EAST TEXAS MEDICAL CENTER

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EAST TEXAS MEDICAL CENTER

• Managing Behavioral Restraint or Seclusion in the
  Hospital
• Knowledge-Based Physician Training
• Revised 2-13

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Required Training

• CMS Rule 482.13(e)(11)
• Physician and other LIP training requirements
  must be specified in hospital policy. At a
  minimum, physicians and other LIPs authorized to
  order restraint or seclusion by hospital policy
  in accordance with State law must have a working
  knowledge of hospital policy regarding the use of
  restraint or seclusion.

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• Joint Commission PC.03.03.03
• The hospital has written policies and
• procedures that guide the use of restraint and
  seclusion for behavioral
• health purposes which include staff
• competence and training

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• Texas Administrative Code
• 25 TAC 415.257
• Physicians authorized to give
• orders for restraint or seclusion
• must receive training and
• demonstrate competency

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DEFINITION OF RESTRAINT

• 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

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THREE TYPES OF RESTRAINT

• MEDICAL OR NON-BEHAVIORAL
• BEHAVIORAL
• FORENSIC

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MEDICAL RESTRAINT

• Examples

• Definition

• Orthopedic devices
• Helmets
• Surgical dressings
• IV arm boards
• Devices used to achieve body alignment
• Soft foam wrist or ankle straps or hand mitts
• Side rails (2) or crib rails
• Safety belts
• Physical escorts from which the patient can escape

• Any method of holding or securing a patient for
  the purpose of conducting tests, exams, or
  procedures or to protect the pt. from falling
  out of bed or to prevent injuring themselves in
  some type of activity

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FORENSIC RESTRAINT

• DEFINITION
• Application of handcuffs, ankle cuffs, or belly
  chains by peace officers for the purpose of
  security, detention, or public safety
  individuals in forensic custody with these types
  of devices must be maintained and monitored by
  peace officers.

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BEHAVIORAL RESTRAINT

• Any method (physical, mechanical, or chemical) of
  restricting a patients
• freedom of movement (incl. seclusion),
• physical activity, or normal access to his or
  her body, and is not done as a part of a
  medical-surgical condition or procedure.

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TYPES OF BEHAVIORAL RESTRAINTS

• Physical Hold (maximum of 15 min.)
• Mechanical
• Restraint Chair
• Restraint Net
• Seclusion
• Chemical (not used )

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PHYSICAL HOLD RESTRAINT

• The application of body pressure by another
  person to the body of a patient in such a way as
  to limit or control movement of the whole or a
  portion of a patients body. The various
  techniques such as physical hold or take down
  procedures are considered forms of physical
  restraint.

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Bear Hug Type of Physical Hold
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MECHANICAL RESTRAINT

• This is any device used to restrict the movement
  of the whole or a portion of a patients body.
  It can be in the form of ankle or wrist straps, a
  body net or a restraint chair.
• Caution Geri Chairs and Side rails (4) can be
  considered a mechanical restraint if the patient
  cannot control egress

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Example Of Mechanical Restraint
Adult In the Body Net Restraint
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RESTRAINT CHAIR Type of Mechanical Restraint
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SECLUSION

• Seclusion is the confinement of the patient alone
  in a locked room or alone in an identified area
  from which egress is prevented. Patients in
  seclusion must be monitored by a trained staff
  member at all times.

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Seclusion Room at BHC
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CHEMICAL RESTRAINT

• Use of medication is considered a chemical
  restraint when it is used as a restriction to
  manage the patients behavior or restrict the
  patients freedom of movement and is not a
  standard treatment or dosage for the patients
  condition or diagnosis. Chemical restraints are
  not used at BHC.

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CRITERIA FOR BEHAVIORAL RESTRAINT

• All less restrictive measures were attempted and
  failed
• No time to attempt less restrictive measures
• Must be evidence of eminent danger

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Definition of a Least Restrictive Measure

• This is a term that is used extensively in mental
  health and in patient rights issues. It simply
  means the least intrusive or restrictive service
  or treatment that can effectively and safely
  address the patients needs and stated
  preferences. All less restrictive measures must
  be tried and documented before a behavioral
  restraint or seclusion is ordered.

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EXAMPLES OF LESS RESTRICTIVE MEASURES

• Making a contract for safe behavior
• Helping the patient to identify the stressor
  causing the behavior
• Redirecting the patients attention by suggesting
  another activity
• Reducing the noise level and light intensity
• Allowing the patient to speak to a patient
  advocate, minister, supervisor, or family
• Deep breathing exercise
• Negotiating a solution based on options available
• Offering medications to assist in reducing
  agitation/anxiety

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EMINENT DANGER

• There must be evidence that there is eminent
  danger to the patient or others in order to
  justify the need for a behavioral restraint or
  seclusion. Threatening to do something is not
  acceptable. Patients must be in the act of or
  process of attempting to do something that
  could result in injury or damage.

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TIME LIMITS FOR RESTRAINT AND SECLUSION BY AGE

• Physical Hold 15 minutes for all
  ages (child-adult)
• 8 yrs. of age and younger 1 hour
• 9-17 yrs. of age 2 hours
• 18 yrs. and older 4 hours
• Patient must be released as soon as the risk of
  harm to self or others no longer exists.

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MONITORING REQUIREMENTS EVERY 15 MINUTES WHILE IN
RESTRAINT OR SECLUSION

• Circulation
• Respiration Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Behaviors
• Food/Fluid Needs
• Elimination Offered

• ROM Provided
• Hygiene Needs Met
• Physical Comfort Provided
• Psychological Support Offered
• Signs of Injury
• Evaluated for Release

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PHYSICAN REQUIREMENTS

• Face-to-Face Evaluation of Patient within one
  hour of the onset of the R/S
• Completion the Physician Order Set for a
  behavioral restraint
• Completion of Physician Progress Note for a
  behavioral restraint
• Notification of attending physician if physician
  ordering the R/S is not the attending

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Physician Order Set For Behavioral Restraint (lo
cated in red folder with all other physician
orders)
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Physician Progress Note for a Behavioral Restraint
or Seclusion.
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CONGRATULATIONS! You have completed the
physician Training module for Restraint and
Seclusion. Please print the certificate below
and sign and date as indicated. Submit this
document to the medical staff office to be filed
in your record. Thank you.
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Certificate of Training RESTRAINT AND
SECLUSION Physician Name______________________
Date________


Print Physician
Signature_____________________________