Hospital-Wide Restraint Initiative

Committee Members

•Vickie Geha•Cathy Klotz•Barb Kvale•Deb Hanson

•Cathy Benninghoff•Kathy Boyk•Caryn Flournoy•Kerri Rahman

Ad hoc member:•Deana Sievert

Plan – Current Situation

• Many different accreditation bodies have developed standards around the use of restraints. Most have to do with restraint reduction – following the philosophy that inappropriate restraint use could result in patient harm, including death

• The FDA now estimates that approximately 100 deaths per year are from restraint use

Plan – Improvement Goal

• Reduce restraint use against external benchmark throughout the hospital

• Use of external benchmarks as available

• Increase staff awareness regarding the standards, use of least restrictive alternatives, and the goals of restraint reduction

• Improve documentation of restraint use

Benchmarks

• Med/surg benchmark - 3.4• Rehab benchmark - 3.4• ICU benchmark - 24.3• Continue with internal benchmarks

for psychiatric units

Plan – Opportunity Statement

• Meet compliance regarding documentation of restraint/seclusion use

• Maintain or decrease restraint/seclusion in all hospital areas as reasonable

• Meet all compliance standards for restraint/seclusion use

Measure - Indicator

• Various indicators were used• M/S: number of restraint episodes (any time

an order is written) ÷ number of patient days x 100

• MCCU/Rehab: number of hours in restraints ÷ number of patient hours x 100

• Child Psych: number of hours in seclusion/restraints ÷ number of patient days x 100

• Geri-Psych: number of hours in seclusion/restraints ÷ number of patient days/24 hours x 1000

• Documentation indicators

Analyze - Results

• Geripsych is almost 100% restraint free

• Kobacker continues to make program changes to become restraint free

• Increased awareness of staff in the use of restraints

• There has been some improvement in documentation, but 90% compliance is not met

Actions

• Purchased least restrictive devices such as lap buddies, chair alarms, Velcro waist wrap, activity aprons, wedge cushions, and side-rail protectors

• Continue with the Family Sitter Program• Use of 1:1• Added new committee members• Integrated restraint education in hospital

orientation• Revised the documentation tool to

include all required elements

Actions

• Added the use of freedom splints in the ICUs

• Changed to using an external benchmark• Presented to the Med/Surgical Zone

yearly• Independent study program offered

(contact hours provided)• Presented poster presentations• Recognized staff nurses who documented

thoroughly• Counseling staff for documentation issues

Actions

• Restraint care plan revised• Recognized 5CD for achieving nursing

documentation standards above 90% for one month

• Documentation tool revised• Kobacker PI project won first place at

the PI fair• Develop 1:1 policy• Develop 1:1 Standards of Care• Continue to have ACs review restraint

documentation

Actions – Future Steps

• Education of physicians will occur in the area of order writing

• Slice/dice data further• Continue to look for patterns• Identify opportunities by population

or unit• Continuing to educate at the new

employee orientation and nursing orientation

Actions – Future Steps

• Independent studies are available • Include restraint education in skills

labs• Continue to monitor documentation

compliance regarding the many required documentation elements

• Make some revisions to the current charting tools to streamline, including the physician order form

Response

• Restraint use as it relates to PI is complex, challenging, and often, slow moving

• Data collection is time-consuming and labor intensive

• Goals must be well defined and the team must celebrate even small successes

• Value and perception regarding restraint use varies, but most staff do not think about restraint use the same as a form of treatment

Response

• When you think you have the rules down – they change

• PI around restraint use is here to stay

• It is possible to achieve perfection with efforts from all

• Have to keep up with the monitoring to achieve perfection