RESTRAINTS

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RESTRAINTS
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Current CMS Regulatory Requirementsand JCAHO
Requirements

• Staff involved with applying, assessing/monitoring
  /or providing care to patients with restraints
  must
• be trained and demonstrate competency on an
  ANNUAL BASIS to care for a patient in restraints

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Definition of a Restraint

• Restraint is 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
• A drug or medication 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.

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Saint Joseph Health SystemPhilosophy

• Minimize restraint use
• Maximize safety
• Prefer less restrictive interventions
• Discontinue at earliest possible times
• Use only in clinically appropriate and justified
  situations

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Types of Restraint and Clinical Areas of Use
Vest Restraint All Clinical Nursing Areas
Soft Cloth Extremity All Clinical Nursing Areas
4 raised side rails All Clinical Nursing Areas
Chemical All Clinical Nursing Areas
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Classification of Restraint

• Medical
• Behavioral Management
• Chemical
• Side rails

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What is a Medical Restraint?

• A medical restraint is used to manage a patient
  who presents a risk of harm to themselves and/or
  others and/or interferes with medical/surgical
  healing

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Medical Restraint Orders

• The RN must notify the MD within 12 hours of
  initiation to obtain the medical restraint
  protocol order
• Medical Restraint orders must be renewed each
  calendar day

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• If the restraint is removed for a time period
  longer than to complete the patients personal
  needs (i.e. toileting/feeding) or for certain
  treatments or procedures, a new restraint order
  is needed.

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• A new Medical Restraint Protocol Order must be
  completed with each initiation.

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• Orders for restraint use are never written as a
  PRN order or as a standing order

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Criteria for Discontinuation

• Not pulling at essential lines/tubes/dressings
• Movement not causing dislodgement of lines/tubes
• Follows directions to avoid self-injury
• Not attempting to get out of bed
• No interference with medical healing
• Lines/Tubes/Dressings have been discontinued

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Medical Restraint Flow sheet Monitoring and
Documentation

• Monitor at least every hour the patients
• Physical and emotional well being
• Rights, dignity and safety are maintained
• Restraint has been appropriately applied
• Behavior that necessitates less restrictive
  methods or continuation of restraints or removal
  of restraints (nurse only)

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Document every 2 hours

• That toileting, food and fluids are offered
• Distal circulation and skin integrity of involved
  extremities
• ROM/Rotate restraint sites, if patient condition
  permits
• Use appropriate codes listed on flow sheet

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Monitoring/DocumentingRehab. Therapist

• When caring for a restrained patient greater than
  1 hour, document the restraint monitoring
  criteria in the progress notes as indicated

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What is a Behavioral Restraint?

• A behavioral restraint is used only in
  emergencies when nonphysical interventions are
  ineffective or not viable and when there is
  imminent risk of a patient physically harming
  self or, staff or others.

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Determine the need for Behavioral Management
Restraint

• Mark the appropriate criteria on the Behavioral
  Management Restraint Order Sheet
• Criteria
• Emergency severely aggressive / destructive
  behavior
• Behavior places staff/others in imminent danger
• Behavior places patient in imminent danger

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Behavioral Restraint Orders

• The RN must
• Notify a MD and/or LIP within one hour of
  application of the restraint(s).
• The MD and/or LIP must
• Evaluate the patient within one hour of the time
  the restraint(s) are applied. If a physician is
  not available to perform a face-to-face
  evaluation within one hour, then contact the
  On-Call Physician for Restraint Evaluation.

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Criteria for Discontinuation

1. Able to demonstrate behavioral control
2. Responds to administered medications
3. Demonstrates no threat of harm
4. Able to respond to staffs directions

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Behavioral Management Restraint Flow sheet
Monitoring and Documentation

• Continuous monitoring -
• Continuous means uninterrupted observation of
  that patient for as long as behavior management
  restraint is used.
• Observer must have direct eye contact with the
  patient. (This can be through a window or a
  doorway)

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(Cont.) Behavioral Restraint Flow sheet
Monitoring and Documentation

• Assess the patient at the initiation of restraint
  and every 15 minutes thereafter.
• The assessment includes the following
• Distal circulation and skin integrity of involved
  extremities
• Signs of any injury associated with restraint
• Offer toileting, hygiene, food and fluids
• Perform ROM and rotate restraint sites, if
  patient condition permits
• Physical and psychological status and comfort
• Readiness for discontinuation of restraint

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Documentation

• Use the hospital approved Behavioral Management
  Restraint Flow sheet
• Include
• Date, time and type of restraint
• Appropriate Codes for Criteria for continuation,
  discontinuation or
• re-initiation of the restraint

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Document

• Name, initials and department of staff completing
  care
• Patient/family education, if applicable,
• Understanding of education, if applicable

Initial _______ Signature _______________ Dept _________ Initial ______ Signature ______________ Date ______
Initial _______ Signature _______________ Dept _________ Initial ______ Signature ______________ Date ______
Patient/Family Education Initials ________
Demonstrates Understanding Initials ________
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Side Rails

• Side rails are considered a medical restraint
  when used to
• Restrict or prohibit movement
• Restrict access to the patients body

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Side Rails (Cont.)

• Side rails on a hospital bed are not required.
• Side rails on a stretcher are not considered a
  restraint.
• 3 side rails are not considered a restraint.
• 4 side rails ARE a restraint, unless patient is
• Unable to move
• Requesting side rail(s) as a mobility aid
• Requesting side rail(s) as reminder not to get
  out of bed.
• Unconscious/sedated.
• Recovering from anesthesia.
• Using for support purpose (i.e. obese patient)
• On the Total Care Sp02RT in the rotational mode.

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Chemical Restraint

• Is Not considered a restraint when the behavior
  arises as part of a medical, surgical or
  psychiatric condition
• Is considered a restraint when it involves the
  use of a medication which is not standard
  treatment for the patients condition
• If used as a restraint, follow the appropriate
  Restraint Policy

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Patient/Family Education

• Explain the following information to patients and
  family regarding the need for restraints
• Promotion of safety is the goal
• Frequent monitoring by staff
• Time-limited procedure
• Alternatives to restraints have been reviewed
• Rationale for restraint use
• Document education on the Restraint Flow sheet
• Education information is available on Micromedex

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Reporting Requirements

• Injury or death of a patient while in restraints
  are to be reported to the House Administrator
  immediately.

Reminder Remove all physical restraints with
the initiation of a Code Blue
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Transporting a Patient in Restraints

• Keep the patient in restraint(s) when
  transporting to another department (i.e. nursing
  unit to radiology) unless other wise indicated.

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• Proper
• Application of a Restraint
• (Add padding to support body part as needed)

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Correct placement and position of a restraint
(secure to the bed frame using the quick release
buckle)
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Correct placement and position of a restraint
(secure to the bed frame)
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Incorrect placement and fastening of restraint
(tied to the bed frame and side rail)
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Incorrect use of a restraint (tied in knot
instead of quick release buckle)
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Help me, Im choking!!!
Incorrect use of Posey (never attach straps to
head of bed)
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Has anyone seen my non-skid foot wear?
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Wheelchair
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• Click Here to Begin Restraint Test for Radiology
  Tech