Description Restraints can be initiated when unanticipated outbursts of severely aggressive or destructive behavior poses an imminent danger to the patient or others due to an underlying behavioral diagnosis and not due to a medical diagnosis (i.e. electrolyte imbalance, head injury). Limited to emergencies where there is an imminent risk of an individual physically harming himself/herself or others, and non-physical interventions were not effective. Behavior management standards for restraints are reserved for patients in emergency crisis situations related to behavioral diagnoses (aggressive, violent). Examples: A patient admitted for a medical problem that has been stabilized. The patient is awaiting transfer to a psychiatric facility and is acting out. His/her behavior presents a threat to self or to others (i.e. biting, strangling, beating, grabbing, throwing chairs, trying to break window to jump out in a suicide attempt). In acute medical and post-surgical care, a restraint may be necessary to ensure that (for example) an intravenous or feeding tube will not be removed, or that a patient who is temporarily or permanently incapacitated with a broken hip will not attempt to walk before it is medically appropriate. Medical/Surgical restraints are for patients who exhibit actions that pose risks to their safety, the safety of Associates, and/or others, such as agitation not relieved by sedation, inability to follow commands, attempting self-injury, combative behavior, climbing over rails, pulling at tubes or wandering that persists despite efforts and which could place the patient in harm. Physician Orders The organization authorizes qualified registered nurses to initiate the use of restraints in emergency situations before an order can be obtained from the licensed independent practitioner. However, the Physician In emergency situations, the nurse may restrain the patient, but MUST notify the primary physician to inform them of the situation and obtain an order (if applicable). Page 1 of 6
Physician Orders (cont. d) Timeframe to See Patient Reevaluation MUST be notified immediately and informed of the situation so that an order may be obtained. Verbal and written orders for restraint are limited to: Four hours for individuals 18 years of age and older Two hours for children 9 to 17 years of age One hour for children under 9 years of age The physician must conduct an in-person evaluation within one hour of the initiation of the restraint, even if the restraints have previously been removed. The physician or RN reevaluates/reassesses the efficacy of the individual s treatment plan and works with the individual to identify ways to help the patient regain control. The physician order may be verbal or written, must not be on a PRN or standing basis, and must be on a calendar day basis. The physician and/or RN will assess the patient s ongoing need for restraints at a minimum of every calendar day. If the patient requires multiple episodes of restraint use or continuous restraint use, an interdisciplinary patient care team will review and evaluate the patient s current treatment plan. The team will attempt to identify other less restrictive alternatives to using restraints. The RN will document discussion with the physician, apply restraints if appropriate and monitor the patient as per the restraint policy. Reevaluation must be done a minimum of every calendar day. Page 2 of 6
Reevaluation by a physician/registered nurse takes place every: - Four hours for patients 18 years of age or older - Two hours for patients 9 to 17 years of age - One hour for patients under the age of 9 In person reevaluation by the physician must be done: - A minimum of every eight hours for patients 18 years of age or older - Every four hours for patients 17 years of age or younger Note: The physician must reorder the restraint every: Note: The physician must reorder the restraint every calendar day either verbally or in writing. Assessment Four hours for individuals 18 years of age and older Two hours for children 9 to 17 years of age One hour for children under 9 years of age A registered nurse will assess the patient immediately after the placement of behavioral restraints to ensure that any physical restraints used are applied correctly and that there are no immediate compromises to the patient s safety. The RN will also ensure that there is adequate staffing allocated to the monitoring of the patient while in behavioral restraints. The need for restraints will be assessed by an RN. All applicable alternatives, to include a least restrictive environment, will be considered first before choosing the type of restraints to be utilized. These attempts will be documented in the patient s record and communicated to the Physician. If the alternatives are not successful, this information will be communicated to the Physician, and an order for physical restraints will be obtained. Page 3 of 6
The RN will assess the patient s readiness for discontinuation of restraints based on the ordered discontinuation criteria, and communicate this to the Physician. A staff member who is trained and competent will monitor the individual at the initiation of restraint, and at a minimum of every two hours. The RN will assess the patient s readiness for discontinuation of restraints, and communicate this to the Physician. Monitoring of Patient The purpose of monitoring is to ensure the individual s physical safety. A Nursing Assistant, who has been trained and demonstrated competency in caring for restrained patients, will monitor the individual at the initiation of restraint and every 15 minutes thereafter. The monitoring includes the following, as appropriate for the type of restraint employed: - Signs of any injury associated with the application of restraint - Nutrition/hydration - Circulation and range of motion in the extremities - Vital signs (as appropriate per physician orders) - Hygiene and elimination - Physical and psychological status and comfort Monitoring will include continuous, in-person/face-toface observation by an assigned Nursing Assistant who has demonstrated competency in this activity. The purpose of monitoring is to ensure the individual s physical safety. Patient needs to be monitored every two hours and this needs to be documented on the restraint checklist. The monitoring includes: - Signs of any injury associated with the application of restraint - Nutrition/hydration - Circulation and range of motion in the extremities - Vital signs - Hygiene and elimination - Physical and psychological status and comfort Page 4 of 6
Training Training requirements for all direct care Associates: In order to minimize the use of restraints, all direct care Associates as well as any other Associates involved in the use of restraints receive ongoing training in and demonstrate Other training requirements: physical holding techniques, takedown procedures; the application and removal of mechanical restraints. Training requirements for staff who are authorized to perform the 15 minutes assessments: 1. taking vital signs and interpreting their relevance to the physical safety of the individual in restraint. 2. recognizing nutritional/hydration needs. 3. checking circulation and range of motion in the extremities. 4. addressing hygiene and elimination. 5. addressing physical and psychological status and comfort. 6. assisting individuals in meeting behavior criteria for the discontinuation of restraints. 7. recognizing readiness for the discontinuation of restraints. 8. recognizing when to contact the physician in order to evaluate and/or treat the individual s physical status. All Associates who have direct patient contact will receive education on: - The proper and safe use of restraint application and techniques - Alternative methods to restraints Page 5 of 6
Licensed Associates, who in the absence of a licensed independent practitioner, are authorized to initiate restraints and/or perform evaluations/reevaluations of individuals who are in restraints in order to assess their readiness for discontinuation or establish the need to secure a new order, receive the training and demonstrate the competence cited above, and are also educated and demonstrate competence in: - recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which and individual reacts to physical contact, and the use of behavioral criteria for the discontinuation of restraints and how to assist individuals in meeting those criteria. Page 6 of 6