INTER-Interdisciplinary
TITLE: Restraints: Nonbehavioral              POLICY NUMBER: INTER-R-118
APPROVED:                ...
TITLE: Restraints: Nonbehavioral              POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                      Pa...
TITLE: Restraints: Nonbehavioral               POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010                       P...
TITLE: Restraints: Nonbehavioral              POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                      Pa...
TITLE: Restraints: Nonbehavioral           POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                   Page 5 o...
TITLE: Restraints: Nonbehavioral             POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                     Page...
TITLE: Restraints: Nonbehavioral             POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010                     Page ...
TITLE: Restraints: Nonbehavioral              POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                      Pa...
TITLE: Restraints: Nonbehavioral             POLICY NUMBER: INTER-R-118
 REVISION DATE: 3/01/2010                     Page...
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C:\Documents And Settings\701406\My Documents\Bh Inter Restraints Nonbehavioral 03012010

  1. 1. INTER-Interdisciplinary TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 APPROVED: PAGE 1 of 9 EFFECTIVE DATE: 7/2008 REVISION DATE: 3/01/2010 Policy Statement The hospital limits its use of restraint for non-behavioral health purposes. Use of restraints from non-behavior health purposes is initiated either by an individual order or by an approved written protocol, the use of which is authorized by an individual order. The decision to use a restraint is not driven by diagnosis, but by a comprehensive individual patient assessment. Purpose The use of restraint for non-behavioral health purposes is a restraint that is used for acute medical and surgical care that directly supports medical healing. Restraints used for acute medical or surgical care is usually an adjunct to planned care or a component of an approved protocol. Patient Alert All patients’ have the right to be free from restraint of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint 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 may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, other patients, or staff from harm. Overview Patients at risk for injury may need to be temporarily restrained. A physical restraint is any device, garment, material, or object that restricts a person’s freedom of movement or access to his or her body. The restraint must be clinically justified and a part of the prescribed medical treatment and plan of care, and all other less restrictive measures must be tried first. The use of restraints has been associated with serious complications. The Food and Drug Administration (FDA), which regulates restraints as medical devices and requires manufacturer’s to label them ―prescription only‖, estimates that hundreds of restraint- related injuries occur each year, approximately 100 of them resulting in patient death. Most patient deaths have resulted from suffocation from a vest or jacket restraint. Numerous institutions have stopped using vest restraints, including Bloomington Hospital. For these reasons vest restraints will not be presented here. Pressure ulcer formation, hypostatic pneumonia, constipation, incontinence, contractures, and neurovascular impairment can result from the enforced immobility that results from using restraints. Altered sensory perception and altered thought processes, such as delirium, may also result. Humiliation, fear, anger, and a decreased sense of self-esteem may occur. For this reason, a patient’s dignity will be maintained while any patient is restrained or secluded.
  2. 2. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 2 of 9 When the use of restraints is the only appropriate intervention to maintain the patients’ safety, the patient should be informed that the restraint is temporary and protective, along with family when applicable. As with other procedures, the nurse and all other staff must follow specific institution guidelines when using restraints. Restraints require a physician’s order, which should specify the type of behavior or condition requiring restraint, the type of restraint, and time limitations for restraint application. Orders should be renewed according to Bloomington Hospital policy and based on reassessment and reevaluation of the restrained patient. Not all patients will be able to accept the use of restraints easily. Cultural values affect how patient’s and family members perceive the use of restraints. The nurse assesses the meaning of restraint to the patient and the family (when applicable). Nurse and family collaboration can help with culturally sensitive care. Removing restraints when family members are present can be an option if patient safety is not jeopardized. Procedure Definitions A Restraint IS: The application of physical force to a patient with or without the patients’ permission to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. Any 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 Restraint may be used in response to emergent, dangerous behavior; as an adjunct to planned care; as a component of an approved protocol; or, in some cases, as part of standard practice. Because a restraint may be necessary for certain patient’s, health care organizations and providers need to be able to use restraints when essential to protect patient’s from harming themselves, other patient’s, or staff. They also need to be aware of the associated risks of both its’ use and nonuse. Any drug or medication when it is used as a restriction to manage the patients’ behavior or restrict the patients’ freedom of movement and is not a standard treatment or dosage for the patients’ condition. A Restraint Does NOT INCLUDE: Generally, if a patient can easily remove a device, the device would not be considered a restraint. In this context, ―easily remove‖ means that the manual method, device, material or equipment can be removed intentionally by the patient in the same manner as it was applied by the staff. The specific device used to restrain a patient does not in itself determine whether these standards apply, it is the device’s intended use (such as physical restriction), its’ involuntary application, and/or the identified patient need that determines whether use of the device triggers the application of these standards. This also does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages or other methods that involve the physical holding of a patient for the purpose of conducting routine physical
  3. 3. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 3 of 9 examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm. These standards do not apply to the following: Standard practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post- procedure care processes (i.e. surgical positioning, intravenous arm boards, radiotherapy procedures, protection of surgical and treatment sites in pediatric patient’s), age or developmentally appropriate protective safety interventions Adaptive support in response to assessed patient need (i.e. postural support, orthopedic appliances, table top chairs [geriatric/cardiac]). Helmets Forensic and correction restrictions used for security (i.e. handcuffs) Four side rails up would not be a restraint if a patient was on a Stage IV mattress. Alternatives to Restraints: Non-physical techniques are always considered the preferred intervention. Such interventions may include: Reality orientation (redirecting the patient’s focus) Review medication regimen Changes in environment Optimize positioning/comfort Velcro Belt Staff/Family/Patient safety provider present Physical activity/ambulate patient Patient education Lowering beds Open visitation to elicit family help Placing a pillow in the lap of the patient who is sitting Stuffed animal Involving Occupational/Recreational Therapy to structure patient time Angled cushions for chairs Bed Alerts/personal alarms Arm sleeves (netting) Verbal De-Escalation Allowing the patient to voluntarily cooperate Cardiac chair Geriatric chair
  4. 4. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 4 of 9 Non-Behavioral Restraint Orders Time Limited, Medical – Surgical Units If a registered nurse initiates use of restraint for non-behavioral health purposes, a licensed independent practitioner (LIP) provides a verbal or written order as soon as possible, not to exceed 12 hours of initiation. The patient must be examined by a LIP within 24 hours of initiation of restraints. If the restraint for non-behavioral health purposes is continued beyond 24 hours, its use is ordered once each calendar day by a LIP, based on his or her examination of the patient. If a significant change in patient’s condition or behavior the attending physician is to be notified immediately. Non-Behavioral Restraint Orders – Critical Care Protocol During treatment of certain specific conditions (i.e. Post-traumatic brain injury) or certain specific clinical procedures (i.e. intubation), restraints may be necessary to prevent significant harm to the patient. Protocols for restraint use may be established based on frequent presentation in those conditions or procedures of behavior by patients that seriously endangers the patient or seriously compromises the effectiveness of the procedure. Restraint protocols include guidelines for assessing the patient; criteria for applying the restraint and criteria for monitoring the patient and reassessing the need for restraint and criteria for terminating restraints. A licensed independent practitioner (LIP) issues a patient specific order authorizing the use of a restraint protocol. Authorized staff maintains and terminates restraint in accordance with established criteria based on the individual patient needs and appropriate clinical justification. The Non-Behavioral Care Restraint protocol orders at Bloomington Hospital may only be utilized in the Critical Care Areas (CCE, CCW, CVR). Each patient must be assessed, and interventions should be tailored to meet the individual patient’s needs. The protocol is used in the care of patients who are at risk for self-harm secondary to: o Airway Management o Feeding/Drainage Tube o Invasive Lines The order will remain in effect until selected medical treatments are discontinued, patient no longer meets criteria for use OR the patient is transferred to any medical/surgical unit. If none of the above applies, a Time- Limited Restraint Order must be used. Monitoring & Documentation of Medical Restraints All documentation of patient in Non-Behavioral Time Limited & Critical Care Protocol Restraints is to be noted every 2 hours and be individualized taking into consideration variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen intervention and other relevant factors.
  5. 5. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 5 of 9 Time of the initiation of the restraints Reason for the restraint Alternatives used prior to placing the patient in restraints AND ongoing alternatives to ensure the use of restraint is discontinued at the earliest possible time Restraint placement Restraint type Intervention/Assessment – for continued use of restraints Capillary refill Food & Fluid Toileted Released – note if released temporarily, directly supervised, for the purpose of caring for a patient’s needs (toileting, feeding, range of motion exercises) Reapplied - after caring for patient’s needs Range of Motion Repositioning Any injuries noted during restraint episode or related to continuation of restraints – chart in comment section Significant changes in patient’s condition – chart in comment section Vital Signs Discontinued – restraints removed, requires new order to re—start Application and Staff Training Requirements The person applying and monitoring of the patient in restraints must have received education, training, and demonstrated knowledge based on the specific needs of the patient population in the following: Techniques to identify behaviors, events, and environmental factors that may trigger circumstances that require the use of restraint. Use of nonphysical skills. Choosing the least restrictive intervention based on an individualized assessment of the patients medical, or behavioral status. The safe application and use of all types of restraints used at Bloomington Hospital, including training in how to recognize and respond to signs of physical and psychological distress (i.e. positional asphyxia). Physical and psychological assessment of the patient who is restrained. Use of first aid techniques (i.e. management of minor scrapes/bleeding) CPR Certification, monitoring and establishing vital signs of the patient in restraints. Application of restraints Maintain annual competency in all of the above. Hospitals must report deaths associated with the use of restraints according to the following CMS guidelines: Each death that occurs while the patient is in Non-Behavioral Restraints Each death that occurs within 24 hours after the patient has been removed from
  6. 6. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 6 of 9 Non-Behavioral Restraints Each death known to the hospital that occurs within 1 week after Non-Behavioral Restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient’s death Bloomington Hospital Patient Care Directors will be responsible for reporting the above circumstances to the CMS no later than the close of business the next day following knowledge of the patient’s death The Patient Care Director will document in the patient’s medical record the date and time the death was reported to the CMS Patient Assessment and Preparation Assessment a. Determine patient’s need for restraint if other less restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with psychiatrist or primary health care provider. b. Assess patient’s behavior, such as confusion, disorientation, agitation, restlessness, combativeness, or inability to follow directions. c. Review institution policies regarding restraints. Check physician’s order for purpose of restraint and type, location, time and duration of restraint. d. Review manufacturer’s instructions for restraint application before entering patient’s room. Determine the most appropriate restraint. e. Inspect area where restraint is to be placed. Note if there is any nearby tubing, jewelry, or devices. Assess condition of skin, sensation, and joint range of motion, if applicable, of underlying area on which restraint is to be applied. Preparation a. Identify patient by checking armband and having patient state name, if applicable. b. Approach patient in a calm, confident manner. Explain what the plan is and what staff will be doing. c. Gather equipment, and perform hand hygiene. Procedure a. Provide privacy and maintain patient’s dignity, as the situation permits. Position and drape patient as needed. Rationale: Prevents lowering of patient’s self-esteem b. Adjust bed to proper height, and lower side rails. Rationale: Allows nurse and staff to use proper body mechanics and prevent injury c. Maintain patient’s comfort and in correct anatomic position. Rationale: Prevents contractures and neurovascular impairment d. Pad skin and bony prominences (as necessary) that will be under the restraint. Rationale: Reduces friction and pressure from restraint on skin and underlying tissue
  7. 7. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 7 of 9 f. Apply appropriate size restraint and refer to manufacturer’s directions. 1. Extremity (ankle or wrist) restraint: Restraint designed to immobilize one or all extremities. Restraints are composed of foam padding. Limb restraint is wrapped around wrist or ankle with soft part toward skin and secured snugly in place with Velcro straps and/or locks. Rationale: Maintains immobilization of extremity to prevent patient injury from fall or accidental removal of therapeutic device (i.e. IV tubing, Foley catheter). Tight application may interfere with circulation. Patient with wrist and ankle restraints is at risk for aspiration if placed in a supine position. Place patient in lateral position rather than supine. g. Attach restraint straps to bed frame and to an area that does not cause the restraint to tighten when head of bed is raised or lowered. (movable part of the bed). Do not attach to side rails. In the use of soft wrist restraints the straps may be attached to chair frame for patient in a chair or wheelchair. Rationale: Patient may be injured if restraint is secured to side rail And it is lowered. h. Secure restraints with a quick-release tie. Rationale: Allows for quick release in emergency. i. Insert two fingers under secured restraint Rationale: Checking for constriction prevents neurovascular injury. A tight restraint may cause constriction and impede circulation. j. Restraints should be removed at least every 2 hours. If patient is noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Rationale: Provides opportunity to change patient’s position, perform full range of motion, toileting, and exercise; and provide food or fluids. Restraints restrict movement; making patient’s unable to perform their activities of daily living (ADLs) without assistance. Providing food/fluids and assisting with toileting and other activities is essential. k. Secure call light or intercom system within reach. Rationale: Allows patient, family, or caregiver to obtain assistance quickly. l. Leave bed or chair with wheels locked. Bed should be in the lowest position. Rationale: Locked wheels prevent bed or chair from moving if patient attempts to get out. If patient falls when bed is in lowest position, chances of injury is reduced. m. Perform hand hygiene.
  8. 8. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 8 of 9 Rationale: Reduces transmission of microorganisms. Post Procedure a. Evaluate proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part at least every 2 hours or sooner, according to need and Bloomington Hospital policy. Rationale: Frequent assessments prevent complications, such as suffocation, skin breakdown, and impaired circulation b. Inspect patient for any injury, including all hazards of immobility, while restraints are in use. Also inspect patient during routine removal of restraint. Rationale: Patient should be free of injury and not exhibit any signs of complications from immobility. c. Observe IV catheters, urinary catheters, and drainage tubes to determine that they are positioned correctly and that therapy remains uninterrupted. Rationale: Reinsertion can be uncomfortable and can increase risk of infection or interrupt therapy. d. Reassess patients need for continued use of restraint at least every calendar day, with documentation every 2 hours. A face to face assessment by a physician for Non- Behavioral Restraints is every calendar day with a new written order for continuation of the restraints. Patients in Critical Care areas who meet the criteria for the protocol will remain in effect until selected medical treatments are discontinued, patient no longer meets criteria for use OR patient is transferred to any medical/surgical unit. Rationale: The intent is to discontinue restraints at the earliest possible time. Expected Outcomes Patient remains free from injury Patients therapy is uninterrupted Patients self-esteem and dignity are maintained Unexpected Outcomes Patient experiences impaired skin integrity related to improper or prolonged use of restraint Patient has altered neurovascular status of an extremity, such as cyanosis, pallor, and coldness of skin, or complains of tingling, pain, or numbness Patient exhibits increased confusion and disorientation Patient experiences shortness of breath and impaired air exchange Patient releases restraint and experiences a fall or other traumatic injury Patient has psychological distress Patient has death Patient & Family Education Thoroughly explain the use of restraints
  9. 9. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118 REVISION DATE: 3/01/2010 Page 9 of 9 Caution family against removing, repositioning, or retying restraints in Acute Medical Surgical situation Age-Specific Considerations Pediatrics The use of restraints should be limited to clinically appropriate and adequately justified situations after all appropriate alternatives have been used. Restraints are only used on children to restrict movement when patient’s are at risk of injuring themselves or others When a child needs to be restrained for a procedure, it is best that the person applying the restraint not be the child’s parent or guardian A mummy restraint is a safe, efficient, short-term method to restrain a small child or infant for examination or treatment. Open blanket and fold one corner toward the center, place child on blanket with shoulders at fold and feet toward opposite corner. With child’s right arm straight down against body, pull right side of blanket firmly across right shoulder and chest and secure it beneath left side of body. Place left arm straight against body, and bring left side of blanket across shoulder and chest and lock it beneath child’s body on right side. Fold lower corner and bring it over body and trunk or fasten it securely with safety pins. Geriatrics Advanced age is not in itself an indication for use of restraints. Promoting functional restoration by performing individual assessment of risk factors, determining if a need is not being met, orienting patient as needed, modifying the environment, teaching muscle strengthening exercises, and meeting older patient’s needs in ADLs will help prevent falls and other traumatic injuries. Documentation/ Related Documents General Information Ages Served Neonatal Infant Pediatric Adolescent Adult Geriatric References The Joint Commission reference is: Comprehensive Accreditation Manual (CAMH) - June 2009 CMS Manual System Pub. 100-07 State Operations - October 17, 2008

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