1. The Safe Use of Patient Restraints
Mandatory Annual Review Course

2. Click each button for details
Definitions
Any method of physically restricting a person’s freedom of movement, physical activity or normal access to his or her body.
Patient immobilization that is a normal component of a procedure is not considered restraint.
Restraint is:
Medical
(Non-behavioral)
Restraint:
A 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 to protect the patient.
Behavioral Health
Restraint:
The restriction of patient movement in response to severely aggressive, destructive, violent or suicidal behaviors that place the patient or others in imminent danger.
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Restraint is not:
Forensic restriction used by law enforcement for security purposes.

3. Side Rails – Restraint or Not?
Click the answer
The use of side rails may pose risk to patient’s safety. Clinical judgment determines whether or not the use of side rails is considered restraints.
Raising all four side rails to prevent the patient from exiting the bed
Not
Restraint
Restraint
Four or full side rails to prevent the patient from rolling our of bed
Patient actively seizing
Post-op patient recovering from anesthesia
Patient on a gurney
Not
Restraint
Restraint
Click the photo for examples
Not
Restraint
Raising fewer than four side rails (when bed has more than two)
Restraint

4. Alternatives to Restraints
Restraints must never be used as a substitute for good nursing care or staff convenience. Restrained patients require MORE CARE and INCREASED DOCUMENTATION.
PHYSICAL MEASURES
SPIRITUAL NEEDS
Relaxation techniques
Promote normal sleep patterns
Use of lap belt in chair as a reminder
Provide glasses, hearing aid, dentures
Tape foley to abdomen of male patient
Use Activity Apron
Exercise and activities
Anticipate and provide for basic needs
PSYCHOLOGICAL MEASURES
Provide for companionship: family, friends
Orient to reality
Explain all procedures
Use TV, radio, music
Collaborate w/other healthcare members
Provide pain medication, eliminate itch
Contact patient’s pastor, minister, priest, rabbi
Offer sacrament of Communion, Reconciliation, Anointing of the Sick
Use sitter or volunteer to read to patient
Use audio tapes, CDs
ENVIRONMENTAL NEEDS
1:1 communication
Use of cushions to maintain safety
Locate patient next to Nurse’s station
Use appropriate lighting
Use Geri chair, position commode, walker, near bedside
Decrease noise, control activity level
Place Call light within reach
Position tubes/drains out of site
Initiate frequent bathroom rounds
Review medications for side effects & interactions
PHYSIOLOGICAL MEASURES

5. To Determine the NEED for RESTRAINT USE:
Patient Assessment
To Determine the NEED for RESTRAINT USE:
Attempt Alternatives
Use safe, effective and least restrictive method of restraint
Clinical Justification based on observed patient actions or behaviors
Interference with therapy or patient care
Pulling tubes
Picking at wounds
Removing dressings
Activity or thoughts with a reasonable probability of harm to self
Wandering
Unsteady gait (high risk for falls)
Suicidal
Activity or thoughts with a reasonable probability of harm to others
Confused patient striking out at others
Homicidal attempt or talks about killing/harming someone
Violent patient in alcohol or drug withdrawal

6. Reason for the restraint. Be time specific Include type of restraint.
Restraint Orders
Restraints will be initiated or continued on the order of a treating physician. The order must meet the following criteria:
Reason for the restraint.
Be time specific
Include type of restraint.
Reflect least restrictive manner.
Be in accordance with safe and appropriate restraining techniques.
Be discontinued at the earliest point in time.
Never be written as a standing order or PRN.

7. Medical vs. Behavior Health Orders
Behavioral Health
Time Limitations
24 hours
4 hours 18yrs or older
2 hours 9-17yrs
1 hour 8yrs and under
RN Assessment
Every 2 hours or sooner
Continuously document every 15 mins
MD Assessment
Every 24 hours prior to writing new order
Every 8 hours 18yrs or older
Every 4 hours 17yrs and younger
Emergency Application by RN
Notify MD ASAP, within 1 hour MD must provide telephone or written order. MD must assess patient ASAP, within 24 hours.
Notify MD ASAP, within 1 hour MD must assess patient and write order.
Restraint Reapplication
Requires new order, and MD assessment. -Even if original order has not exceeded its “time limit.” This does not include the temporary release that occurs for patient assessment.

8. Observation & Monitoring
Assessment will include:
The patient’s physical and emotional well-being .
Comfort and care needs, including hygiene, elimination, hydration, nutrition
The appropriateness of restraint application, removal, and reapplication
Assessment of the need for continuing or discontinuing restraint
Patient death associated with restraint use:
RN will immediately notify Nurse Manager or House Supervisor
Complete a UOR (unusual occurrence report)
Hospitals AR&L Director or designee will notify CMS

9. Application of Restraint
Must have quick-release application
Use the correct size
Note “front” and “back” of device
Secure to bed springs or frame, not mattress or bed rails
Do not apply one-sided restraints
Do not restrain feet while their hands are free
Place call light and necessary items within reach
Do not position pregnant patients 20 weeks or greater on their back, nor should chest or waist restraints be used
Restraints should be discontinued as soon as it is no longer indicated by the patient’s actions.

10. Patient basic needs must be attended to, including:
Documentation
Patient basic needs must be attended to, including:
Nutrition
Circulation
Range of motion
Hygiene
Elimination
Hydration
Document the following in Patient’s record in KP Health Connect:
Physician’s order
Initial assessment by the RN and 1 hour in-person evaluation by MD
Patient’s actions or condition that indicated the initial and continued use of restraint
Less restrictive alternatives considered
Patient monitoring and response to interventions used
Significant changes in the patient’s condition
Reassessment/observations, discontinuation of restraints
Education and information about restraints provided to the patient and family