EAST TEXAS MEDICAL CENTER Managing Behavioral Restraint or Seclusion in the Hospital Knowledge-Based Physician Training Revised 2-13

Required Training CMS Rule: 482.13(e)(11) Physician and other LIP training requirements must be specified in hospital policy. At a minimum, physicians and other LIPs authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.

Joint Commission: PC.03.03.03 The hospital has written policies and procedures that guide the use of restraint and seclusion for behavioral health purposes which include staff competence and training

Texas Administrative Code: 25 TAC 415.257 Physicians authorized to give orders for restraint or seclusion must receive training and demonstrate competency

DEFINITION OF RESTRAINT 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

THREE TYPES OF RESTRAINT MEDICAL OR NON-BEHAVIORAL BEHAVIORAL FORENSIC

MEDICAL RESTRAINT Examples: Definition: Orthopedic devices Helmets Surgical dressings IV arm boards Devices used to achieve body alignment Soft foam wrist or ankle straps or hand mitts Side rails (2) or crib rails Safety belts Physical escorts from which the patient can escape Any method of holding or securing a patient for the purpose of conducting tests, exams, or procedures or to protect the pt. from falling out of bed or to prevent injuring themselves in some type of activity

FORENSIC RESTRAINT DEFINITION: Application of handcuffs, ankle cuffs, or belly chains by peace officers for the purpose of security, detention, or public safety; individuals in forensic custody with these types of devices must be maintained and monitored by peace officers.

BEHAVIORAL RESTRAINT Any method (physical, mechanical, or chemical) of restricting a patient’s freedom of movement (incl. seclusion), physical activity, or normal access to his or her body, and is not done as a part of a medical-surgical condition or procedure.

TYPES OF BEHAVIORAL RESTRAINTS Physical Hold (maximum of 15 min.) Mechanical •Restraint Chair •Restraint Net Seclusion Chemical (not used )

PHYSICAL HOLD RESTRAINT The application of body pressure by another person to the body of a patient in such a way as to limit or control movement of the whole or a portion of a patient’s body. The various techniques such as “physical hold” or “take down” procedures are considered forms of physical restraint.

Bear Hug Type of Physical Hold

MECHANICAL RESTRAINT This is any device used to restrict the movement of the whole or a portion of a patient’s body. It can be in the form of ankle or wrist straps, a body net or a restraint chair. Caution: Geri Chairs and Side rails (4) can be considered a mechanical restraint if the patient cannot control egress

Example Of Mechanical Restraint Adult In the Body Net Restraint

RESTRAINT CHAIR Type of Mechanical Restraint

SECLUSION Seclusion is the confinement of the patient alone in a locked room or alone in an identified area from which egress is prevented. Patients in seclusion must be monitored by a trained staff member at all times.

Seclusion Room at BHC

CHEMICAL RESTRAINT Use of medication is considered a chemical restraint 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 or diagnosis. Chemical restraints are not used at BHC.

CRITERIA FOR BEHAVIORAL RESTRAINT All less restrictive measures were attempted and failed No time to attempt less restrictive measures Must be evidence of eminent danger

Definition of a “Least Restrictive Measure” This is a term that is used extensively in mental health and in patient rights issues. It simply means “the least intrusive or restrictive service or treatment that can effectively and safely address the patient’s needs and stated preferences”. All less restrictive measures must be tried and documented before a behavioral restraint or seclusion is ordered.

EXAMPLES OF LESS RESTRICTIVE MEASURES Making a contract for safe behavior Helping the patient to identify the stressor causing the behavior Redirecting the patient’s attention by suggesting another activity Reducing the noise level and light intensity Allowing the patient to speak to a patient advocate, minister, supervisor, or family Deep breathing exercise Negotiating a solution based on options available Offering medications to assist in reducing agitation/anxiety

EMINENT DANGER There must be evidence that there is “eminent” danger to the patient or others in order to justify the need for a behavioral restraint or seclusion. Threatening to do something is not acceptable. Patients must be in the “act of” or “process of attempting” to do something that could result in injury or damage.

TIME LIMITS FOR RESTRAINT AND SECLUSION BY AGE Physical Hold: 15 minutes for all ages (child-adult) 8 yrs. of age and younger: 1 hour 9-17 yrs. of age: 2 hours 18 yrs. and older: 4 hours Patient must be released as soon as the risk of harm to self or others no longer exists.

MONITORING REQUIREMENTS EVERY 15 MINUTES WHILE IN RESTRAINT OR SECLUSION Circulation Respiration Rate Heart Rate Blood Pressure Oxygen Saturation Behaviors Food/Fluid Needs Elimination Offered ROM Provided Hygiene Needs Met Physical Comfort Provided Psychological Support Offered Signs of Injury Evaluated for Release

PHYSICAN REQUIREMENTS Face-to-Face Evaluation of Patient within one hour of the onset of the R/S Completion the Physician Order Set for a behavioral restraint Completion of Physician Progress Note for a behavioral restraint Notification of attending physician if physician ordering the R/S is not the attending

Physician Order Set For Behavioral Restraint (located in red folder with all other physician orders)

Restraint or Seclusion. Physician Progress Note for a Behavioral Restraint or Seclusion.

You have completed the physician CONGRATULATIONS! You have completed the physician Training module for Restraint and Seclusion. Please print the certificate below and sign and date as indicated. Submit this document to the medical staff office to be filed in your record. Thank you.

Certificate of Training RESTRAINT AND SECLUSION Physician Name______________________ Date:________ Print Physician Signature:_____________________________