1. RESTRAINT & SECLUSION (R/S) for LICENSED NURSES
Module 7
RESTRAINT & SECLUSION (R/S) for LICENSED NURSES

2. Definition: Restraint
- Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. If the patient can easily remove the device, material or equipment, it is not considered a restraint.

3. Definition: Seclusion
The involuntary confinement of a patient in a room alone or in an area where the person is physically prevented from leaving. It may only be used for management of violent or self destructive behavior.
Note:
Seclusion does not include confinement on a locked unit or ward where the patient is with others.

4. When can R/S Be Used?
Restraint and/or Seclusion may only be used if needed to improve the patient’s well being and when less restrictive interventions have been determined to be ineffective in protecting the patient or others from harm. Once the unsafe condition /situation ends, the use of R/S will be discontinued.

5. Are 4 Side Rails up considered a restraint?
Side rails are not considered a restraint when used to prevent the patient from falling out of bed when on a stretcher, recovering from anesthesia, sedated, experiencing involuntary movement, or on certain types of therapeutic beds
Side rails are considered a restraint when all four are in used to restrict the patient’s freedom to exit the bed unless the patient is able to easily lower the side rails.

6. Restraint Physical Holding
Physical holding is not considered a restraint when holding for the purpose of conducting a routine physical examination or test. However, the patient has the right to refuse treatment.
Physical holding is considered a restraint if the patient is being held against their will.
Holding the patient down in order to administer a medication against the patient’s wishes is considered a restraint.
In certain emergency situations, with a physician order, some patients may be medicated against their will (example: the behavioral health setting)

7. Restraint NON-VIOLENT OR NON-SELF DESTRUCTIVE RESTRAINT
Restraint used to limit mobility or temporarily immobilize an acute care patient for a reason specifically related to a medical or post-surgical procedure
applies to situations in which behavior changes are caused by medical conditions or symptoms, e.g., confusion or agitation in which protective interventions may be necessary
applies when restraints must be applied to directly support medical healing
Example : a patient is attempting to dislodge a tube or line or is trying to get out of the bed and would compromise healing

8. Restraint VIOLENT OR SELF-DESTRUCTIVE RESTRAINT NOTE:
Restraint used only in an emergency or in a crisis situation if a patient’s behavior becomes violent or self-destructive presenting an immediate, serious risk to his/her safety or that of others and non-physical interventions are not effective
- applies to clinical justification to protect self from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive
NOTE:
The use of R/S for violent/self-destructive behavior must be limited to the duration of the emergency safety situation regardless of the length of the order.

9. When to Apply Restraint
Non-Violent or Non-Self Destructive Restraints
Patient is pulling at lines, tubes or dressings
The confused patient is interfering with the provision of care
The patient is attempting an unsafe activity
patient is thrashing around in bed or attempting to get out of bed in a way or under conditions where it might cause harm
patient is exhibiting behaviors related to acute withdrawal syndrome
The patient’s diagnosis or condition is such that they may unpredictably and suddenly awaken and harm themselves.
One example is the intubated patient:
When an intubated patient has a neurological condition that may cause them to unpredictably and suddenly awaken with a significant risk of self-extubation before staff could have an opportunity to intervene

10. When to Apply Restraint
Violent or Self-Destructive Restraints
applies when the patient’s behavior is irrational, uncooperative, aggressive, and/or violent and poses a danger to himself/herself or others and which behavior may also interfere with medical or surgical procedure or medical healing

11. Restraint : Assessment
Non-Violent/Non-Self Destructive
Violent/Self Destructive
One hour face-to-face assessment of the patient’s physical and psychological status will be done by a physician or an RN who has successfully completed the competency for performing a face-to-face assessment
Assessment must be conducted within one hour of the initiation of the restraint and/or seclusion
The attending physician will perform an in-person assessment of the restraint patient within 24 hours of the initiation of the restraint and at least once every calendar day, at which time the restraint will either be reordered or discontinued as indicated

12. Who can perform face-to face assessment
At chsb, The following can perform a ONE HOUR face-to-face assessment
Nursing House Supervisors
BHS Charge Nurses
Who successfully completed the One Hour Face-to-Face Competency
For any assistance or questions, call Nursing House Supervisor at 1800

13. Forensic Restraint
If a patient in forensic restraints requires R/S for violent/self-destructive behavior or non-violent/non- self destructive behavior beyond the forensic restraint, this policy become applicable to that patient following a comprehensive assessment and consideration/attempted use of alternatives.

14. Orders
R/S will be ordered by a physician who is a member of the medical staff.
As needed (prn) R/S orders will not be accepted.
A “trial release” is not permitted.
Temporary release while caring for the patient for feeling, range of motion and/or toileting is permitted and not defined as a “trial release”.
The order will specify the method of R/S to be used. Indications will be documented in nursing or physician’s notes.
If the initial order is not obtained from the patient’s attending physician, consultation with the attending physician will occur as soon as possible.
- The attending physician is the physician who is responsible for the management and care of the patient.

15. Time Limited Orders Non-Violent or Non-self destructive restraints
One calendar day
Violent or self-destructive restraints
4 hours for patients 18 years of age and older
2 hours for patients 9-17 years old
1 hour or less for children under 9 years of age
*** Orders may be renewed according to the time limits set above for a maximum of 24 consecutive hours

16. Physician Order
What happens if the order time limit expires but the patient still needs restraints and/or seclusion and the physician is not available to re-evaluate the patient?
A competent RN may conduct the re-evaluation of restraints and/or seclusion for the patient.
After the evaluation, the competent RN must:
Document the assessment in the medical record, including the justification and continued use of restraints and/or seclusion
Promptly call the physician and discuss the evaluation
Write a new verbal order for the continued use of restraints and/or seclusion
4 hours for adults 18 yrs and above
2 hours for 9 yrs to 17 yrs old
1 hour for under 9 yrs old

17. Physician Order
The physician must sign the order for restraints and/or seclusion:
Upon the next visit
Within 24 hours of the original order, whichever is less
If the physician is not the ordering physician, the nurse
will notify him/her of the restraint and/or seclusion
order upon their next visit.

18. Documentation Documentation of restraint and seclusion use includes:
The behavior, indications, and rationale which necessitates the use of restraint
The less restrictive alternatives which are attempted and failed
Time restraints applied
Type of restraint used
Patient’s response to restraint intervention
Education of patient for the reasons restraint applied
Behavior to be eliminated
Notification of family the reason for restraints applied for the initial application (When authorized by adult patient, all patients under 18 years)
Identification of pre-existing medical conditions, as well as abuse history

19. Hospital policy and procedure
Physician, clinical psychologist and other authorized LIP training requirements
Staff training requirements
The determination of who has authority to order restraint and or seclusion
The determination of who has authority to discontinue the use of restraint and or seclusion
The circumstances under which restraint or seclusion is discontinued
A definition of restraint in accordance with 42 CFR.13 (e)(1)(i)(A-C)

20. Hospital policy and procedure
A definition of seclusion in accordance with 42 CFR (e)(1)(ii)
A definition or description of what constitute the use of medications as restraint in accordance with 42 CFR (e)(1)(i)(B)
A determination of who can access and monitor patients in restraint or seclusion
Time frames for assessing and monitoring patients in restraint and seclusion

21. Hospital policy and procedure
Physicians, clinical psychologists and other LIP authorized to order restraint or seclusion (through hospital policy in accordance with law and regulation) have a working knowledge of the hospital policy regarding the use of restraint and seclusion.

22. General Provisions
Indications: R/S will only be used for the protection of the patient, staff members or others, hospital property or to maintain provision of care. Such indications will be present and documented at the initiation of and throughout the episode of restraint.
Least Restrictive Means: R/S will not be used when less restrictive interventions would be effective.
Early Release: R/S will be discontinued by the RN or physician when the behavior or condition which was the basis for the order is resolved, regardless of the duration of the original order.

23. Discontinuing R/S
The use of R/S will be discontinued when there is adequate and appropriate clinical justification that would indicate that restraint or seclusion is no long necessary

24. Please Complete the Post Test After Reviewing The Module