Restraint and Seclusion Dec 2013 nlp

Definitions Violent/Self-Destructive Restraint: Seclusion Restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others Seclusion - Involuntary confinement of a patient alone; physically prevented from leaving. Non-Violent Restraint: - All restraints other than Violent/Self Destructive Restraints/Seclusion (e.g., pulling at tubes, lines, drsgs) Medical/Surgical Examples: Protect IV site, NG tube History of falls - preventing falls Wandering episodes - preventing Patient is nonviolent and non-aggressive Alzheimer patient with hip fracture - Immobilize hip to prevent re-injury Behavioral Examples: Slapping, spitting, or throwing furniture Alzheimer patient has a catastrophic reaction - becomes agitated and aggressive and physically attacks staff member

Types of restraints Medium Large Using restraint on patients should only occur when the risk of using the restraint is LESS than the risk of NOT USING IT ! Medium Large Multi-purpose arm splint Helps protect tubes, IV sites or wounds Easily applies with velcro loop closure May be clipped to the patient’s sleeve to help prevent sliding Filled with tiny, flame retardant polystyrene beads

Small - Medium - Large - X-Large Types of restraints Using restraint on patients should only occur when the risk of using the restraint is LESS than the risk of NOT USING IT ! Small - Medium - Large - X-Large

Types of restraints One Size Only Using restraint on patients should only occur when the risk of using the restraint is LESS than the risk of NOT USING IT ! One Size Only

Types of restraints One Size Only Using restraint on patients should only occur when the risk of using the restraint is LESS than the risk of NOT USING IT ! One Size Only

Exceptions to Restraints Law enforcement restrictive devices Positioning/securing devices during medical, dental, diagnostic, or surgical procedure or related to post-procedure care Physically redirecting/holding a child (<30 min) Time out in an unlocked room Protective equipment (Orthopedic devices, helmets) Medications if part of a medical diagnostic or treatment procedure Hand mitts (unless mitts are attached to bed or mitts are so bulky that the patient’s ability to use their hands is significantly reduced) Side rails – if a patient is not physically able to get out of bed regardless if the side rails are up or not Examples: Law enforcement devices: handcuffs Voluntary mechanical/adaptive support: postural support, orthopedic devices Positioning/securing devices: surgical positioning, IV arm boards, surgical site protection in pediatrics Restraint during formal behavior management: biofeedback, reinforcement, aversion Protective equipment: helmets Brief focused interactions: hygiene Physically holding a child <30 min. requires the training, does not require the documentation

Factors Influencing a Patient that may result in Restraint/Seclusion Underlying factors (medical) Tumors Infections Metabolic or endocrine disorders Alcohol/drug use Trauma Disrupted sleep patterns Fluid or electrolyte imbalance Poor hearing, eyesight Medications These factors influence behavior and therefore may increase the possibility of restraint/seclusion Medications - Combination - eg. Antidepressants and Beta blockers--> decreased antidepressant effect Underdose Overdose

Physical Interventions (environmental factors that staff may control) Noise Paging Intercom “Nurse noise” Avoid using the intercom with confused patients HALLWAY NOISE Leave a night light on Reduce the number of visitors Respond promptly to all call lights Implement the fall risk policy Acknowledging patient feelings - if it’s important to the patient, it’s IMPORTANT to the patient!!

What is a Restraint? 1) Is your patients’ freedom to move less? 2) Is “it” applied so that the patient is not able to independently release it? 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 = a physical restraint (Restraint and Seclusion policy 11/19/2010)

Are Medications Considered A Chemical Restraint? Drugs that are used as a part of a patient’s standard medical or psychiatric treatment, and are administered within the standard dosage for the patient’s condition…… IS NOT CONSIDERED A CHEMICAL RESTRAINT

Restraint Application Prevent Injury to Patient Limb restraint Skin protection Applied properly Applied/removed in accordance with the manufacturer’s instructions Must be in position of function Proper number of restraints Opposite arm & leg vs. both arms CSMT NEVER tied to mattress or side rails

Patient Safety Smoking Materials To prevent patient injury, remove all smoking materials from patient’s access, including access from family and friends.

Observation/Monitoring Frequency Non-Violent: - Document all alternatives and/or less restrictive forms of restraint considered at least once per shift * Document ongoing restraint rationale assessment at least once per shift * Monitor activities (listed below – but not limited to) a minimum of every 2 hours and document at least once per shift: signs of injury associated with restraint use nutrition and hydration needs circulation ROM hygiene/elimination physical/psychological status/comfort readiness for discontinuation/or temporary removal from restraint * Document on Shift Summary of Activities Detail on seclusion observation in policy - refer Community Behavioral Health and EPS staff to read the policy Audio/Visual - The first section of this training is required for those who watch patients via audio/visual

Observation/Monitoring Frequency Violent/Self-Destructive behavior: Restraint or seclusion Monitor at least every 15 minutes Restraint and Seclusion: Monitor continuously (ongoing, without disruption) either through face-to-face observation or through the use of both video and audio equipment Monitor activities (listed below – but not limited to) a minimum of every 15 minutes and document at least once per shift: signs of injury associated with restraint use nutrition and hydration needs circulation ROM hygiene/elimination physical/psychological status/comfort readiness for discontinuation/or temporary removal from restraint

Discontinuation Recognizing Readiness for Release Behavior/condition is resolved “Something” is removed (e.g., NG tube, IV) RELEASE/REAPPLICATION: - Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order - A “trial release” constitutes a PRN use of restraint or seclusion – this is NOT permitted!

Discontinuation Restraint Removal Emergency release One-pull tie release Leather Key Scissors Planned release Earliest possible time RN/LIP assessment - See RN section for detail A RESTRAINT SHOULD BE USED IN THE LEAST RESTRICTIVE MANNER POSSIBLE AND BE DISCONTINUED AT THE EARLIEST POSSIBLE TIME

Discontinuation of the restraint When a restraint is released, and the patient is not under the direct supervision of CMC staff, the restraint is considered to be discontinued A “trial release” is considered a PRN use of restraint or seclusion, and IS NOT PERMITTED. A restraint that is released when family is in the room (CMC staff not present) is considered as being discontinued. If reapplication is required, a new order must be obtained.

Family Education of patient restraints is A PRIORITY !!! Family and visitors must be educated as to reasons why restraint application is necessary, criteria for discontinuation, and the plan to achieve that goal Encourage family to stay at the bedside when they can to reduce the patient’s anxiety, but family supervision is not a substitute when a restraint is necessary for patient safety Remind family that they ARE NOT to remove their loved one’s restraints.

What do you do if the family/visitor(s) do not comply with the patient’s restraint plan??? RN initiates the chain of command - notify the Clinical Supervisor who will assess if a patient safety risk factor exists Clinical Supervisor consults with House Supervisor - determine if a Patient Monitor is necessary for patient safety RN explains to the family/visitor(s) all risks associated with restraint removal.

Reporting Immediate notification required Staff role Death (CMS and CDPH report requirement) While in restraint/seclusion Within 24 hours of being released from restraint or seclusion A death that occurs within 1 week after restraint or seclusion has been discontinued (if it is reasonable to assume that the restraint use/seclusion contributed directly or indirectly to the death). Staff role Notify Manager/Clinical Supervisor or designee if above situation(s) occur to initiate the Sentinel Event Chain of Command Complete an IRIS

Restraint Order Restraint Order: Both Nonviolent and Violent Self Destructive Restraints. The Physician or other licensed independent practitioner (LIP) responsible for the care of the patient is required to order the restraint or seclusion prior to restraint or seclusion application. Exception: When the need for a restraint or seclusion intervention occurs so quickly that an order cannot be obtained prior to application. The order must be obtained either during the emergency application of the restraint or seclusion or immediately afterwards.

Restraint Physician Orders Non violent restraints orders * The order expires at the END of the restraint episode Violent/Self-Destructive and Seclusion restraint orders * The order expiration is dependent upon the patient’s age: - Up to four (4) hours-adult age 18 and older - Up to two (2) hours-children and adolescents ages 9 to 17 - Up to one (1) hour for patients under age 9

Procedural areas A restraint order is not needed for patients who are restrained during a procedure HOWEVER……. When the patient has completed the recovery phase and the patient continues to require restraints a restraint order is required.

New Order? Patients transferred, while in restraints, to a higher or lower level of care require a new restraint order.

The End