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Labette Health LABETTE HEALTH POLICY AND PROCEDURE SUBJECT: RESTRAINT REFERENCE:A/N/SWING BED/ER APPROVED BY: Restraint Committee PAGE 1 OF 10 EFFECTIVE: SEPT/97 REVISED: FEB/JULY99 MAR/01, JAN/02, OCT/03, DEC/03 AUG/05/MAY/07/JULY/08, APR/09, OCT/09, APRIL/12 TITLE: RESTRAINT DEFINITIONS: A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Patients Who May Require Restraint 1. Non-violent or non-self destructive patients (Medical): patients who require restraints to prevent removal of tubes, lines, dressings, or to support medical healing or well-being. 2. Violent or self-destructive patients (Behavior): patients who display severely aggressive or destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others. This category includes patients for which a Dr. Strong might be called. POLICY: 1. It is the intent of Labette Health to be Restraint free. 2. All patients have the right to be free from restraints or seclusion of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Labette Health does not use seclusion as a form of restraint. 4. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury. 5. The application of the least restrictive physical restraint necessary will be limited to clinically appropriate and clinically justifiable situations when documented alternatives are unsuccessful. 6. Clinical staff not trained in restraints will contact nursing staff trained in restraints when requiring assistance removing or reapplying restraints. 7. The type of restraint employed shall be consistent with the behavior demonstrated by the patient. The type of restraint selected will be the least restrictive of the appropriate choices available and is to be applied in such a manner that there is due regard for the comfort, privacy, and dignity of the individual. Every patient has the right to be treated with dignity and respect. 8. The condition of the restrained patient must be continually assessed, monitored, reevaluated, and documented. 9. The patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patients medical symptoms. 10. The patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 11. Restraints may be used in response to emergent, dangerous behavior, addictive disorders, as an adjunct to planned care. 2 12. Restraints may be used to protect the patient’s safety and the safety of others. Because restraints may be necessary for certain patients, our health care organizations and providers need to be aware of the associated risks of both use and non-use. Restraints may be necessary in order to prevent significant harm to the patient 13. Restraints are to be applied as humanely as possible. Caregivers will be sensitive to the effects of restraint on the patient's self esteem, feelings of independence and pride. 14. Restraints are never to be used as punitive measure or for the convenience of caregivers. Restraints are not to be used in a manner that causes undue harm, physical discomfort or pain to the patient. 15. Patient and family will be involved in the decision to use restraints to fullest extent possible. 16. Patient and family will be educated about safety measures and care while restraints are in place. 17. The plan of care should be modified to reflect the use of Restraints. PHYSICIAN ORDER A physician’s order is required for the application of restraints. NOTE: PRN or routine (standing) orders for use of restraints will not be accepted. 1. Initial restraint orders may be given to the RN in print, verbal, or telephone format. The preprint restraint order sheet or an electronic order will be completed and placed on the patients chart. 2. All restraint orders (initial and renewal ) must include the following: a. date and time b. time limit c. type of restraint d. list of behavior necessitating use of restraint e. physician’ signature 3. To ensure continuity of care, if a physician other than the patient’s attending physician orders restraints, the attending physician will be notified as soon as possible about the use of restraints on his/her pateint. 4. Restraint order renewal: Prior to implementing a renewal order for restraint, the physician must see the pateint and evaluate the need for continued restraint by completing a face-to face evaluation within time frame of the order. Specific Requirements for Use of Restraints on Non-Violent or Non-Self Destructive Pateints (Medical) A. A physician’s order will be obtained prior to the application of restraints. B. The original order must be renewed within each 24 hours period/calendar day. If restraints are removed for reasons other that nursing care, a new order must be obtained prior to re-application of restraints. C. Restraints will be discontinued at the earliest possible time, regardless of the time specified in the physician’s orders. D. Patients in restraints will be regularly monitored/ assessed. The Restraint Flow chart will contain every 2 hour documentation by the RN. 3 Specific Requirements for Use of Restraint on Violent or Self-Destructive Pateints (Behavioral) In some situations the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. In these emergency application situations: A. The order must be obtained either during the emergency application of the restraint or immediately (without time interval) after the restraint has been applied. B. The RN or licensed staff will document the assessment findings and justification for emergency restraint application in the patients record. C. A physician will be asked to conduct a face to face evaluation within one hour after restraint application to evaluate the pateints immediate situation, response to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints. If a physician other than the attending physician conducts the face to face evaluation, the attending will be notified by phone of the evaluation. Physician’s orders may only be renewed in accordance with the following limits for up to a total of 24 hours: (Behavior) 3 hours adult(18 years old and older) 2 hours children ages 9-17 1 hour children under 9 D. Patients in restraints will be regularly monitored and assessed. The Restraint Flow sheet will be completed every 2hours by the RN. E. Restraints will be discontinued at the earliest possible time, regardless of the time specified in the physician’s order. PROCEDURE: Assessment and Clinical Justification 1. Restraints will only be utilized in situations when less restrictive measures have been attempted and are unsuccessful and documented. Such as: a. 1:1 talk b. PRN Medication c. Attempted reorientation d. Placed near nursing station e. Chair time f. Team support g. Pain level assessed and attended to h. Quiet time i. Relaxation Activity j. Bed alarm k. Environmental noise controlled l. Redirect patient's focus m. Attempted toileting n. Requested family to stay with patient o. Food/fluids offered p. Side Rails up X’s 3 2. Restraint use is based on a thorough assessment of the patient and is based on individual need and clinical justification for use. Such as: a. Interference with medical devices, tubes, dressings, or other essential treatment modalities. b. Altered Mental Status (Document, identify specific behavior). c. Marked agitation d. Altered level of consciousness 4 e. Neurological impairment due to anesthesia, longer than 30 min. post- anesthesia care. f. Unable to comprehend the seriousness of condition or the need for treatment. g. High risk of injury to self or high risk of injury to others. 3. Explain to the patient and/or family the plan and rationale for using restraints and the condition/behavior required for release from restraints. a. Document patient/family articulation of understanding, b. If patient/family unable to articulate understanding document reason. MONITORING, REASSESSMENT ,DOCUMENTATION 1. The patient is to be monitored at least every 15 minutes via a visual observation by a member of the patient care team. 2. The visual observation is to include a visual circulation check to any restrained extremity, proper positioning of the patient and restraints, and that the patient has not harmed him or herself. 3. The RN assesses the patient at intervals not greater than 2 hours. The assessment includes the following: a. Neurologic, level of consciousness, orientation and emotional status to determine if the clinical justification for restraint continues or if there is a potential for reduction or removal of restraints. b. Proper application of restraint. c. Circulation, joint mobility and sensation of affected limb(s) d. Skin integrity under the restraint. Physical needs, ROM/activity, elimination, nutrition and hydration. 4. Assessment should be performed more frequently as warranted by the condition of the patient and type of restraint. 5. Restrains will be released at least every 2 hours for 10 minutes. 6. The use of restraints will be terminated as soon as criteria for release of restraints have been met. DOCUMENTATION 1. Assessment and clinical justification for the use of restraints. 2. Behavior that warranted restraint use 3. The less restrictive measures that have been attempted and the patient response to the measures 4.
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