Restraints and Seclusion

2018Medical Staff/ APP Training

TJC requirementsThe hospital’s policies and procedures regarding restraint or seclusion include the following:- Staff training requirements- The determination of who can initiate the use of restraint or seclusion- A definition of restraint- A definition of seclusion

Definitions

• Physical Restraint: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient/resident to move his or her arms, legs, body or head freely.

• Medical/Surgical Restraint: Restricting a patient/resident’s movement to assist with the provision of medical or surgical care.

Definitions

• Drugs Used as Restraint: The use of medication to manage behavior or to restrict the patient/resident’s freedom of movement and is not a standard treatment or dosage for the specific medical or psychiatric condition.

• Behavioral Restraint: Used in the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient/resident, a staff member, or others.

Definitions

Seclusion: • The involuntary confinement of a

patient/resident alone in a room or area from which they are physically prevented from leaving.

• Seclusion may only be used for the management of violent or self-destructive behavior.

CMS Conditions of Participation• Decision to use restraints must be based on an

individual assessment, not a diagnosis, and must have documented specific behaviors that are warranting the use of restraint

• Restraints may only be used when alternatives to restraint have been attempted and failed. These must be documented. Least restrictive measures must be used when using restraints

• Restraints may not be used as a means of fall prevention

Key Points• Orders must be updated daily to continue use of

restraint– Order must include specific behaviors that warrant

continuation of restraint• Order must match the restraint applied• Use of restraint should be addressed in the patient’s

plan of care• Any death of a patient in restraint, within 24 hours of

the discontinuation of restraint, or within one week where the restraint is reasonably believed to have contributed to the patient’s death must be reported

General Considerations• Patient/residents have the right to be free from

restraint or seclusion of any form imposed for coercion, discipline, convenience or retaliation by the staff.

• Patient/residents have the right to individualized treatment and to the provision of services within the least restrictive environment possible.

General Considerations

• A MD/LIP order is required for the initiation of restraints. Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). The decision to discontinue the restraint should be made as soon as the patient no longer exhibits the behavior requiring the restraint use

General Considerations

• Patients/residents are assessed by a Registered Nurse or MD/LIP to identify clinical justification for initiation of restraint and to determine that the risk associated with the use of restraint is outweighed by the risk of not using it.

Clinical Guideline for PracticeFund-15 Restraint and Seclusion

Restraint/seclusion guidelines are divided into two categories based on the reason for use:• Acute medical/surgical care reasons are for use

involving direct support of medical healing.• The management of violent or self-destructive

behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

Justification for Use of Medical/Surgical Restraints

• The use of restraints is limited to clinically appropriate and adequately justified situations. Potential clinical justifications for medical/surgical are:

• Disruption of acute medical/post procedure care by:– Attempting to remove essential medical equipment.– Demonstrating activity that poses a high risk for injury.

• Medical condition or symptoms indicating the need for protective interventions:– Unaware of own limitations and attempting potentially harmful

activities– Attempting to removing medical equipment– Activity posing high risk for injury– Other conditions/symptoms

Medical/Surgical Care Reasons• A Registered Nurse (RN) may initiate restraint use and an MD/LIP is

notified as soon as possible after the initiation of restraint. – A verbal or written order is obtained and entered into the medical record.

• MD/LIP must conduct a face-to-face evaluation of the patient/resident within 24 hours from the initiation of restraint. A face-to-face reevaluation will occur no less than each calendar day to determine continued clinical justification of restraint use.

• MD/LIP order should include:– Date and time of order– Type of restraint– Reason for the restraints– Duration

Examples of Restraints for Medical/Surgical Reasons

• In order of least restrictive:– All side rails up– Enclosure bed– Roll belt/all side rails up– Mittens– Limb

Behavioral Restraint/Seclusion Usage

Justification for Restraint/Seclusion Due to Violent or Self-Destructive Behavior:– The use of such restraint/seclusion is limited to

clinically appropriate and adequately justified situations presenting an immediate, serious danger to his/her safety or that of others. Potential clinical justifications for behavioral restraint/seclusion:• Disrupting medical treatment or therapy• Exhibiting dangerous, overt actions• Harmful to self or others• Making significant threats

Behavioral Restraint/Seclusion Usage

The MD/LIP order must contain the following:• Date and time of order• Type of restraint• Reason for the restraints/seclusion• Duration

Behavioral Restraint/Seclusion Usage

• The patient/resident must be seen by the MD/LIP within one hour of the application of the restraint/seclusion even if the length of time in use is less than one hour.

• The One Hour Face to Face– Assessment includes the patient/resident’s:– Immediate situation– Reaction to the intervention– Medical and behavioral condition– Need to continue or terminate the restraint or

seclusion

Behavioral Restraint/Seclusion Usage

The orders are time limited as follows:• 4hrs for patient/residents 18 and older• 2hrs for patient/residents 9-17• 1hr for patient/residents under age 9