Transcript Restraint or Seclusion

Prevention, Intervention and
Postvention: Restraints and Seclusion
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Battle Creek Health System
Behavioral Health Units
Restraint or Seclusion
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BCHS
Behavioral Health
Guidelines
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Centers for Medicaid and
Medicare
Joint Commission on
Accreditation of Hospitals
Michigan Mental Health
Code
The following course addresses meeting the
requirements of CMS, the Joint Commission and the
State of Michigan Mental Health Code related to the
implementation of restraint or seclusion.
Course Objectives
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Define Physical Restraint, Drug or Chemical Restraint,
Legal/Administrative/Forensic Restraint and Seclusion
Define patient rights regarding the use of restraint or seclusion
Identify dangers associated with placing a patient in restraint in
prone position
Identify required documentation for initiating, monitoring and
discontinuing restraint or seclusion
Identify least restrictive interventions
Identify the requirements for reporting a death related to
restraint or seclusion
Physical Restraint
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A physical restraint is 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.
Drug or Chemical Restraint
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A drug or medication, or a combination, when
it is used as a restriction to manage the
patient’s behavior, restrict the patient’s
freedom of movement, or to impair the
patient’s ability to appropriately interact with
their surroundings and is not standard
treatment or dosage for the patient’s
condition.
Legal/Administrative/Forensic
Restraint
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Corrective restraints used for security reasons and
administered by forensic personnel.
(Use of handcuffs, manacles, shackles, other chaintype devices, or other restrictive devices applied by
non-hospital employed or contracted law
enforcement officials for custody, detention, and
public safety reasons are considered law
enforcement restraint devices to patients at BCHS.)
Seclusion
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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 selfdestructive behavior.
Timeout is not considered seclusion – patient
consents to being alone in a designated area for an
agreed upon timeframe from which the patient is not
physically prevented from leaving.
New Terminology for Behaviors
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CMS defines two types of behavior that could
warrant the use of restraint or seclusion
Non-violent, Non-self-destructive Behavior
Violent, Self-destructive Behavior
Staff Behavioral Triggers
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Staff may exhibit behaviors that trigger patient
behaviors requiring restraint or seclusion
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Attitude: hurried, inattentive, preoccupied, non-supportive,
non-open
Routines: becoming so involved in following the routines
that the patient’s needs become secondary
Rules: being too rigid with rules and not individualizing the
care because it would break a rule
Personal triggers: not being in touch with own triggers or
preconceptions related to patients and their care
Environmental Triggers
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Noise
Confusion
Increased census
Overall milieu
Admissions and discharge processes
Activities happening on the unit
Restraint or Seclusion Interventions
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“Seclusion and restraint when used properly,
can be life-saving and injury-sparing
interventions. These emergency measures
aim to protect patients in danger or harming
themselves or others and to enable patients
to continue in treatment successfully and
effectively” (Success Stories and Ideas for
Reducing Restraint/Seclusion, p.3)
Patient Rights
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All patients have the right to be free from physical or
mental abuse, and corporal punishment. All patients
have the right to be free from restraint or seclusion,
of any form, imposed as a means of coercion,
discipline, 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.(CMS 4821.13(e))
Patient Rights
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Least restrictive interventions must be implemented
or at least considered prior to initiation of restraint or
seclusion
Restraint or seclusion use can not be based solely
on the patient’s diagnosis or history of dangerous
behavior
The type or technique of restraint or seclusion used
must be the least restrictive intervention that will be
effective to protect the patient, a staff member, or
others from harm.
Asking the patient who is demonstrating the behavior
“what would help you right now at this moment?”
Risks Associated with Restraint or
Seclusion
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Use may result in strong
negative physical effects
such as:
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Discomfort
Increased risk of pressure
ulcers
Increased risk of
pneumonia
Increased cardiac load
Increased risk of deconditioning
Increased risk of injury or
death
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Use may result in strong
negative psychological
effects such as:
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Increased disorganized
behavior
Social isolation
Demoralization
Humiliation
Sense of being punished
Interferes with therapeutic
relationship
Awareness of Escalating Behaviors
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CPI training for each Behavioral Health staff member
Majority of restraint or seclusion events occur within
the first 24 hours of admission in BCHS Behavioral
Health
Escalating signs may include:
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Pacing, hand wringing, clenching fists
Red faced, perspiring heavily, rapid breathing
Loud, pressured or rapid speech
Lack of eye contact
Least Restrictive Interventions
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Re-direction
Counseling
1:1 Intervention
Decreased
environmental stimuli
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Increase rounding
frequency
Move patient closer to
nurse station
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Approach patient in
calm, unhurried manner
Limit setting
Quiet atmosphere
Visual suprvision
Diversional Activities
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Television, radio
Games
Least Restrictive Interventions
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Refocusing attention
Reality orientation
Pain relief/comfort measures
PRN medication
All interventions attempted must be documented
Any interventions that were considered but not
attempted should be documented and the reason
not implemented
Is it Time for Restraint or Seclusion?
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Behavior that precipitates a decision to restrain or
seclude a patient should first trigger investigation
and treatment aimed at understanding and
eliminating the cause of the behavior.
Underlying causes of threatening behavior may
include:
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Fear
History of physical or sexual abuse, past restraints
Misinformation
Symptomatic behavior related to diagnosis, i.e. paranoia
Initiation of Restraint or Seclusion
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Assessment of patient’s needs
Addressing medical problems may eliminate or
minimize the need for restraint or seclusion.
Medical problems may include:
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Substance abuse, drug interaction or drug side effect
Elevated temperature and infection
Pain
Organic Brain Syndrome or delerium
Hypoxia
Hypoglycemia
Electrolyte imbalance
Positional Asphyxia and Restraint or
Seclusion
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The prone position (face down) should not be used for restraint
as it may lead to positional asphyxia
“Positional asphyxia is insufficient intake of oxygen as a result
of body position that interferes with one’s ability to
breathe”(Mohr & Mohr, 2000, p.289;National Institute of Justice
Program [NIJP], 1995, p.1)
As a consequence of the restraint application respiration is
compromised causing insufficient oxygen in the blood to meet
the body’s oxygen needs or demands (hypoxia) which then
results in a disturbed heart rhythm (cardiac
arrhythmia)(Patterson,et.al., 1998, p.62).
Prone Restraint Complications
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Compression or restriction of movement of the ribs (intercostal
muscles) limits the ability to expand the chest cavity and
breathe
Abdominal organs may be pushed up, restricting movement of
the diaphragm and further limiting the available space for the
lungs to expand
Further restriction of the chest cavity may come from a staff
person pressing a hand or knee into the patient’s back or
leaning body weight into or against the back or chest
Agitation or aggressive struggle further increases the body’s
oxygen demands and increases the heart rate
Increased heart rate and insufficient oxygen may cause a fatal
cardiac arrhythmia
Agitated Delerium and Sudden Death
Involving Restraints
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Condition of extreme mental and motor excitement
characterized by aggressive activity with confused
and unconnected thoughts, hallucinations, paranoid
delusions and incoherent or meaningless speech.
Display extraordinary strength and endurance when
struggling
Hyperthermia is often present
Described in patients with psychosis, chronic
schizophrenia, mania, and high blood concentrations
of cocaine, methamphetamines or other stimulants
Obtaining an Initiation Order
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Order may be initiated prior to receiving order, if imminent
danger to patient or others
Nurse initiated order is for 30 minutes. If physician was not
notified prior to restraint or seclusion, within a few minutes
contact the psychiatrist or physician to obtain an order for up to
4 hours.
In Powerchart – click Add an order – and then choose
Restraint/Seclusion Behavioral Problem
If order was not received from the attending or the physician
covering for the attending, notify the attending as soon as
possible
Behavioral Health Administrator on Call must be notified of
every restraint or seclusion event
Restraint or Seclusion Order
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Must Never Be Written as PRN
Choose Restraint or Seclusion
Include Duration (hours or minutes)
Include Duration Unit (number of hours or minutes)
Include least restrictive interventions attempted or
considered/not attempted and why not attempted
Include clinical justification for use
Include type of restraint
Include behavioral criteria that must be
demonstrated for discontinuation and this
information is also shared with the family when
authorized by the patient
Physician Face to Face Assessment
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Must be performed within one hour of the
initiation of the restraint or seclusion
RN documents on the restraint form the time
the physician performs assessment
Physician documents the assessment
findings in Powerchart
Monitoring of Restraint or Seclusion
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Staff will be assigned to monitor the patient one to one
In seclusion, the staff member will remain outside the locked
door to observe the patient
In restraint, the staff member will remain in the room with the
patient
Documentation must be done every 15 minutes on the
assessment section of the restraint form
A simultaneous combination of restraint and seclusion
(restrained alone in a room that the patient would not be able to
leave if he/she were not restrained) is not practiced at BCHS
Behavioral Health
Restraint or Seclusion Assessments
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Document every 15 minutes
Vitals
– Based on the patient’s condition
Circulation and range of motion
– Checking skin color and temperature
– Complaints of numbness, tingling
– Asking how extremities feel
Repositioning and release of restraints
– Which restraints have been released
– Patient was repositioned
Restraint or Seclusion Assessments
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Offer and document every 2 hours
Hygiene and elimination
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With assistance, loosen restraints and assist patient to
commode for elimination needs and or hygiene needs
Nutrition and hydration
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Increased calories being used related to behaviors
Increased risk for dehydration and or electrolyte imbalance
related to increased perspiration
Psychological Status and Comfort
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Continue to offer support to the patient, focusing on
what they need and how we can help them
Continue to rebuild therapeutic rapport
Continue to listen for their concerns or complaints
Continue to learn from the patient what led to the
behaviors that required restraint or seclusion
Vulnerable Patient Populations at Risk
While in Restraint or Seclusion
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Pregnant
Respiratory conditions such as asthma or COPD
Cardiac disease
Seizure disorder
Fractures, arthritis
Head or spinal injury
Victim of sexual, physical or emotional abuse
Victim of rape
Cognitive limitations, language limitations
Assessment of Patient Distress
Related to Restraint or Seclusion
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Shortness of breath, coughing, choking, gasping, saying he/she
can’t breathe
Changes in vital signs, changes in mental status or speech
Skin cool or cold to touch, perspiring heavily and hot to touch
Pain symptoms - guarding an area, grimacing, saying he/she is
in pain, pointing to a painful area
Nausea and vomiting
Any physical changes must be reported to RN for further action
up to and including calling 911 for transport to the Emergency
Department
Initiation of CPR for absent pulse or respirations
Helping the Patient Meet the Criteria
for Discontinuation
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Criteria has been identified in the initial order
and communicated with the patient and/or
family
Offer to contact the family if that would help
Ask how we can help the patient meet his/her
needs
Continue to dialogue with the patient
Recognition of Patient Readiness to
Discontinue Restraint or Seclusion
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Behavioral criteria identified at initiation of order has been met
Changes in physical activity and verbalizations
Must be discontinued at the earliest possible time,
regardless of the length of time identified in the order
Once discontinued, a new order must be obtained if restraint or
seclusion needed again (releasing for hygiene or elimination
needs is not discontinuation)
A final assessment documentation must be performed 15
minutes after discontinuation
The restraint or seclusion event must be entered on the
restraint/seclusion log on the unit
Care Plan Modification
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The use of restraint or seclusion must be in
accordance with a written modification to the
patient’s plan of care.
Use of restraint or seclusion constitutes a
change in a patient’s plan of care.
The change in the plan of care should be
based on assessment and evaluation of the
patient.
Debriefing after Restraint or Seclusion
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As soon as possible, but no longer than 24 hours, after the
event hours
Includes all staff present during the event and the patient and/or
family as applicable
Documentation in the EMR should indicate any injuries the
patient sustained and how the patient perceived the
restraint or seclusion. Document if the patient identifies
something else that could have been done to help he/she
regain control and avoid restraint or seclusion.
Postvention form needs to be completed after each restraint or
seclusion event and should be submitted to the Nurse Manager
or the Educator for use in staff training and for Performance
Improvement
Death Reporting Requirements
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You must report any death that occurs in relationship to
restraint or seclusion to Risk Management
– Death that occurs while a patient is in restraint (physical or
drug/medication) or seclusion
– Death that occurs within 24 hours after the patient has been
removed from restraint or seclusion
– Each death known to the hospital that occurs within 1 week
after restraint or seclusion where it is reasonable to assume
that use of restraint or placement in seclusion contributed
directly or indirectly to the patient’s death
– A PEERS must also be completed
Contact Required for Reporting a
Death
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Must be reported to Risk Management
Call operator and ask Risk Management be
paged to your number
Sending an email or leaving a phone
message is not acceptable
You must speak to someone from Risk
Management
Staff Training Requirements
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CPI certification on initial hire and annual
recertification for all staff
Staff are not allowed to participate in restraint
application or seclusion procedures until CPI
training has been completed
Review of this Behavioral Management
training module
Patient Safety and Quality
Performance Indicators
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Every restraint or seclusion event in
Behavioral Health will be audited through
concurrent chart reviews at the unit level and
reviewed at staff meetings
Report of restraint or seclusion events to
Behavioral Health Quality Improvement Team
monthly
Report of restraint or seclusion events to
Patient Safety and Quality monthly
References
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BCHS Restraint & Seclusion Policy # TX-70
CMS Manual System. (2008). Pub. 100-07 State Operations
Provider Certification. 482.13(e)
– Standard: Restraint or Seclusion, 482.13 (f)
– Standard: Restraint or Seclusion: Staff Training
Requirements, 482.13 (g) Standard: Death Reporting
Requirements
Crisis Prevention Institute, Inc. 2002. Instructor manual:
Nonviolent crisis training program. Brookfield, WI: Compassion
Publishing, Ltd.
Michigan Association of CMH Boards. (2001). Michigan’s
Mental Health Code. Lansing, MI.
References
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American Psychiatric Association, American Psychiatric Nurses
Association, National Association of Psychiatric Health Systems. 2003.
Success stories and ideas for reducing restraint/seclusion in
behavioral health.
DeLacy,L.C.(2001). Seclusion and Restraint Standards: A platform for
creating safety for patients and staff. Journal of the American
Psychiatric Nurses Association, 7 (4) 99-102.
Mohr & Mohr, 2000, p.289;National Institute of Justice Program [NIJP],
1995, p.1.
Myers, R.E., Williams, J.E. (2001). Relationship of less restrictive
interventions with seclusion/restraints usage, average years of
psychiatric experience, and staff mix, 7 (5) 139-144.