1. Restraints Update 2014 Objectives Review types of restraints
Review RBMC policy and forthcoming changes regarding use of restraints & seclusion
Review documentation and forms: Physician Order form, Restraint flow sheet, Occurrence Screening form
Review correct application of restraint devices: Chest posey/vest and limb restraints

2. RBMC Philosophy Patients have the right to be free of restraints
Limited only to clinically justified situations.
Will be discontinued at the earliest possible time based on the re-evaluation of the patient’s condition.
Not determined by the treatment setting or the patient’s diagnosis but by the situation the restraint/seclusion is intended to address.

3. What are Restraints?
Any manual methods, 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 used as a restraint to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard of treatment or dosage for the patient condition
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Educator
Course Outline:

4. Restraint Devices Body Restraints Vest (Chest Posey)
Soft Limb Restraints
Hand Mitts
Wrist
Ankle
Freedom Splint
Leather Restraints
4 point
3 point
2 point
Medications
Seclusion
4 Side rails up
Only approved manufactured products are to be used as restraints
If possible, try alternatives to restraints before using restraints
Least restrictive Most restrictive
Leather restraints can be applied for safety if the patient’s size or presentation would render a cloth restraint ineffective.

5. *Physical Hold for Forced Medications
The application of force to physically hold a patient in order to administer a medication against the patient’s wishes.
Must have a physician’s order prior to application of the restraint (use of force).
If physical holding for forced medications is necessary with a violent patient, the one hour face to face evaluation is required.
*Forthcoming changes in the policy

6. The following are NOT considered restraints
Temporary immobilization for medical, dental, diagnostic, or surgical procedures
Methods to hold a patient during routine exam/procedures as long as pt’s right to refuse the procedure is honored
IV board used to maintain IV access
Adaptive support devices such as postural supports or orthopedic appliances
Side rails on a stretcher
Developmentally appropriate safety devices such as stroller safety belts, high chair lap belts, raised crib rails or crib covers
Hand mitts unless pinned or attached to the bed, or if applied so tightly that hands & fingers are immobilized.
Medications that are used as part of a patient’s standard medical or psychiatric treatment and are administered within the standard dosage for the patient’s condition.

7. *Side Rails up
If a patient is not physically able to get out of bed regardless of whether the side rails are raised or not, raising all 4 side rails for this patient would not be considered restraint because the side rails have no impact on the patient’s freedom of movement.
In this example, the use of all 4 side rails would not be considered a restraint.
4 side rails up are not considered restraints when patient is sedated or experiencing involuntary movements, or is on seizure precautions.
*Forthcoming changes in the policy

8. Restraint Orders Reason for restraint Type of restrain
Order parameters
Physician Assessment (One hour face to face assessment)
Must be signed by a licensed independent practitioner
NEVER written as a standing order or prn order
If a patient was recently released from restraints and exhibits behavior that can only be handled by reapplication of restraints, a new order is required.
NOTE: Another face-to-face evaluation by the LIP is required if the restraint is to continue past 24 hours.

10. Classification of Restraints
Non-Violent or
Non Self-Destructive
Violent or
Self-Destructive Behavior
Order parameter:
Daily
Face to face evaluation by LIP *(1 hour time frame does not apply)
Visual observation and documentation at least q 2 hrs
If on chest posey/vest, visual observation during sleep time 10pm-6am is at least q 1 hr
Order parameters:
Adults: 4 hours
Children 9-17 yrs old: 2 hours
Children < 9 yrs old: 1 hour
Face to face evaluation by LIP w/in 1 hour of initiation of restraint
Continuous monitoring
Documentation at least
q 15 min
LIP: Licensed Independent Practitioner
*Forthcoming changes in the policy

11. How to apply Restraints
Should be…
Applied in a way that allows for quick release/removal
Snug but not too tight – should be able to insert 1 to 2 fingers between the wrist/ankle restraint and the patient’s limb.
Secured to the movable part of the bed, stretcher frame, or chair frame according to the manufacturer’s guidelines
Should never be secured to the side rails
If feasible, the bed should be kept in low position with the wheels locked.
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Instructor
Course Outline:
Restraint Policy

12. Seclusion
Involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving
Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others
Seclusion rooms are located in the CLI and CSU
*In all other areas, if a pt. is restricted to a room alone and staff is physically intervening to prevent the patient from leaving the room or giving the perception that threatens the pt. with physical intervention if the patient attempts to leave the room, the pt. is being secluded.
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Educator
Course Outline:
Restraint Policy
*Forthcoming changes in the policy

13. Debriefing
Debriefing of patients released from restraints for violent or self-destructive behavior will occur as soon as appropriate but not more than 24 hours after the restraint/seclusion episode.
Discussion includes:
Factors that led to the restraint/seclusion
Steps to reduce the potential for future need of restraint/seclusion
Clinical impact on the patient
Identification of ways the situation could have been handled differently
Document the debriefing meeting on the Restraint Flow Sheet.
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Educator
Course Outline:
Restraint Policy

14. Occurrence Screening Form
Complete this form for patients in restraints for violent or self-destructive behavior for more than 12 hours or if pt. has 2 or more episodes of restraint use for violent or self destructive behavior within 12 hours.
Send to the Clinical Outcomes Dept.
A copy is sent to the Director of Nursing Quality, Research, and Resources.
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Educator
Course Outline:
Restraint Policy

15. Assessment & Monitoring – Responsibility of the RN
Revaluation of the need for restraints at least every 2 hrs.
Toileting at least every 2 hrs
Release of restraints at least every 2 hrs: circulation checks, skin assessment and care, ROM for a minimum of 5 minutes per limb.
Meals and fluids at least 3x a day, more often if necessary
Assistance with bathing at least once per day
Ambulation at least once every 4 hrs, if clinically feasible
Documentation – Restraint Flow Sheet
Should match the rationale for continued use, e.g.  patients noted to be awake, oriented and cooperative should not still be restrained. 
Modify Interdisciplinary Plan of Care to reflect use of restraints/seclusion
Update Kardex
Objective: Discuss the RBMC Restraint Policy
Time Frame: 5 mins.
Method: Lecture/Discuss
Faculty: SD Instructor
Course Outline:
Restraint Policy

17. Informing Patient and Family
Inform patient of the plan of care and rationale for using restraints/seclusion, if clinically feasible.
Document on the Restraint Flow Sheet.
Notify patient’s family/guardian/healthcare decision maker
This notification will be done as soon as possible after the initiation of restraints/seclusion, but no longer than 24 hours after application.
Document on the Restraint Flow Sheet and in the Nurses’ Notes.

18. Forensic Restraint
Handcuffs, manacles, shackles, and other chain type restraint devices used for custody, detention, and public safety reasons.
Used only for patients in the custody of the police and the Department of Corrections and is not governed by the restraints policy.
RBMC is still responsible for appropriate patient assessment and provision of safe appropriate care (with law enforcement officer prisoner).

19. Reportable Events
Serious, preventable adverse events, as well as death, are reportable events.
Any patient death, loss of body part, disability, or loss of bodily function lasting more than 7 days or still present at discharge is considered a Serious Preventable/potentially Preventable Adverse Event. This includes incidents associated with the use of restraints.
Any death that occurs under the following circumstances must be reported to the Center for Medicare and Medicaid Services (CMS)
Every death that occurs while the patient is in restraints/seclusion.
Every death that occurs within 24 hours after the patient has been removed from restraints/seclusion.
Every death known to the hospital that occurs within 7 days after restraints/seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death.