Transcript Restraints
RESTRAINTS Annual Required Training Reviewed and Revised VP 10-2013 Your Patient Has Rights To be cared for in an environment that preserves dignity, fosters a positive self-image, and provides privacy To be free of seclusion & restraints , of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff 2 Restraints SO, What is a physical restraint? A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. 3 Qualified Staff Staff must be trained and able to demonstrate competency: in the application of restraints, removal of restraints, monitoring, assessment and providing care of the patient in restraints. Competency will be reviewed and documented on a regular basis 4 Types of Restraints There are many types of restraints: Restraints requiring monitoring and assessment as described in policies Non Violent Violent or Self Destructive Seclusion Chemical Restraint Restraints options that do not require monitoring or assessment as described in policies, but should be monitored/assessed based on clinical judgment Time-Out Adaptive Support Protective Devices Medical Immobilization The initial assessment of need is warranted by the patient’s behavior. Remember, the plan of care MUST be modified to include restraint. 5 Restraints for Medical/Surgical Reasons (Non-violent) Non-Violent, non-self destructive restraint is used to limit mobility or temporarily immobilize in relation to a medical, post surgical, or dental procedure (for example: mechanical ventilation). The patient’s behavior is non-violent and non-aggressive. The primary reason for use directly supports the medical healing of the patient. 6 Restraints for Behavior Management (Violent) Violent or Self Destructive Restraint is used in an emergency or crisis situation in which a patient’s behavior becomes aggressive or violent. The behavior presents an immediate, serious danger to his/her safety or that of others. 7 Chemical Restraint A chemical restraint is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition. 8 Seclusion Seclusion is the involuntary confinement of a patient alone in a room or an area especially designed to minimize harm to self & others, from which the patient is physically prevented from leaving. This is carried out in behavioral health and emergency department settings. 9 Orders for Restraints An order for physical restraints or seclusion must be provided by a physician or other LIP. Orders can never be written as a standing order or on an as needed basis(PRN) In the critical care setting, a specific order for the protocol for intubated/trached patients includes parameters for restraint. 10 Restraints for Medical/Surgical Reasons (Non-violent) In the event of an emergency, the qualified RN may initiate the use of a restraint; but, must obtain a physician’s order according to the time frames specified below. A physician order is required within 12 hours of applying non-violent restraints at BMC and 1 hour at JMC. Time limit of 24 hours If the restraint was initiated due to significant change in patient condition, physician must be notified immediately 11 Restraints for Behavior Management (Violent) In the event of an emergency, the qualified RN may initiate the use of a restraint; but, must obtain a physician’s order and the LIP must see the patient face to face and evaluate the need for the restraint within ONE hour after initiation of the intervention. Orders are time limited as follows: Up to 4 hours for adults 18 years & older Up to 2 hours for ages 9 – 17 Up to 1 hour for children less than 9 years 12 Documentation The following will be documented in the patient’s medical record: Description of behavior leading to restraint or seclusion Alternatives or less restrictive measures that were attempted and failed Observed physical condition of the patient and response to restraints, seclusion Type of restraint applied, with date and time applied Date and time LIP’s order obtained Clinical observation and interventions carried out while the patient is restrained or secluded 13 Documentation Cont. Rationale for release and date and time the restraint is removed or seclusion ended and patient’s response Restraint or seclusion included in the patient’s plan of care and /or treatment plan LIP’s order addressing reason for restraints or seclusion, signature on phone orders and assessment and rationale for continued use of restraints or seclusion Education of patient and family regarding use of restraints, seclusion, alternatives and care provided 14 Alternatives to Restraints The use of non-physical techniques are the preferred method for intervening to manage patient behavior. Alternatives to restraint should be considered or tried as appropriate to the risk of harm to self or others. Alternatives might include: Verbal interventions (CPI Techniques)and re-orientation activities Frequent rounds Schedule for toileting opportunities Arranging for family or friends to stay with patient Decrease in stimulation Physical / diversion activity Relaxation techniques / soothing music Pain control management Increase visual observation by moving patient within line of vision of nurses station Use of bed/chair exit alarm Lap buddy Collaborating with LIP to discontinue IV’s, NG’s, Foley catheters, ET tubes, etc. as soon as medically feasible 15 Least To Most Restrictive 1. 2. 3. 4. 5. 6. 7. 8. Geri-chair with table / seat belt Mitts tied down Roll belt Vest Restraint Soft limb holders – 2 extremities Soft limb holders -4 extremities Seclusion Leather or nylon limb holders 16 Monitoring of Restraints Frequency of monitoring is determined based on the assessed needs of the patient. The actual monitoring may be delegated to assistive personnel with oversight by the RN. Assistive personnel who are authorized to monitor patients must have specific training and competency validation. The RN is responsible for reassessing the behavior and need for continued restraint. 17 Monitoring of Restraints The condition of the restrained patient or patient in seclusion must be continually assessed, monitored and reevaluated. At a minimum, monitoring & documentation for a patient in: non-violent restraints is every 2 hours and violent restraints is every 15 minutes. 18 Monitoring of Restraints Monitoring and documentation must include, but not limited to: Nutrition and hydration needs Circulation, skin integrity and range of motion Hygiene and elimination needs Physical and psychological status, behavior and comfort Making sure patient rights and dignity are being maintained Checking if less restrictive means are possible Check readiness for discontinuation of restraints Whether the restraint is appropriately applied, removed or reapplied 19 Monitoring of Restraints Reporting of Death to CMS must occur: If patient dies during restraint or seclusion, or where it is reasonable to assume that the restraint or seclusion contributed directly or indirectly to the patient’s death. As a continuous quality improvement process, reports of restraint usage are provided to the Performance Improvement Committee. Staff will report injuries and deaths related to restraint usage to Risk management. 20 Application of Restraints Select the type of restraint appropriate for patient’s condition/need Use correct size and apply according to manufacturer’s guidelines Secure restraint only to parts of the bed which will move with the patient. Never secure to mattress, bedrails, or fixed portions of the bed frame. Position patient to: promote comfort, maintain proper body alignment, prevent aspiration or restriction to circulation or respiration 21 Application of Restraints (cont.) Side rails should be up when restraints are in use. Inform patient and family of the reason for using the specific restraint and include in plan of care Reassure the patient and family that the restraint will be removed as soon as it is no longer necessary All types of restraints must be of the type to provide a “quick release” if and when necessary. Injuries or death occurring during restraint use will be reported to the Risk Manager. 22 Discontinuation & Removal of Restraints Patients will be continually assessed for the opportunity for removal of restraints. Restraints will be discontinued when the clinical treatment is discontinued or the patient’s actions or behavior no longer warrant the need for restraint. If the behavior or need which led to the patient being restrained presents again, the restraints may be reapplied under the original order if: It is documented that the behavior is part of the same episode that prompted the original order And the total time specified in the original order has not lapsed. 23 Patient and Family Education Education should include: Explanation of potential risk of the patient’s unsafe behavior necessitating the use of restraint Explanation of alternatives Identification of possible family participation in the care that limits or halts restraint use Incorporation of patient’s preferences whenever possible The care the patient will receive while restrained Criteria used to discontinue use of restraint or seclusion and that any type of restraint or seclusion will be ended at the earliest possible time. 24 References Berkeley Medical Center: Administrative Policies: 302 Restraint and Seclusion Gateway Behavioral Health Policies: Behavioral Management Plan Jefferson Medical Center: Administrative Policies: Patient Rights Nursing Policy: Restraints for Medical /Surgical Reasons Restraints and Seclusion for Behavior Management 25 RESTRAINTS – ONLY AS A LAST RESORT Thank you for completing this learning module. Please answer a few questions on your post test to complete this course. 26