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Bh inter restraints_behavioral_03012010


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Bh inter restraints_behavioral_03012010

  1. 1. INTER-Interdisciplinary TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 APPROVED: PAGE 1 of 13 EFFECTIVE DATE: 7/2008 REVISION DATE: 3/01/2010 Policy Statement Purpose Procedure Documentation / Related Documents Patient Alert All patients’ have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 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 or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, other patients, or staff from harm. The least restrictive intervention must be used first and then determined if a more restrictive environment, restraint, or seclusion will better meet the needs of the patient. 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: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 2 of 13 This may include visiting restriction of family, primarily on the Behavioral Health Units at Bloomington Hospital. 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 or seclusion 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. A face-to-face assessment by the physician or other licensed independent practitioner or a registered nurse who has been trained by established guidelines is required within one hour of initiation of restraints for violent or self-destructive behavior. 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. 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: 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
  3. 3. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 3 of 13 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 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) 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) Seclusion Is the 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. Alternatives to Restraints: Non-physical techniques are always considered the preferred intervention. Such interventions may include: Redirecting the patient’s focus 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) Reality orientation Verbal De-Escalation Allowing the patient to voluntarily cooperate Cardiac chair Geriatric chair Getting patient out of bed and out of room (if applicable)
  4. 4. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 4 of 13 General information Assessment and Documentation for Restraints/Seclusions for Violent or Self Destructive Behaviors 1. The Restraint/Seclusion Orders are to be filled out with the computer or written clinical documentation placed in patient’s chart containing: a. Initial reasoning for the restraint/seclusion, including all behaviors b. The alternatives which were attempted first c. The type of restraint initiated or if only the use of seclusion was needed. 2. Begin a Nursing Care Plan for the Restraint/Seclusion 3. Notations are to be made every 15 minutes for adults 18 years and older, 5 minutes for adolescents and children 17 years and younger, and placed on a 1:1 with staff to remain at arms length of patient at all times. 4. A time limit for verbal/written orders for patient’s in restraints/seclusion with Behavioral Health needs. a. 4 hours for adults (18 yrs and older) b. 2 hours for children and adolescents (9-17 yrs) c. 1 hour for patient’s under the age of 9 years. 5. Document any injury noted during the restraint or seclusion episode in patient’s chart. 6. Document physical and psychological status every 2 hours including: a. Hygiene b. Nourishment c. Elimination needs d. Capillary refill e. Need for continuation of restraints/seclusion f. Any significant changes in behaviors g. Any significant changes with physical appearance or findings h. Notify physician immediately if f or g have occurred 7. If patient remains in restraints up to 2 hours reposition and continue repositioning every 2 hours. 8. Assess and document patient’s readiness for discontinuation of restraints/seclusion at least every 2 hours including: a. Patient’s awareness of the rationale for the restraint or seclusion and the behavior criteria for discontinuation.
  5. 5. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 5 of 13 9. Restraint or Seclusion is discontinued as soon as the patient meets his or her behavior criteria. 10. Patient’s dignity and privacy is to be maintained at all times to the best of the situation occurring. 11. Once patient removed from restraints or seclusion a debriefing is to be completed with input from staff and patient. The debriefing form is to be given to the Clinical Director. Documentation that the debriefing form was completed and all other appropriate documentation is placed in the patients’ chart. Use of Restraint or Seclusion in the Management of Violent or Self Destructive Behavior 1. Restraints 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. 2. When restraints or seclusion are initiated it is preferred the physician be notified and give the order for restraints/seclusion prior to the application. If the behaviors or situation do not permit the notification prior to placing the patient in restraints/seclusion staff may initiate and then notify the physician and receive the verbal or written order as soon as possible, not to exceed 1 hour. 3. In the utilization of restraints or seclusion on the Behavioral Health inpatient units it is the responsibility of the attending psychiatrist or on call psychiatrist to give the written or verbal orders. These orders are to be given prior to application, during the emergency application, or as soon as the situation permits, not to exceed 1 hour. Written or verbal orders for restraint/seclusion for violent or self destructive behavior with primary behavioral health needs are time limited to: a. Every 4 hours for adults age 18 years and older b. Every 2 hours for children and adolescents age 9-17 years c. Every 1 hour for patient’s under age 9 years 4. The psychiatrist, or specifically trained Registered Nurse (RN), is to do a visual assessment of the patient within one (1) hour of the initiation and application of the restraints/seclusion to evaluate: a. The patients’ immediate situation b. The patients’ reaction to the intervention c. The patients’ medical and behavioral condition d. The need to continue or terminate the restraint or seclusion If the face to face assessment is completed by the specifically trained RN they must consult with the psychiatrist as soon as possible after the evaluation. 5. The psychiatrist will document all above findings in the patients’ chart under the progress notes. The specifically trained RN will document his/her assessment using the Bloomington
  6. 6. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 6 of 13 Hospital restraint assessment form in the SHARQ format (situation, history, assessment, recommendations, questions) and place in the patients’ chart under the progress notes. 6. If the patient has not met the behavioral criteria for discontinuation of restraints or seclusion for patients with a primary behavioral health need the attending or on call psychiatrist is to do a face to face full assessment and document in patients’ chart: a. Every 8 hours for adults 18 years and older b. Every 4 hours for children and adolescents 9-17 years c. Every 1 hour for children under age 9 years The Simultaneous use of Restraint and Seclusion for Violent or Self Destructive Behavior is not utilized in the Behavioral Health Units at Bloomington Hospital. Seclusion Only for Violent or Self Destructive Behavior the patient is to be 1:1 for the first hour and observed by audio and video by staff continuously after the first hour on the inpatient psychiatric units. The staff person observing the 1:1 is to be trained in Non-Violent Crisis Intervention and must be in close proximity, or within arms length of the patient and available to immediately intervene. Seclusion can only be performed in a security room designed for this purpose. (Crisis Care Unit at Bloomington Hospital) Any type of restraint requires a 1:1 (face to face) on the inpatient psychiatric units. Any patient with 4 way and/or locked restraints requires a 1:1 (face to face) on all units that are appropriate for the patient including: Emergency Department Intensive Care Units Behavioral Health Units Forcing Medications The application of force to physically hold a patient, in order to administer a medication against the patient’s wishes, is considered a restraint. The patient has a right to be free of restraint, and also has a right to refuse medications, unless a court has ordered medication treatment. A court order for medication treatment only removes the patient’s right to refuse the medication. Additionally, in accordance with State Law, some patient’s may be medicated against their will in certain emergency circumstances. However, in both of these circumstances, health care staff is expected to use the least restrictive method of administering the medication to avoid or reduce the use of force, when possible. The use of force in order to medicate a patient, as with other restraint, must have a physician’s order prior to the application of the restraint (use of force). If physical holding for forced medication
  7. 7. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 7 of 13 is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply. All restraints used on the Behavioral Health Units are considered Behavioral. In an event that 4 way and/ or locked restraints are required on any other units not mentioned above must have a 1:1 who is a trained Behavioral Health staff person for monitoring and maintaining appropriate documentation at all times. Staff Training Requirements for the Application and Monitoring of Behavioral Health Patient’s with Primary Behavioral Health Needs in Restraints/Seclusion The person applying restraints/seclusion must have received education, training, and demonstrated knowledge based on the specific needs of the patient population requiring the application, monitoring and documentation of Behavioral Restraints and Seclusion in: Techniques to identify behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion Use of nonphysical intervention skills Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical or behavioral status or condition The safe application and use of all types of restraints used at Bloomington Hospital including training on how to recognize and respond to signs of physical and psychological distress (i.e. positional asphyxia) Clinical identification of specific behavioral changes that indicate the restraints are no longer necessary Monitoring the physical and psychological well-being of the patient who is restrained or secluded Use of first aid techniques (i.e. management of minor scrapes/bleeding), CPR certification, and monitoring vital signs Initiation, Application, Monitoring and Documentation of restraints/seclusion Recognizing nutritional/hydration needs Checking circulation/capillary refill Range of Motion Hygiene and elimination needs Maintain annual competency in all of the above Face to Face Evaluation: In addition to the restraint and seclusion education and training, designated RN’s will complete the following training Non-Violent Crisis Intervention Advanced assessment training presented by a psychiatrist
  8. 8. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 8 of 13 Management of delirium and dementia Designated RN’s includes: Behavioral Health Charge Nurses, Critical Care/Cardiovascular Charge Nurses, Pediatric Charge Nurses, Rapid Response RN, and all Patient Care Director’s. All physicians caring for patients at Bloomington Hospital will receive training in regards to any updates or revisions made to the policies and orders for Behavioral and Medical Restraints and Behavioral Seclusion. Monitoring and Reporting Requirements of Behavioral or Medical Restraints and Seclusion The use of Behavioral or Medical Restraints and/or Seclusion will be reported to the Patient Care Director including patient name and room number. The collection of data regarding the use of restraints and seclusion will be utilized in reducing the risk of restraints and the use of seclusion. Hospitals must report deaths associated with the use of restraints or seclusion according to the following CMS guidelines: Each death that occurs while the patient is either in Medical or Behavioral Restraints or Seclusion Each death that occurs within 24 hours after the patient has been removed from Medical or Behavioral Restraints or Seclusion Each death known to the hospital that occurs within 1 week after Medical or Behavioral Restraint or Seclusion where it is reasonable to assume that use of restraint or placement in seclusion 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 If any patient remains in Behavioral Restraints or Seclusion for a period of 8 hours, or experiences two or more separate episodes of restraint and/or seclusion of any duration within 8 hours the Clinical Leaders (i.e. Clinical Director, Psychiatrist) are to be notified to do the following: Assess whether additional resources are needed to facilitate discontinuation of restraint and/ or seclusion Minimize recurrent instances of restraint and/or seclusion Thereafter, the Clinical Leaders are notified every 8 hours if either of the above conditions continues.
  9. 9. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 9 of 13 Patient Assessment and Preparation Assessment 1. 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. 2. Assess patient’s behavior, such as confusion, disorientation, agitation, restlessness, combativeness, or inability to follow directions. 3. Review institution policies regarding restraints. Check physician’s order for purpose of restraint and type, location, time and duration of restraint. Determine whether signed consent for use of restraint is needed. 4. Review manufacturer’s instructions for restraint application before entering patient’s room. Determine the most appropriate restraint. 5. 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 1. Identify patient by checking armband and having patient state name, if applicable. 2. Approach patient in a calm, confident manner. Explain what the plan of staff is and what staff will be doing. 3. Gather equipment, and perform hand hygiene. Procedure 1. 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 2. Adjust bed to proper height, and lower side rails. (Crisis Care beds are non-adjustable and will be utilized appropriately) Rationale: Allows nurse and staff to use proper body mechanics and prevent injury 3. Maintain patient’s comfort and in correct anatomic position. Rationale: Prevents contractures and neurovascular impairment 4. 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 5. Apply appropriate size restraint and refer to manufacturer’s directions.
  10. 10. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 10 of 13 a. Extremity (ankle or wrist) restraint: Restraint designed to immobilize one or all extremities. Commercially available limb restraints are composed of sheepskin or 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. 6. 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. 7. Secure restraints with a quick-release tie. Rationale: Allows for quick release in emergency. 8. Insert two fingers under secured restraint. Rationale: Checking for constriction prevents neurovascular injury. A tight restraint may cause constriction and impede circulation. 9. Restraints should be removed at least every 2 hours. If patient is violent or 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. A violent or aggressive patient should not be left unattended while restraints are off. 10. Secure call light or intercom system within reach. (Patient’s in Behavioral Restraints will have staff with them at all times). Rationale: Allows patient, family, or caregiver to obtain assistance quickly. 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. 11. Leave bed or chair with wheels locked. (Crisis Care beds are bolted to floor). Bed should be in the lowest position.
  11. 11. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 11 of 13 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. 12. Perform hand hygiene. Rationale: Reduces transmission of microorganisms. Post Procedure 1. 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 2. 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. 3. 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. 4. Review Behavioral Restraints every 2 hours, with documentation every 15 minutes, and every 2 hours in nursing notes. A face to face assessment by a physician for Medical Restraints is every 24 hours with a new written order for continuation of the restraints. A face to face assessment by a psychiatrist for Behavioral Restraints every 8 hours with a new written order for continuation of the restraints. (See Bloomington Hospital’s specific policy) 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
  12. 12. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 12 of 13 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 Education Thoroughly explain the use of restraints In the use of restraints for Violent or Self Destructive Behaviors on the Behavioral Health Units patients family will not be allowed to visit to maintain patients dignity and safety Patient has extensive debriefing after discontinuation of restraints and/or seclusion Documentation/ Related Documents Record nursing interventions employed to ensure patients safety before use of restraints Record patients behaviors before restraints were applied, level of orientation, and patients or family members understanding of the purpose of the restraints. (If applicable) In nurses’ notes or on restraint flow sheet, record type and location of restraint applied, time restraint was applied, and specific assessments related to oxygenation, skin integrity, musculoskeletal system, and peripheral vascular integrity an Record patients behavior after restraints were applied, times patient was assessed while restraints were on and findings, attempts to use alternatives to restraint and patients response, times restraint was released (temporarily and permanently), and patients response when restraints were removed 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
  13. 13. TITLE: Restraints: Behavioral POLICY NUMBER: INTER-R-117 REVISION DATE: 3/01/2010 Page 13 of 13 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. General Information Ages Served Neonatal Infant Pediatric Adolescent Adult Geriatric References Center for Medicare and Medicaid Services Joint Commission