Focus o n... Safe Use of Restraints

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a When and how to use restraints r t s e Learn about possible indications for restraint, types of restraints, R f and how to monitor patients in restraint. o e

s By Gale Springer, RN, MSN, PMHCNS-BC U e f ew things cause as much angst who are violent or aggressive, a for a nurse as placing a patient threatening to hit or striking staff, or S .

. Fin a restraint, who may feel his banging their head on the wall, who .

n or her personal freedom is being need to be stopped from causing

o taken away. But in certain situa - further injury to themselves or oth -

s tions, restraining a patient is the on - ers. The goal of using such restraints u ly option that ensures the safety of is to keep the patient and staff safe c

o the patient and others. in an emergency situation. For ex -

F As nurses, we’re ethically obli - ample, a patient responding to hal - gated to ensure the patient’s basic lucinations that commands him or right not to be subjected to inap - her to hurt staff and lunge aggres - propriate restraint use. Restraints sively may need a physical restraint must not be used for coercion, to protect everyone involved. punishment, discipline, or staff con - venience. Improper restraint use Chemical restraint can lead to serious sanctions by the Chemical restraint involves use of state health department, The Joint a drug to restrict a patient’s move - Commission (TJC), or both. Use re - ment or behavior, where the drug straints only to help keep the pa - or dosage used isn’t an approved tient, staff, other patients, and visi - movement (such as when giving an standard of treatment for the pa - tors safe—and only as a last resort. intramuscular injection against the tient’s condition. For example, a patient’s will) is considered a physi - provider may order in Categories of restraints cal restraint. A physical restraint a high dosage for a postsurgical pa - Three general categories of re - may be used for either nonviolent, tient who won’t go to sleep. (If the straints exist—physical restraint, nonself-destructive behavior or vio - drug is a standard treatment for the chemical restraint, and seclusion. lent, self-destructive behavior. (See patient’s condition, such as an an - What isn’t a restraint? ) tipsychotic for a patient with psy - Physical restraint Restraints for nonviolent, non - chosis or a ben zodiazepine for a Physical restraint, the most fre - self-destructive behavior . Typically, patient with alco hol-withdrawal quently used type, is a specific these types of physical restraints delirium, and the ordered dosage is intervention or device that prevents are interventions to keep appropriate, it’s not considered a the patient from moving freely or the patient from pulling at tubes, chemical restraint.) Many healthcare restricts normal access to the pa - drains, and lines or to prevent the facilities prohibit use of tient’s own body. Physical restraint patient from ambulating when it’s for chemical restraint. may involve: unsafe to do so—in other words, to • applying a wrist, ankle, or waist enhance patient care. For example, Seclusion restraint a restraint used for nonviolent be - With seclusion, a patient is held in a • tucking in a sheet very tightly so havior may be appropriate for a room involuntarily and prevented the patient can’t move patient with an unsteady gait, in - from leaving. Many emergency de - • keeping all side rails up to pre - creasing confusion, agitation, rest - partments and psychiatric units have vent the patient from getting out lessness, and a known history of a seclusion room. Typically, med - of bed , who now has a urinary ical-surgical units don’t have such a • using an enclosure bed. tract infection and keeps pulling room, so this restraint option isn’t Typically, if the patient can easily out his I.V. line. available. Seclusion is used only for remove the device, it doesn’t qualify Restraints for violent, self-destruc - patients who are behaving violently. as a physical restraint. Also, holding tive behavior . These restraints are Use of a physical restraint together a patient in a manner that restricts devices or interventions for patients with seclusion for a patient who’s

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What isn’t a restraint? u s

The following items aren’t consid - behaving in a violent or self-de - ered restraints: straint. Facility leaders should focus o structive manner requires continu - on reducing restraint use by sup - n

• devices used to immobilize a pa - . . ous nursing monitoring. tient temporarily during a diag - porting ongoing monitoring and . nostic procedure quality-improvement projects. S a

Determining when to use a • orthopedic supportive devices To help ensure a restraint is ap - f • helmets or age-appropriate pro - plied safely, nurses should receive e restraint The patient’s current behavior de - tective equipment, such as hands-on training on safe, appropri - U

strollers and cribs. s

termines if and when a restraint is ate application of each type of re - e needed. A history of violence or a straint before they’re required to

Keeping all side rails up on a bed o

previous fall alone isn’t enough to for seizure precautions and placing apply it. Such training also should f

support using a restraint. The deci - the patient on a narrow stretcher are occur during orientation and should R sion must be based on a current considered safety interventions, not be reinforced periodically. e s thorough medical and psychosocial restraints. The goal is to use the least re - t r nursing assessment. Sometimes, ad - strictive type of restraint possible, a i dressing the issue that’s underlying and only as a last resort when the n t

a patient’s disruptive behavior may the following risks: risk of injury to the patient or oth - s eliminate the need for a restraint. • Placing a restrained patient in a ers is unacceptably high. Consider Also, caregivers must weigh the supine position could increase using restraint only after unsuccess - risks of using a restraint, which aspiration risk. ful use of alternatives, and only as could cause physical or psychologi - • Placing a restrained patient in a long as the unsafe situation occurs. cal trauma, against the risk of not prone position could increase Remember—restraint use is an ex - using it, which could potentially re - suffocation risk. ceptional event and shouldn’t be a sult in the patient harming him- or • Using an above-the-neck vest part of a routine protocol. • herself or others. Input from the that’s not secured properly may entire care team can help the increase strangulation risk if the Selected references provider decide whether to use a patient slips through the side American Psychiatric Nurses Association. restraint. rails. APNA Position Statement on the Use of Seclusion and Restraint. Original 2000; re - • A restraint may cause further vised 2007; revised 2014. www.apna.org/i4a/ Alternatives to restraints psychological trauma or resurfac - pages/index.cfm?pageid=3728. Accessed Use restraints only as a last resort, ing of traumatic memories. November 4, 2014. after attempting or exploring alter - To help reduce these risks, make American Psychiatric Nurses Association. natives. Alternatives include having sure a physical restraint is applied Seclusion & Restraint Standards of Practice. staff or a family member sit with safely and appropriately. With all May 2000; Revised May 2007; revised April the patient, using distraction or de- types of restraints, monitor and as - 2014. www.apna.org/i4a/pages/index.cfm? pageid=3730. Accessed November 4, 2014. escalation strategies, offering reassur - sess the patient frequently. To re - ance, using bed or chair alarms, and lieve the patient’s fear of the re - Federal Register. Part II; Department of Health and Human Services, Centers for administering certain medications. straint, provide gentle reassurance, Medicare & Medicaid Services; Medicare and If appropriate alternatives have support, and frequent contact. Mon - Medicaid Programs. 42 CFR Part 482; Medi - been attempted or considered but itor vital signs (pulse, respiration, care and Medicaid Programs; Condi - have proven insufficient or ineffec - blood pressure, and oxygen satura - tions of Participation: Patients’ Rights; Final tive or are deemed potentially un - tion) to help determine how the Rule. December 8, 2006. www.cms.gov/ Regulations-and-Guidance/Legislation/ successful, restraint may be appro - patient is responding to the re - CFCsAndCoPs/downloads/finalpatientrights priate. A provider order must be straint. rule.pdf. Accessed November 26, 2014. obtained for patient restraint. Be Joint Commission, The. Hospital Accredita - sure to update and revise the care Changing the culture tion Standards. Provision of Care, Treatment plan for a restrained patient to help The American Psychiatric Nurses and Services. Standards PC.03.05.01 through find ways to reduce the restraint Association’s position statement on PC.03.05.19. 2010. period and prevent further restraint the use of restraint suggests a unit’s Joint Commission, The. Sentinel Event Alert. episodes. philosophy on restraint use can in - Issue 8, November 18, 1998. Preventing Re - fluence how many patients are straint Deaths. www.jointcommission.org/ assets/1/18/SEA_8.pdf. Accessed November Reducing restraint risks placed in restraints. Interacting with 4, 2014. Restraints can cause injury and patients in a positive, calm, respect - even death. In 1998, TJC issued a ful, and collaborative manner and Gale Springer is a mental health clinical nurse sentinel event alert on preventing intervening early when conflict aris - specialist at the Providence Regional Medical in restraint deaths, which identified es can diminish the need for re - Everett, Washington.

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a Choosing the right restraint r t s e Keeping patients and others safe is crucial, but restraints R f should be used only as a last resort. o e

s By Christy Rose, MSN, RN, CCRN, CNRN U e f a urses at the bedside are ex - or manual locked restraints. If such patients who meet the criteria for S .

. perts in driving the safest, options don’t apply to your patient, this bed. (For more information, .

n Nmost effective patient care. In proceed with restraints applicable read “Enclosure bed: A protective

o some cases, nursing assessment for nonviolent, nonself-destructive and calming restraint” in this issue.)

s and clinical judgment suggest the patients, such as mitts, soft wrist u need to apply restraints. A patient restraints, or a chest vest. (See De - c Chest vests and lap belts

o who is violent or self-destructive or cision tree for nonviolent, nonself- Chest vests and lap belts (also

F whose behavior jeopardizes the im - destructive restraint .) called waist belts) may be warrant - mediate physical safety of him- or ed for confused or impulsive pa - herself or another person may Restraint options tients who are continually trying to meet the behavioral health require - Which type of restraint to use de - get out of bed or a chair after re - ments for restraints. Examples of pends on the patient’s behavior peated redirection, when it’s unsafe such behaviors include: and condition. for them to get up unaided. Apply • hitting, kicking, or pushing the vest or belt according to the • pulling on an I.V. line, tube, or Hand mitts and freedom sleeves manufacturer’s instructions. Fasten other medical equipment or de - If the patient is confused and im - it securely to an immovable part of vice needed to treat the patient’s pulsive and doesn’t follow direc - the bed or chair. Make sure you condition tions but can be redirected, consid - can easily slide your fingers under - • attempting to get out of a bed, er hand mitts to decrease grabbing neath the vest or belt so it’s not chair, or hospital room before ability. Or consider “freedom too tight. It shouldn’t press uncom - discharge, in patients who are sleeves” (also called soft splints). fortably against the skin, which confused or otherwise unable to These are a good deterrent for pa - could cause redness or impede ex - follow safety directions. tients trying to remove a medical pansion of the patient’s midsection Before using restraints, always device from the face or head (such during respiration. Instruct the pa - explore alternatives for keeping the as a nasogastric tube or drain). tient to call for assistance when he patient and others safe. When con - With freedom sleeves, patients or she wants to get up. sidering such options, discuss with have difficulty bending their arms. the patient any conditions that may Be aware, though, that the sleeves Limb restraints need to be addressed, such as don’t necessarily prevent them Soft bilateral limb holders on both pain, anxiety, fear, or depression. If from removing I.V. lines. wrists may be appropriate for pa - distraction and other alternatives Hand mitts and freedom sleeves tients who are becoming increas - prove ineffective at calming the pa - let the patient move the arms up ingly agitated, can’t be redirected tient and he or she continues to and down but limit the ability to with distraction, and keep trying to pose a risk, consult with other bend and grab tubes or drains. remove needed medical devices. healthcare team members. You may They can be removed by unstrap - When device removal would pose want to use an algorithm to help ping the hook-and-loop closures serious harm to the patient and determine if your patient requires and sliding them off the arms. Be cause a significant setback to re - restraints. (To access the author’s sure to monitor patients closely be - covery, or if the patient is a physi - algorithm, visit www.American cause they may try to remove these cal threat to him- or herself or oth - NurseToday.com/Archives.aspx .) restraints themselves. ers, limb restraints help protect the Placing a patient in restraints re - patient and staff and remind the quires a consult from the behav - Enclosure bed patient not to pull on the device. ioral health team to consider be - An enclosure bed helps prevent Typically, these restraints are used havioral restraint options—for patient injury by stopping the pa - for patients in intensive care units instance, certain medications, dis - tient from getting out of bed unas - who have endotracheal tubes, in - traction, seclusion, blanket wraps, sisted. It may be a good option for tracranial pressure monitoring de -

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Decision tree for nonviolent, nonself-destructive restraint u s

selves or others. Care - o

givers may use a com - n . .

bination of chemical se - . dation and four-point S a

restraints to calm the f patient as long as he or e

she poses a danger. U s

Monitor the patient e

in four-point restraints o

every 15 minutes. Know f

that these restraints R must be reduced and e s

removed as soon as t r

safely possible. To re - a i

duce a four-point re - n t

straint, remove it slow - s ly—usually one point at a time—as the patient becomes calmer. During removal, reorient the patient and contract with him or her for safe behavior.

A last resort Keeping patients and others safe is extremely important, but restraints should be used only as a last resort. When they’re needed, choose the least restrictive re - straint possible. Re - assess a restrained pa - tient continually and remove restraints as soon as possible. During the restraint episode, educate pa - © Christy Rose, MSN, RN, CCRN, CNRN. 2014. tients and their families about the restraints and vices, chest tubes, external fixators, straint, or both. These methods keep them engaged in the care the skeletal traction, or other devices should be used only for short peri - patient’s receiving. Be sure to docu - whose removal would imperil the ods. Monitoring requirements may ment your assessment findings and patient’s health. In many cases, call for one-to-one observation. Soft progress toward restraint removal to these patients are receiving seda - limb restraints are preferred, but help “tell the story” of the restraint tives or opioids to relieve pain and locked cuff restraints can be used incident. • anxiety, impairing their safety if soft restraints prove ineffective. awareness. Chemical restraints require a pro - Visit www.americannursetoday.com/?p= In more extreme cases, patients vider assessment and a one-time or - 18948 for information on distraction tech - who are severely agitated or intoxi - der with close patient monitoring. niques and on applying restraints and a list cated, are undergoing alcohol or Four-point restraints, which re - of selected references. drug withdrawal, or can’t follow strain both arms and both legs, Christy Rose is a staff nurse in the surgical intensive safety directions may require arm usually are reserved for violent pa - care unit at Denver Health Medical Center in Denver, and leg restraints, chemical re - tients who pose a danger to them - Colorado. www.AmericanNurseToday.com January 2015 American Nurse Today 29 s t n i

a Enclosure bed: A protective and r t s e

R calming restraint f o

e Learn about an alternative to more restrictive restraints. s

U By Jennifer L. Harris, RN, MS, NE-BC e f a n enclosure bed can be used S .

. as part of a patient’s plan of . A look at the

n Acare to prevent falls and pro -

o vide a safer environment. This spe -

enclosure bed s cialty bed has a mesh tent connect -

u The enclosure bed ed to a frame placed over a c shown here (manufac - o standard medical-surgical bed. Al - tured by Posey Co.) is F though it’s considered a restraint for adults and children. because it limits the patient’s ability A casing over the mat - to get out of bed, an enclosure bed tress is attached to the is less restrictive than other types sides, preventing the of restraints. It can be used as an patient from slipping alternative when a vest restraint underneath. The proce - would cause more agitation and dures used to elevate wrist restraints aren’t appropriate. the head of the bed My 750-bed academic medical and change bed height are the same as those center became interested in the en - for a standard med- closure bed in 2007 as a way to surg bed. decrease patient falls and patient- sitter costs. We’ve seen the enclo - sure bed have a calming effect on delays. The bed also may be indi - enclosure bed if they are violent, patients and give them more free - cated for patients recovering from combative, self-destructive, suicidal, dom than wrist and ankle re - stroke, as well as for patients with or claustrophobic. Although the straints. Our hospital rents the bed; delirium associated with alcohol bed has small holes for one or two for a 24-hour period, the daily withdrawal who have completed I.V. lines and an indwelling urinary rental expense is much lower than treatment for acute withdrawal. catheter, patients with multiple the cost of a patient sitter. (See A lines generally are excluded. If the look at the enclosure bed .) Inclusion criteria patient becomes increasingly agitat - To be considered for the enclo - ed, terrified, or distraught after be - Indications sure bed, the patient must be at ing placed in the bed, clinicians Use of the enclosure bed hinges on high risk for falling and must must reassess the situation and try the patient’s behavior, so a patient- demonstrate one or more of the a different intervention. specific comprehensive assessment following: must be done. The bed may be in - • impulsiveness Evaluation period dicated for patients who are at high • agitation Before our hospital decided to add risk for falls; are confused, impul - • inability or unwillingness to ask the enclosure bed to our approved sive, restless, or agitated; are unable for assistance or respond to redi - specialty rental inventory, staff to ask for assistance or respond to rection nurses and other providers con - redirection; or who climb out of • unsteady gait ducted an evaluation to identify pa - bed when it’s unsafe to do so. • wandering behavior. tient risk behaviors that could be Other patients who might bene - A history of falling alone isn’t managed in this bed. The hospital fit from an enclosure bed include enough to warrant use of the en - conducted a 6-month trial of the those with Alzheimer’s disease or closure bed or other restraints. enclosure bed, during which staff other types of dementia, traumatic used the bed and completed an brain injury, seizure disorder, Hunt - Exclusion criteria evaluation tool. The tool asked ington’s disease, or developmental Patients shouldn’t be placed in an specific questions about staff com -

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fort level with the bed, ease of use, tion. Once the decision to use an a discontinuation of the restraint. o family response to the bed, and enclosure bed is made, clinicians As long as the patient remains n . .

whether the bed met the patient’s must educate the family about the under direct staff supervision, the . needs. bed, its function, the reason for us - restraint is not considered to be S a

ing it, how the panels are zipped discontinued because the staff f and unzipped, and how the bed member is present and is serving e Education and implementation Based on staff feedback and posi - contributes to a cocoon-like envi - the same purpose as the restraint.” U s

tive patient outcomes during the ronment. If family members aren’t e evaluation, the enclosure bed was available in the hospital, the charge

Outcomes o

added to potential interventions to nurse contacts a family member by In our hospital, the enclosure bed f

prevent falls and to provide a safer phone to explain the change in the was incorporated quickly into the R environment for patients. Our facil - patient’s care. safety plan for med-surg patients. e s ity has developed processes to re - Using a restraint flowsheet, nurs - The adult med-surg nursing staff t r quest or order the bed, monitor the ing staff document the patient’s re - has used the bed with more than a i patient while in the bed, and dis - sponse to the enclosure bed and 200 patients. On average, patients n t

continue the bed. the frequency with which they met stay in the bed about 6 days; no s The enclosure bed was intro - the patient’s care needs during bed patient falls or injuries have oc - duced as a type of restraint to use. curred. In some facilities, using the providers who have the authority When the patient’s behavior im - bed decreases overall sitter expens - to order restraints. Staff nurses re - proves, the enclosure bed is dis - es. Our experience has shown a ceived education on indications for continued. The specialty bed coor - slight reduction in sitter hours the bed, how to operate it, and dinator is notified and the vendor when the bed is used. documentation requirements. Nurs - picks up the bed. Based on our positive experi - ing staff at the unit level worked ences and patient outcomes, we with provider teams to implement Placing the patient in the bed will continue to use the enclosure the enclosure bed. Before using the bed, inspect it for bed as an option for fall prevention Education consisted of reviewing proper assembly. Then unzip the and patient safety. the procedural checklist, watching bed and adjust the head of the Several patients have been dis - an instructional video and complet - bed. Once the patient has been charged from our hospital with a ing a self-learning module on re - placed in the bed, sit in a chair plan of care that included an enclo - straint use. During the demonstra - next to the bed for a few minutes sure bed. In the home, the bed can tion on how to zip the panels and with the sides unzipped to help be used for patients with agitation use the locks on the zippers, nurs - him or her get acclimated. Adjust secondary to dementia or for pedi - es had the chance to get into the the head of the bed so the patient atric patients with significant chron - bed to see what it’s like. can sit in it comfortably. Then zip ic neurologic or behavioral prob - the sides and see how the patient lems. The experience the families Required processes reacts to the enclosure. If the pa - gained with the enclosure bed in Before an enclosure bed is request - tient will be left alone, place a call the hospital helped provide a safe ed, nursing staff must review with button within reach. discharge plan for several patients. the provider team the behavior that The patient’s activity schedule Involving staff with an initial tri - puts the patient at risk for falls and should include getting him or her al of the bed, identifying appropri - injury, as well as for impulsive be - out of the bed multiple times a ate patient criteria, and educating havior that harm the patient or day. Staff should assist the patient staff, patients, and families about staff. One example is an impulsive to ambulate at least three times the bed’s benefits have contributed patient with early-onset dementia daily. The patient should sit in a to successful implementation of who is hitting and kicking at staff. bedside chair for all meals, if able this specialty bed. • As with all restraints, an enclo - to tolerate ambulation and activity. sure bed requires a provider re - According to the Centers for Visit www.americannursetoday.com/?p= straint order that must be renewed Medicare & Medicaid Services’ 18950 for information on caring for a patient every 24 hours. Before a patient is Interpretive Guideline §482.13(e) in an enclosure bed, using the enclosure bed placed in the bed, staff try less re - (6), “a temporary, directly super - with pediatric patients, and a list of selected references. strictive options, such as distrac - vised release…for the purposes tion, bed and chair alarms, reduc - of caring for a patient’s needs Jennifer L. Harris is a senior advanced practice nurse ing stimuli, and moving the patient (e.g. toileting, feeding, or range-of- at the University of Rochester Medical Center-Strong to a room closer to the nursing sta - motion exercises) is not considered Memorial Hospital in Rochester, New York.

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a Assessing and documenting patient r t s e

R restraint incidents f o

e Accurate information can promote restraint-free care. s

U By Jim Woodard, RN, MBA e f a estraining a patient is consid - baseline, assess his or her mental ument assessments. The flowsheet S .

. ered a high-risk intervention status, mood, and behavioral con - should include the following: .

n Rby the Centers for Medicare & trol. This allows clinicians to later • patient behavior that indicates

o Medicaid Services, The Joint Com - determine how the patient is toler - the continued need for restraints

s mission (TJC), and various state ating restraint and helps ensure re - • patient’s mental status, including u regulatory agencies, so healthcare straint will be discontinued as soon orientation c

o pro viders must carefully assess and as clinically indicated. • number and type of restraints

F document the patient’s condition. Medications can be an important used and where they’re placed part of a restraint inter - • condition of extremities, includ - vention. Appropriate use ing circulation and sensation of as-needed medications • extremity range of motion can shorten the restraint • patient’s vital signs time. Assess the patient’s • skin care provided response to medications. • food, fluid, and toileting offered. Also, include the education you Assessment during the re - provide to the patient and family. straint period Remember—the goal is to remove A restrained patient is the restraints as soon as possible. susceptible to injuries caused by restricted Post-restraint debriefing breathing, circulatory When the restraint episode ends, a problems, and mechani - nurse or other qualified caregiver cal injuries. Once re - should debrief the patient. Review - straints have been ap - ing the restraint episode with the plied, take steps to patient yields important informa - ensure a safe, injury-free tion that can help lead to restraint- outcome. Perform a quick free treatment. Information gained head-to-toe assessment to from debriefing helps the treatment help identify areas of team design therapeutic interven - concern or conditions tions that may help prevent the Assessing the patient’s medical con - that require further monitoring. need for restraints. Be sure to doc - dition Being restrained is a traumatic ument the debriefing. Review the patient’s medical record experience for the patient, so con - for preexisting conditions that can tinually assess how he or she is Toward restraint-free care cause behavioral changes —for in - dealing with the stress. Accurate assessment and documen - stance, delirium, intoxication, and tation of restraint episodes provide adverse drug reactions. If the be - Documentation valuable information to improve havior results from an underlying Accurate documentation of the re - treatment processes, ultimately medical problem, accurate assess - straint episode is vital to safe, ef - helping nurses create an environ - ment allows timely medical inter - fective patient care and provides ment where restraint-free care is vention and may reduce the re - information that can improve the possible. • straint period required or even quality of care. Document the rea - eliminate the need for restraint. son for restraint and that you ex - Visit www.americannursetoday.com/?p= 18952 for a list of selected references. plained the reason to the patient Assessing the patient’s behavior and family. Jim Woodard is the associate chief nursing officer at To establish the patient’s behavioral You can use a flowsheet to doc - Porter Adventist Hospital in Denver, Colorado.

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