1. Restraint and Seclusion
Dec 2013
nlp

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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!!

10. 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)

11. 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

12. 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

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

14. 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

15. 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

17. 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!

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

26. 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

27. 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.

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

29. The End