Behavioral Emergency/Seclusion

Violent

Patients have the right to be free from

restraints and/or seclusion of any form

imposed as a means of coercion,

discipline, convenience or retaliation.

› “Generally used in the med-surg patient

population and applies when the primary reason for use directly supports medical healing” (i.e. a patient pulling out lines or tubes)

› “Limited to emergencies and implemented for

the management of violent or self destructive behavior that jeopardizes the immediate safety of the patient, a staff member or others”

The type of restraint (violent vs.

nonviolent) is based on the behavior

demonstrated by the patient, not the

diagnosis.

Requires a physician’s, resident’s, fellow’s or APP’s order › If a resident, fellow or app orders, must be

approved by staff physician and documented on order sheet

› Before initiation OR

› As soon as possible (defined as “within a few minutes”) in an emergent situation

› Med Surg/ICU: Wrench in and document on the Non-Violent Restraint Flowsheet in Doc Flowsheets

Must specify

Restraint Type

and Reason

Type of Restraint or Seclusion Who May Accept

Signed, Dated, and Timed by Ordering Provider

Non-Violent/Non-Self-Destructive Behavior (Restraint only)

Licensed Nurse

Within 48 hours of issue

Behavioral Emergency (Restraint or Seclusion)

RN Within 24 hours of issue

A PRN order or Trial Release is not permitted. Note: A temporary release for the purpose of caring

for the patient’s needs (e.g., toileting, range of

motion exercises) is not considered a discontinuation or trial release as long as the patient remains under

direct staff supervision.

PRN orders

Wrench in Restraints non violent tab in flowsheet tab and document the following:

Alternatives tried (A minimum of one) › Bed Alarm, Repositioning, disguise equipment, etc…

Clinical Justification

Q2 Monitoring

Restraint Type › Wrist, Side Rails X4, etc…

Education: › Behaviors or criteria required to discontinue restraints/pt

response › Why the patient is being restrained

› Who was educated

The standard CMST checks - RN › Visual Check

› Circulation

› Range of Motion

Interventions – RN, LVN, CNA › Restraints released

› Food & fluids offered

› Toileting needs met

Comments

› Add any additional information

1) Click on

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Template”

2) Type in

“restraint” in

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3) Choose type of

restraint then click

accept.

4) Check the problem,

goals, and interventions

appropriate for the

patient

5) Click

Accept

3) Check the problem

and mark both goals as

completed

4) Click

Accept

1) Highlight

the Problem

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Resolve

Problem

Medical non-violent restraints must be renewed each calendar day

“PRN” or “standing” orders are not allowed

If the restraints have been discontinued, then a new order is needed, not a renewal order

Only a Physician, Resident, APP or RN

may discontinue restraints

Add a column for the

time you discontinued

them and mark the

restraint type as

discontinued

Behavioral Emergency/seclusion:

Behavioral Emergency is defined as:

A situation in which it is immediately

necessary for Restraint or Seclusion of

an individual to prevent

Imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit

suicide or serious bodily harm; or

Imminent physical harm to others because of acts the individual is committing.

The definition of seclusion is involuntary confinement of a patient, alone in a room or area, from which the patient is prevented from leaving

Note: Seclusion includes when staff is physically intervening to prevent the patient from leaving

the room as well as giving the patient the perception that threatens the patient with

physical intervention if the patient attempts to leave the room, regardless of whether the door is

actually locked.

Behavioral Emergency (Restraint or Seclusion)

can be ordered by:

› Physician, resident, or fellow only

Before initiation OR

› As soon as possible (defined as “within a few

minutes”) in an emergent situation

Wrench in and document on the Violent or Self-Destructive Restraints flowsheet for hourly assessment

Safety documentation every by the person providing direct (1:1) observation

Requires a physician’s renewal (1 time only)order › Adult: Every 4 hours

› Children aged 9-17: Every 2 hours

› Children under 9: Every hour

Patient must be continually monitored in-person

LVNs can not obtain telephone order for behavioral emergency restraints/seclusion, initiate, or discontinue restraints

Elements of assessment & care more detailed

If a patient falls asleep, restraint must be removed

More required documentation

Time of initiation of restraint or seclusion

Patient’s current physical, emotional and

behavioral status

Any medications administered

Type of care needed

Staff member must:

› Assist re-entry of patient into care setting

› Observe patient for 15 minutes and

document patient behavior

Debriefing:

› Must occur and be documented after

discontinuation

› See policy for details