MUSC Health Patient Restraint and Alternatives

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MUSC Health Patient Restraint and Alternatives

• Ramona Smith, MSN,RN
• Mary Allen, BSN, RN
• Celeste Phillips, MN, RN
• Sept 2008

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MUHA Policy on Seclusion and Restraint

• This presentation is based on MUHA Policy C-22
  Restraint and Seclusion
• If you would like to review this policy go to
  this link
• MUSC Policy C-22 Policy

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MUSC Philosophy on Seclusion and Restraint

• to protect the patients health and safety
• preserve the patients dignity, rights and well
  being
• to reduce, prevent or eliminate the use of
  restraints.

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CMS Definitions of Restraints

• Any manual method of head or extremity
  immobilization which prevents movement
• Does not include immobilization for procedures.
• Does not include orthopedic or protective devices

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CMS definition of Seclusion

• The involuntary confinement of a patient, alone
  in an area, to prevent harm to self or others.
• Seclusion may only be used for management of
  violent or self destructive behavior.

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Restraints are used only

• As a last resort
• After alternatives to restraints are used
• To promote medical healing
• To prevent imminent risk of injury to the patient
  or others

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Initial Assessment

• All patients are assessed on admission
• Assess for risk of potential injury that may
  require the use of restraint or seclusion.

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Educate Patient and Family

• If patient is deemed at risk for restraints
  educate patient and family about
• Behaviors leading to restraint
• Alternatives to restraint
• Types of restraint
• Info in Patient Safety Brochure
• Patient rights related to restraint and seclusion.

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Involve Patient and Family in Plan of Care

• Patients family notified no later than 24 hours
  after restraint/seclusion initiated

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Restraint Policy Highlights

• Physician or medical provider order required.
• May never be written as PRN order.
• Seclusion and restraint are never initiated for
• staff convenience
• as a substitute for staffing
• to monitor patients
• or as a punative action

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Restraint Policy Highlights

• The patients face is NEVER covered
• The airway is NEVER obstructed during seclusion
  or restraint
• For example, with a patient who is spitting, the
  staff should use personal protective equipment
  such as gowns, goggles, gloves.

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Release of Restraints

• Restraint or Seclusion must be discontinued at
  the earliest possible time regardless of length
  of order.
• Restraints should be removed when
• Patient is no longer interfering with
  lines/tubes/dressings
• Patient is able to consistently follow directions

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Alternatives to Restraints

• Physical
• Distraction
• Regular physical exercise
• Control of pain
• Call light near
• Frequent toileting

• Environment
• Room at conformable temperature
• Nightlight or bathroom light on
• Minimize noise

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WHAT IF Restraint ALTERNATIVES FAIL?
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TYPES OF RESTRAINT ORDERS AT MUSCHealth
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2 Types of Restraint Seclusion Orders

• Restraint for Acute Medical and Post Surgical
  Care
• Any device used to improve a patients well being
  and promote medical healing regardless of
  diagnosis or setting
• eg. wrist or vest restraints

• Seclusion and Restraint for Behavior Management
• Interventions used in emergency situations when
  there is imminent risk of harming self or others

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Restraint Order Forms

• Medical/Post Surgical Order Form banded in blue
• Seclusion/Behavior Management Order Form banded
  in red
• Complete one of these forms for restraints

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Restraint Order for Medical/Post Surgical
Restraints
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Medical/Post-Surgical Restraint Order Form
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Medical Post Surgical

• RN may initiate restraints in emergency
• Must obtain order within 1 hour
• Order must be signed within 24 hr
• Attending MD must be notified as soon as possible
  within 24 hours.

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Medical/Post-SurgicalPatient Assessment

• Patient assessed at least every hour for
  nutrition, hydration, pain, toileting needs
• Restraints removed every 2 hours and patient
  assessed for range of motion, skin integrity
• These actions are documented on the Restraint
  Documentation Form

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Restraint DocumentationHard copy or Clin Doc
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PRN RESTRAINT ORDERS?
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Behavioral Seclusion/Restraint

• May be initiated by RN
• Notify physician within 30 minutes
• Verbal orders signed within 30 minutes
• Patient seen by physician within I hour
• Strict time limits - maximum time for adults is
  4 hours
• Patient must be assessed every 15 minutes

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Seclusion/Restraint Order for Behavioral
Management
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Behavior Management Order Form
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PRN RESTRAINT ORDERS?
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Length of time for restraints

• The length of time patient is guided both by our
  restraint policy AND on individual patient
  assessment
• Patients should not automatically be placed
  on restraints for the full time allowed by the
  policy.
• Times should be individualized.

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Restraint Alternatives
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Hospitals are required to use the least
restrictive restraints available

• When selecting restraint devices, the least
  restrictive should be tried first.

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Restraint Devices at MUSC Health
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Not this!
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And not this
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Side Rail Protectors

• Must be used on any patient in restraints not
  receiving constant observation
• Specialty bed companies have side rail
  protectors. Be sure to request when you order
  bed.
• Prevents injury
• Fills gap between bed and rails

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Dangers of Not Using Side Rail Protectors

• The following slides show the dangers of not
  using side rail protectors when patients are
  restrained in split rail beds and not under
  constant observation.

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Restraint Products at MUSC Health
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Alternative to Restraint

• Hospitals are required to use restraint
  alternatives whenever possible.

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Activity Apron A restraint alternative

• ESI 1511
• Bright colors and texture variation provide
  visual and tactile stimulation zipper and
  buttoning buttons aids improvement of fine motor
  skills.
• Download Instructions
• Posey Activity Apron

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Restraint Devices

• The following slides will show restraint devices
  available at MUSC Health for
• Prevention of Tube Pulling
• Prevention of Falls
• Restraint devices are presented from least
  restrictive to most restrictive devices.

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Prevent Tube Pulling

• Shown from least to Most Restrictive
• Freedom Splint
• Peek a Boo Mit
• Limb Holder
• Twice as Tough Cuff

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Posey Freedom Splint

• Arm Splint
• ESI 2587 Adult
• ESI ? Peds
• These multi-purpose arm Splints offer a gentle
  reminder to restrict arm movement, without
  resorting to rigid arm splints.
• To download instructions and see application
  video
• Posey Freedom Splints

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Posey Peek a Boo MIT

• Posey Peek-A-Boo Mit
• ESI 2588
• The Posey Peek-A-Boo Mitts feature a
  double-padded design that provides safety and
  comfort. The Quick-Check flap enables circulation
  checks, without having to remove the Mitt.
• To download instructions and see an application
  video see
• Posey Peek-A-Boo Mitts

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Quick Release Limb Holder

• Posey Quick-Release Limb Holders
• ESI 1510 Adult
• ESI 333 Child
• Foam padded ankle and wrist restraint secures
  with hook and loop and a quick-release buckle...
  Cuff fits pediatric or adult limb. One pair per
  package.
• To download instructions and see an instructional
  video go to
• Posey Quick-Release Limb Holders

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Double Strap Limb Holder

• ESI 2625
• Foam padded ankle and wrist restraint with double
  straps secures with hook and loop and a
  quick-release buckle.
• The double connecting straps allow
  "triangulation," which limits range of motion
  more effectively than a single strap
• To download instructions and watch application
  video see
• Posey Double Strap Foam Limb Holders

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Twice as Tough Cuffs

• ANKLE (red)
• ESI 1517 Adult
• WRIST/ANKLE (blue)
• ESI 1509 Adult
• For greatest limitation of limb movement.
• Download Instructions
• Twice as Tough Cuffs

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Devices for Patients at Risk for Falls

• Wrap around self releasing
• Posy Torso support
• Self releasing roll belt
• General Purpose Belt for bed and gurney
• Roll Belt
• Sleeved Vest

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Posey Wrap Around Self Releasing

• ESI 2708 XXL
• May be positioned in front of patient for
  self-release or in the back for assisted release.
  
• Can also be used on a bed or stretcher for
  temporary patient positioning.
• Download instructions
• Posey SR Wrap-Around

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POSEY TORSO SUPPORT

• ESI 1505 Large
• ESI 1506 Med
• Helps prevent tilting, leaning and forward
  sliding. The Torso Support is self-releasing and
  provides soft, broad support around the chest and
  over the shoulders. Allows the caregiver to
  determine method of release and the front hook
  and loop fastener allows "self-assisting"
  patients to open it themselves.
• Download Instructions
• Posey Torso Support

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Roll Belt self releasing

• Posey SR Roll Belt
• ESI 2622 Adult Reg
• The Posey SR Roll Belt allows patients to sit up
  in bed or roll from side to side. Self-releasing
  with quick-release buckle closure. Ends tie to
  bed frame or are available with quick-release
  buckles. Machine washable. One per package.
• To download instructions or see application video
  go to
• Posey SR Roll Belt

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Posey Roll Belt (Quick release buckle)

• ESI 2595 Adult XL
• ESI 2596 Adult
• The Posey Roll Belt is a less restrictive
  restraint that allows the patient to sit up or
  roll from side to side in bed. Helps prevent the
  patient from falling or getting out of bed
  unassisted. Straps attach to bed frame out of
  patient's reach. Download Instructions
• To download instructions or see application video
  go to
• Posey Roll Belt

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Posey Sleeved Jacket http//www.posey.com/posey
store/ProductInfo.aspx?productid3360

• ESI 1982 Adult SmallESI 1983 Adult Med
• ESI 1984 Adult Large
• ESI 1985 Adult XL
• ESI 2593 Adult XXL
• ESI 2594 Adult XXXL
• A versatile restraint for positioning in either
  bed, wheelchair or geri-chair.
• To download instructions and see instructional
  video go to
• Posey Sleeved Jacket - Poly/Cotton Plaid with
  Quick-Release Buckle

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General Purpose Belt - Bed

• ESI 2706 90x3 (for bed)
• ESI 2707 66x3 (for stretcher)
• An appropriate fifth-point restraint for use in
  the Emergency Department or Psychiatric Unit. May
  be applied at chest, waist, or leg position in
  bed or on a stretcher.
• Closes with hook and loop for easy application.
• Download Instructions
• Posey General Purpose Belt

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Pediatric Restraints

• Posey Pediatric Limb Holders
• ESI 333
• Soft, foam ankle and wrist restraints can be used
  on arms or legs. Helps prevent picking,
  scratching or disruption of IV lines or tubes.
• To download instructions
• Posey Pediatric Limb Holders

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Pediatric Restraints

• Duncan Elbow Immobilizer No No
• ESI 406 Small
• ESI 407 Large

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Thank you!

• Remember that the use of restraints often exposes
  patients to more danger than it protects them
  from.
• So
• Use Restraints as a last resort
• Use the least restrictive restraint first