side rails would not be precautions and all side rails are considered restraint. The use of padded raised, side rails in this situation should protect the patient from harm; including falling out of bed should the patient have a seizure. 9 An infant or toddler is placed in a Placement in a crib with raised rails is crib with raised rails an age-appropriate standard safety practice for every infant or toddler and would not be considered restraint.
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APPENDIX C: Exceptions – PRN Orders per CMS Rules
Geri Chairs If a patient requires the use of a Geri chair with the tray locked in place in order for the patient to safely be out of bed, a standing or PRN order is permitted.
Note: Given that a patient may be out of bed in a Geri chair several times a day, it is not necessary to obtain a new order each time.
Example: A patient had a stroke and is unable to move one side. The patient also has problems with balance of his upper body. In order for the patient to be safely out of bed, a geri chair, with the tray locked in place, may be necessary to prevent the patient from falling out of the chair.
Raised side If a patient's status requires that all bedrails be raised (restraint) while the patient rails is in bed, a standing or PRN order is permitted. It is not necessary to obtain a new order each time the patient is returned to bed after being out of bed.
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APPENDIX D: Quick Reference on the Difference between Medical/Non- Violent and Behavioral Health/Violent Restraint/Seclusion
Restraint 1. Restraint – any method or device that immobilizes or reduces a patient from Review: normal freedom of movement
2. What type of restraint category does your patient fall under? First determine the purpose of the restraint application – see III below and/or table.
3. When does a “restraint” NOT fall under restraint monitoring criteria? When restraints are used for:
Treatment immobilization such as
o During a medical/diagnostic or surgical procedure o Arm board for IV administration
Postural support devices used for proper body position and balance (e.g. prosthetic devices) Any device that can be readily removed by the patient (e.g. self-releasing lap belt)
4. If the restraint does not fall under any of the categories in section III, check out the table below. Classification of restraints is determined by reason for the restraint. Classification of restraint is NOT based on patient diagnosis or on the materials used to restrain the patient.
ALWAYS ATTEMPT ALTERNATIVE MEASURES BEFORE ANY RESTRAINT Alternative Examples: measures for Ask patient what would help all patients Increase frequency of engagement w/patient Moving patient closer to nursing station Reduce external stimuli De-escalation strategies Need for appropriate medication such as pain medicine, psychotropic meds(anxiolytics, antipsychotics)** Re-orientation. Diversional activities Ambulation/exercise Bed alarms/ wander-guard alarms Staff/family/friend involvement with patient
**Sedation is not considered an alternative – sedation may be a form of chemical restraint
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APPENDIX D: Quick Reference on the Difference between Medical/Non- Violent and Behavioral Health/Violent Restraint/Seclusion, Continued
Medical/Non-Violent Restraint Behavioral/Violent Restraint (DTO/DTS) Determine If restraint is being used to: If restraint is being used to: cause for restraint use Allow medical treatment to continue Non-BeH Units: Control behaviors without interruption that pose an imminent danger to the Prevent accidental or deliberate physical safety of the patient, staff or removal of essential tubes or drains others Provide medical safety when the BeH Units: Control behaviors that patient is unable to follow direction pose an imminent danger to the physical safety of staff, others o ALOC RELATED TO MEDICAL (SECLUSION) CONDITION (i.e.: hypoglycemia, BeH Units: Control behaviors that altered blood gasses, altered pose an imminent danger to the electrolyte, ICU psychosis) physical safety of the patient or staff and others (RESTRAINT)
Restraint Medical/Non-Violent Restraint Behavioral/Violent Restraint Classification (DTO/DTS) Emergency RN WITH documentation of reason for RN WITH documentation of reason for Application use, patient condition and failed/ use, patient condition and failed/ ineffective alternative measures ineffective alternative measures attempted attempted Telephone or RN to notify provider as soon as RN to notify provider as soon as Verbal Order possible after initiating restraints possible after initiating restraints Provider Provider or Trained RN/PA face to face Trained RN assessment within one hour of initiating Face-to-Face restraints, and again with each NEW Assessment order (at least every 24 hours).
Exception: In the Arizona Behavioral Health Units and Behavioral Health Hospitals, a face-to-face must be completed within one hour of each initiation and renewal order.
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APPENDIX D: Quick Reference on the Difference between Medical/Non- Violent and Behavioral Health/Violent Restraint/Seclusion, continued
Restraint Medical/Non-Violent Restraint Behavioral/Violent Restraint (DTO/DTS) Classification Initiate as soon as possible Limited to: 4 h- 18yrs and older; 2 h- 9yrs-17yrs; 1 h- less than 9 yrs. old
B--UMCS ONLY: 3 h – 18 yrs. old and older 2 h – 12-17 yrs. old 1 h – 11 years and younger
Each order for Violent restraint may only be renewed in accordance to the Order Set above limits up to 24hrs. Orders Initiate as soon as possible; and Renew daily A face-to-face must be completed by Physician, LIP, specially trained RN, or Physician Assistant within one hour of initiating restraints, and again with each NEW order (at least every 24 hours). A face-to-face is not required with each subsequent restraint RENEWAL order. o EXCEPTION: In the Arizona Behavioral Health Units and Behavioral Health Hospitals a face-to-face must be completed with one hour of each initiation and renewal order. May be done by RN/Provider based on Discontinuing May be done by RN/ Provider assessment. All Restraints are removed Restraints when the patient meets the criteria for removal Q 15 min documentation; 1:1 or more as Minimum every 2h Observation clinically needed (i.e. pregnant, obesity, etc.) Nursing Care Plan Update – IPOC: Restraint Use Management. Nursing Care Plan Update – IPOC: Restraint RN Must ------Use Management. Document on initiation Document RN Document every 1hr. while restrained and an assessment at least every shift, reflecting general condition, continued need continued need for restraint, and patient for restraint, and patient response; RN response Document 1 hr. after restraint discontinued for DTO/DTS restraints
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APPENDIX D: Quick Reference on the Difference between Medical/Non- Violent and Behavioral Health/Violent Restraint/Seclusion, Continued
Restraint Medical/Non-Violent Restraint Behavioral/Violent Restraint Classification (DTO/DTS) Document by Every two hours for skin check; Every 15 minutes for circulation checks, Assigned physical/mental condition; nutrition/ general status, patient comfort, offer of: Nursing Staff hydration status; elimination; hygiene; nutrition/hydration, elimination; VS as (RN, BHS, CNA, offering of fluids and toileting; ROM ordered; hygiene as needed; Every 2 hours Observer) exercises (with release of individual for ROM exercises (with release of individual restraint) on appropriate restraint flow sheet restraint), documented on appropriate restraint flow sheet Adult: Notify Guardian and Caregiver (i.e. family, spouse, support) regarding initiation Notify Caregiver (i.e. family, spouse, of restraint or seclusion if release obtained Notification support) and/or Guardian regarding initiation from patient. of restraint Minor: patient’s parents must be notified within 1 hour after initiation of restraint or seclusion Patient Education within 24 h to be held with Debriefing within 24 h to be held with Debriefing, staff & patient (and family if appropriate) staff & patient (and family if appropriate) Education after event.1 Staff Debriefing Debriefing within 24 h to be held with staff Supine position only. Follow Supine position is preferred positioning. Body manufacturer instructions. Pregnant Position wrists at side. Alternative Alignment patients are placed on their left side. positioning, e.g. one arm restrained over the patient’s head, may be required based on the patient’s behavior and risk of harm to themselves or staff. No longer than 15 min. On BeH units, Physical Hold no restraints on ground or carrying patients to seclusion room. Staff are required to review the skills learned in the de-escalation and restraint and Practice Skills seclusion application routinely. Each facility will determine the frequency of practice required.
1 When the restraint episode ends, a nurse or another qualified caregiver should debrief the patient. Reviewing the restraint episode with the patient yields important information that can help lead to restraint-free treatment. Information gained from debriefing helps the treatment team design therapeutic interventions that may help prevent the need for restraints. Be sure to document the debriefing.
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APPENDIX E: Enclosure Beds
An enclosed bed is considered medically necessary for individuals with seizures, disorientation, vertigo, and neurological disorders, where the individual needs to be restrained in bed. Clinical documentation must be provided that states less invasive strategies (i.e., bed rails, bed rail protectors, or environmental modifications) have been tried and have not been successful. A physician order is required for the use of an enclosure bed.
CMS defines a restraint in 42CFR 482.13.e.1
A physical restraint is any manual method, or physical, or mechanical device, material, or equipment, attached or adjacent to the patient's body that he or she cannot easily remove, that restricts freedom of movement or normal access to one's body. Therefore, since the patient cannot remove him or herself from the Bed Canopy system on their own, it is considered a restraint under CMS regulations. The same is also true for the Joint Commission regulations, and requires implementation of the facility’s restraint policies and procedures.
The Posey Bed Canopy System or other enclosed beds are considered restraints and meet the above definition of restraint. The above documentation and monitoring requirements for medical/nonviolent restraint also apply to the patient in an enclosure bed.
If the enclosure bed is unzipped and the patient is able to get out of the bed even if the patient has a 1:1 observer, the restraint is considered to be removed and a new order is required if the patient is returned to the zipped enclosure bed. The patient may be temporarily removed from the bed for ADL activities such as toileting and feeding and returned to the bed. This is considered continuous use and a new order is not required.
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