1. Restraint and Seclusion Overview Medical and Behavioral 5/23/20151

2. Orders for Restraints Orders for medical surgical restraints can be given by physicians or nurse practitioners. Orders for behavioral restraints or seclusion can be given by physicians. Orders for restraints cannot be given by physician assistants. 5/23/20152

3. Standard: Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time. Restraint Types: Medical/Surgical Restraint (Non-Behavioral) is used for patients attempting to remove lines, tubes, equipment or with unsteady gait, attempting to get our of bed or chair. Behavioral Restraint/Seclusion is limited to emergencies in which there is an imminent risk to a patient physically harming him/herself or others. 35/23/2015

4. Order Entry in Alec All Restraint Orders should be entered into Epic by using the GEN IP Restraint order set  Medical-Surgical (Non-Behavioral) Restraints and Behavioral/Seclusion Restraints can be ordered via the order set Ensure that all fields are completed (red stop signs) Standing or PRN orders are NOT allowed If patient may need multiple types of restraints (eg. soft limb and 4 side rails), ensure that the order has all types included. 5/23/20154

5. Medical/Surgical Restraints Medical/Surgical (Non-Behavioral) restraints may be applied by the RN based on assessment. The physician or nurse practitioner must be notified within 12 hours of application and an order obtained within the 12 hours. A physician or nurmust examine the patient within 24 hours of initiation of restraint if a verbal/telephone order for restraint has been given Orders must contain the reason for restraint and be time limited and re-written no less often than once each calendar day based on face to face assessment 5/23/20155

6. Face to Face Evaluation Patients may be placed in behavioral restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, or others. The patient must be seen face to face within one (1) hour after the initiation of the intervention to evaluate: The patient’s immediate situation The patient’s reaction to the intervention Comprehensive evaluation of patient’s medical and behavioral condition; and The need to continue or terminate the restraint or seclusion. An order must be given by the physician. 5/23/20156 Behavioral Restraint/Seclusion

7. Each new occurrence requires a new order by a physician and a face to face assessment within 1 hour of initiation by the physician or a trained physician assistant or nurse practitioner. Orders for Behavioral Restraint/Seclusion can NEVER be written as standing orders or PRN Orders for behavioral restraints are single orders, time limited, and must be renewed after the designated period of time. 4 hours for adults 18 years of age or older 2 hours for children and adolescents 9-17 1 hour for children under 9 years of age Orders can only be renewed for up to a total of 24 hours. 5/23/20157

8. After 24 hours, before writing a new order, patient must be assessed by the physician Restraint/seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order Complete all applicable sections of the Behavioral/Seclusion Restraint order in EPIC including reason for restraint 5/23/20158 Behavioral Restraint/Seclusion

9. If the face to face is done by a Physician’s Assistant or NP, they must have received training in accordance with the requirements. Additionally, the PA or NP must consult the attending physician who is responsible for the care of the patient ASAP after the completion of the 1 hour face to face. References: AAMC Policy GNP.14.6.17 – Restraint/Seclusion CMS Guidelines Maryland Regulations Joint Commission Standards 5/23/20159 Behavioral Restraint/Seclusion