Download Title: RESTRAINT AND SECLUSION

Patient Care Policy
Title: RESTRAINT AND SECLUSION
Scope:
This policy applies to MultiCare Health System acute care facilities.
Policy Statement:
It is the goal of MultiCare Health System to protect and preserve the patient’s
rights, dignity, and well being when a restraint is employed. The use of
restraint has the potential to produce serious consequences, such as physical
or psychological harm, loss of dignity, violation of a patient’s rights, and even
death. Because of the associated risks and consequences of use, the decision
to restrain requires adequate and appropriate clinical justification. Restraint is
to be applied for no longer than it is clearly needed and any doubts about the
need for restraint should be resolved in favor of an alternative to restraint.
Procedure:
I.
Protecting The Patient’s Rights, Dignity, And Well-Being During
Restraint Use:
A. All patients have the right to be free from restraint or seclusion, of any
form, imposed as a means of coercion, discipline, convenience, or
retaliation by staff.
II. Restraint Use Is Based On The Patient’s Assessed Needs:
A. Each episode of restraint will be limited to clinically justified situations,
based on the assessed behavior of the patient.
B. Restraint or seclusion may only be imposed to ensure the immediate
physical safety of the patient, a staff member, or others and must be
discontinued at the earliest possible time.
III. Least-Restrictive Methods:
A. Restraint or seclusion may be used only be used when less restrictive
interventions have been determined to be ineffective to protect the
patient, a staff member or others from harm. Types of less restrictive
interventions that will be considered may include:
1. Assess the patient for (and attempt to correct) possible causes of
agitation and/or confusion:
a. Conditions such as hypoxia, hypoglycemia, acute drug or alcohol
intoxication, stroke, and brain trauma may present as confusion,
combativeness, or agitation.
2. Promote sleep/rest and adjust room temperature, noise/light levels.
3. Review medication sheets, and consult with provider and/or
pharmacy to assess for possible adverse reactions/sensitivities to
medications
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4. Provide frequent observation and reorientation and/or move closer
to nursing station.
5. Ensure that the patient’s pain/comfort, toileting, hydration/nutrition
needs are met.
6. Involve the patient’s family in assisting with increased patient
observation.
7. Consider use of a constant observer (sitter).
8. Remove lines, tubes or drains as able.
B. Restraint or seclusion must be the least restrictive intervention that
will be effective to protect the patient, a staff member, or others from
harm.
The types of devices listed from least to most restrictive are as follows:
Least
Restrictive
Side
Rails
Chair (Geri\
restrictive chair)
Most
Restrictive
Mitts/ Elbow
Immobilizer
Soft limb
Soft belt
Velcro/ hard
limb
restraints
IV. Patient Monitoring and Reassessment During Restraint Use:
A. Assessment and monitoring of the patient during restraint use is the
responsibility of the Registered Nurse. Trained, unlicensed staff may
perform components of monitoring (for example, checking vital signs,
hydration and circulation; the patient's level of distress and agitation;
or skin integrity), and may also provide for general care needs (for
example, eating, hydration, toileting, range of motion).
B. Monitoring of Patients in Non-Behavioral Restraints:
1. A patient in restraints is monitored at least every two hours or
sooner according to patient need. At a minimum this will include
safety checks, and as appropriate to the type of restraint,
nutrition/hydration; circulation and range of motion in the
extremities; hygiene and elimination; physical and psychological
status and comfort; and readiness for discontinuation of restraint or
seclusion.
2. Monitoring is accomplished by observation, interaction with the
patient, or related direct examination of the patient by qualified
staff.
C. Monitoring of Patients in Emergency Behavioral Restraints:
1. A staff member who is trained and competent assesses the patient
at the initiation of restraint or seclusion and every 15 minutes
thereafter. The assessment includes, as appropriate to the type of
restraint or seclusion, the following:
a. Signs of injury associated with the application of restraint or
seclusion; nutrition/hydration; circulation and range of motion in
the extremities; vital signs; hygiene and elimination; physical
and psychological status and comfort; and, readiness for
discontinuation of restraint or seclusion.
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b. It is not expected that all of these items be assessed every 15
minutes, but that at a minimum, the patient be assessed for
safety and signs of injury. In some cases, approaching the
patient or attempting some of these activities could be
dangerous and may increase the patient’s agitation. Use clinical
judgment and knowledge of the patient to set a schedule of
when and what items need to be evaluated. Visual checks can be
done when and if the patient is too agitated to approach.
2. A patient in emergency behavioral restraints must have “continuous
monitoring,” which is defined as uninterrupted in-person
observation of the patient. For the patient in seclusion, the inperson observation can progress to audio and visual monitoring
after the first hour in seclusion. In-person means that the observer
must have direct eye contact with the patient; however, this can
occur through a window or through a doorway.
3. If the patient is in a physical hold, a second staff person is assigned
to observe the patient.
D. Vulnerable patient populations, such as emergency, pediatric, and
cognitively or physically limited patients may require additional
monitoring as determined by the caregiver.
V. Patient and Family Education:
A. Staff will make every effort to discuss the issue of restraint, when
practical, with the patient and family around the time of use.
VI. Orders:
A. All episodes of restraint will be in accordance with the order of a
physician or other Licensed Independent Practitioner (LIP) who is
responsible for the care of the patient and authorized to order restraint
or seclusion.
B. In the event that restraints are initiated and discontinued prior to the
signing of the restraint order, the LIP will still examine the patient and
enter an order into the patient’s medical record within 24 hours of the
initiation of restraint.
C. Orders must never be written as a standing or PRN order.
D. The attending physician must be consulted as soon as possible if the
attending physician did not order the restraint or seclusion.
E. Emergency Behavioral Restraint or Seclusion Orders:
1. May be renewed in accordance with the following limits for up to a
total of 24 hours.
a. 4 hours for adults 18 years of age or older
b. 2 hours for children and adolescents 9 to 17 years of age
c. 1 hour for children under 9 years of age
2. After 24 hours a physician or other LIP who is responsible for the
care of the patient as and authorized to order restraint or seclusion
must see and assess the patient.
F. Non-Behavioral Restraint Orders:
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1. If an LIP is not available to issue an order, an RN may initiate
restraint use based on an appropriate assessment of the patient.
2. The LIP is notified within 12 hours of the initiation of restraint, and
a telephone or written order is obtained from the practitioner and
entered into the patient’s medical record. If the initiation of
restraint is based on a significant change in the patient’s condition,
the registered nurse immediately notifies an LIP.
3. A written order, based on an examination of the patient by an LIP,
is entered into the patient’s medical record within 24 hours of the
initiation of restraint.
4. Continued use of restraint beyond the first 24 hours is authorized
by an LIP renewing the original order or issuing a new order if
restraint continues to be clinically justified. This order is issued no
less often than once each calendar day and is based on the LIP’s
examination of the patient.
G. The use of restraint or seclusion must be discontinued at the earliest
possible time, regardless of the length of time identified in the order.
Staff helps patients meet behavior criteria for discontinuing restraint or
seclusion.
VII. Seclusion May Only Be Used To Manage Violent Or SelfDestructive Behavior That Jeopardizes The Immediate Physical
Safety Of The Patient, A Staff Member, Or Others.
VIII. Plan of Care:
A. The use of restraint or seclusion must be in accordance with a written
modification to the patient's plan of care.
B. The plan for care, treatment, and services considers strategies to limit
the use of restraints or seclusion as appropriate.
IX. When Restraint Or Seclusion Is Used, There Must Be
Documentation In The Patient's Medical Record Of The Following:
A. A description of the patient's behavior and the restraint/seclusion
intervention used;
B. Alternatives or other less restrictive interventions attempted (as
applicable);
C. The patient's condition or symptom(s) that warranted the use of the
restraint or seclusion;
D. Results of patient monitoring and reassessment;
E. The patient's response to the intervention(s) used, including the
rationale for continued use of the intervention;
F. Any significant changes in the patient’s condition;
G. For Emergency Behavioral Restraints - the 1-hour face-to-face medical
and behavioral evaluation.
X. Restraints Do Not Include the Following:
A. If the patient has any of the following - documentation in the medical
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record should clearly indicate that the device does not fall under the
restraint standard. For example: If the patient is shackled to the bed
– document, “shackled to the bed by law enforcement,” rather than,
“restraints applied by law enforcement.” If a patient has side rails up
for seizure precautions, this should be documented as such.
1. Forensic restrictions (handcuffs/shackles) and restrictions imposed
by correction and law enforcement authorities for security
purposes.
2. Protective equipment such as helmets.
3. Adaptive support in response to the patient’s assessed physical
needs (for example, postural support, orthopedic appliances).
4. Standard practices that include limitation of mobility or temporary
immobilization related to medical, dental, diagnostic, or surgical
procedures and the related post-procedure care processes (for
example, surgical positioning, intravenous arm boards, radiotherapy
procedures, protection of surgical and treatment sites in pediatric
patients). When an elbow immobilizer is placed over the IV site
and is essentially functioning as an IV arm board, this is not
considered restraint.
5. Age or developmentally appropriate protective safety interventions,
such as stroller safety belts, swing safety belts, high chair lap belts,
raised crib rails, and crib covers, that a safety-conscious child care
provider outside a health care setting would utilize to protect an
infant, toddler, or preschool-aged child.
6. Placement in a crib with raised rails is an age-appropriate standard
safety practice for every infant or toddler and would not be
regarded as a restraint.
7. A staff member picking up, redirecting, or holding an infant,
toddler, or preschool-aged child to comfort the patient is not
considered restraint.
XI. Side Rails:
A. The use of side rails to prevent a patient from exiting a hospital bed
may pose risk to the patient's safety, particularly for the frail elderly
who may be at risk for entrapment between the mattress and the bed
frame. A disoriented patient may attempt to climb over the bed rails or
climb between split rails and may have an increased risk for a fall or
other injury. The risk presented by side rail use should be weighed
against the risk presented by the patient's behavior as ascertained
through individualized assessment.
B. The use of side rails is not considered a restraint when:
1. The patient is on a stretcher/gurney.
2. He/she is recovering from anesthesia during the immediate postoperative period.
3. The patient is experiencing involuntary movement (such as
seizures).
4. The patient is on a therapeutic bed which requires the side rails to
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be up to prevent the patient from falling out of the bed (per
recommendation by the manufacturer). An example of this would
be the ICU beds when the rotation module is in use; or a bariatric
bed that requires all side rails up per the manufacturer’s
recommendation. The type of bed used must be clearly
documented in the patient’s medical record.
5. Two side rails are used to facilitate mobility in and out of bed (as in
total hip patients).
6. The patient can release the side rail independently.
7. Fewer than four side rails are raised when the bed has more than
two side rails.
C. The use of side rails is considered a restraint (except as noted
above) when all four side rails are raised even if they are raised to
ensure the immediate physical safety of the patient.
D. NOTE: Even if the all four side rails are raised per the patient’s or
family’s request - this is still considered a restraint and must have a
physician order and all other relevant monitoring.
XII. Medications Used As Restraint:
A. Medications that are a standard treatment for a patient's condition
are not subject to the requirements of this regulation. A standard
treatment for a medication used to address a patient's condition would
include all of the following:
1. The medication is used within the pharmaceutical parameters
approved by the Food and Drug Administration (FDA) and the
manufacturer for the indications it is manufactured and labeled to
address, including listed dosage parameters.
2. The use of the medication follows national practice standards
established or recognized by the medical community and/or
professional medical association or organization.
3. The use of the medication to treat a specific patient’s clinical
condition is based on that patient's symptoms, overall clinical
situation, and on the physician's or other LIP's knowledge of that
patient's expected and actual response to the medication.
4. The standard use of a medication to treat the patient's condition
enables the patient to more effectively or appropriately function in
the world around them than would be possible without the use of
the medication.
5. If the overall effect of a medication is to reduce the patient's ability
to effectively or appropriately interact with the world around the
patient, then the medication is not being used as a standard
treatment for the patient's condition. Trained practitioners identity
when a drug or medication is being used as a standard treatment
for the patient's condition and when it is not.
B. An example of when the use of a medication may be considered a
restraint:
1. A patient who has Sundowner's Syndrome becomes agitated,
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angry, or anxious at sundown leading to wandering, pacing the
floors, or other nervous behaviors. The unit's staff find the patient's
behavior bothersome, and ask the physician to order a high dose of
a sedative to “knock out'' the patient and keep him in bed. The
patient has no medical symptoms or condition that indicates that he
needs a sedative. In this case, for this patient, the sedative is being
used as a restraint for staff convenience. Such use is not permitted
as drugs are not to be used to restrain the patient for staff
convenience, to coerce or discipline the patient, or as a method of
retaliation.
C. An example of when the use of a medication may not be considered a
restraint:
1. Patients who are suffering from serious mental illness who need
appropriate therapeutic doses of medications to improve their level
of functioning so that they can more actively participate in their
treatment.
2. Appropriate doses of sleeping medication prescribed for patients
with insomnia or anti-anxiety medication prescribed to calm a
patient who is anxious.
XIII. The Hospital Must Report To the Regional Office of the Centers of
Medicaid and Medicare (CMS) Each Death That:
A. Occurs while a patient is in restraint or in seclusion at the hospital;
B. Occurs within 24 hours after the patient has been removed from
restraint or seclusion;
C. Occurs within 1 week after restraint or seclusion (if known by the
hospital) where it is reasonable to assume that use of restraint or
placement in seclusion contributed directly or indirectly to a patient's
death.
1. “Reasonable to assume'' includes, but is not limited to deaths
related to restrictions of movement for prolonged periods of time,
or death related to chest compression, restriction of breathing or
asphyxiation.
D. Each death referenced in this section must be reported to CMS by
telephone no later than the close of business the next business day
following knowledge of the patient's death.
E. The date and time of CMS notification of the patient’s death is
documented on the Death Notification form in the patient’s medical
record.
XIV. Physician Training Requirements:
A. 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 and
seclusion.
XV. Staff Training Requirements:
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A. All staff who have direct patient contact must have ongoing education
and training in the proper and safe use of seclusion and restraint
application and techniques and alternative methods for handling
behavior, symptoms, and situations that traditionally have been
treated through the use of restraints or seclusion.
B. Staff must be trained and able to demonstrate competency in the
application of restraints, implementation of seclusion, monitoring,
assessment, and providing care for a patient in restraint or seclusion
before performing any of the actions specified in this paragraph; as
part of orientation; and subsequently on an annual basis.
C. Training content:
1. Appropriate staff will have education, training, and demonstrated
knowledge based on the specific needs of the patient population in
at least the following:
a. Techniques to identify staff and patient behaviors, events, and
environmental factors that may trigger circumstances that
require the use of restraint or seclusion;
b. The use of nonphysical intervention skills;
c. Choosing the least restrictive intervention based on an
individualized assessment of the patient's medical, or behavioral
status or condition;
d. The safe application and use of all types of restraint or seclusion
used in the hospital, including training in how to recognize and
respond to signs of physical and psychological distress (for
example, positional asphyxia);
e. Clinical identification of specific behavioral changes that indicate
that restraint or seclusion is no longer necessary;
f. Monitoring the physical and psychological well-being of the
patient who is restrained or secluded, including, but not limited
to, respiratory and circulatory status, skin integrity, vital signs,
and any special requirements specified by hospital policy
associated with the 1-hour face-to-face evaluation;
g. The use of first aid techniques and certification in the use of
cardiopulmonary resuscitation, including required periodic
recertification.
2. The hospital is expected to provide education and training at the
appropriate level to the appropriate staff based upon the specific
needs of the patient population being served. For example, staff
routinely providing care for violent or self-destructive behavior that
jeopardizes the immediate physical safety of the patient, a staff
member, or others (such as in an emergency department) generally
require more in-depth training in the areas included in the
regulation than staff routinely providing medical/surgical care.
Training should include instruction on:
a. How to identify patients who may have conditions that would
require special attention, (for example, a history of respiratory
or cardiac problems);
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b. How to monitor patients in restraints; and
c. What conditions are necessary for a person to be released from
restraints.
d. Also included would be instructions on how to screen patients for
special problems that could affect the use, type, or duration of
restraints (for example, emotional problems associated with a
history of abuse or neglect).
D. Trainer requirements:
1. Individuals providing staff training must be qualified as evidenced
by education, training, and experience in techniques used to
address patients' behaviors.
E. Training documentation:
1. The hospital must document in the staff personnel records that the
training and demonstration of competency were successfully
completed.
XVI. Definitions:
A. A restraint is:
1. 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; or
2. A drug or medication when it is used as a restriction to manage the
patient's behavior or restrict the patient's freedom of movement
and is not a standard treatment or dosage for the patient's
condition.
B. NON-BEHAVIORAL RESTRAINT – A restraint used to ensure the
immediate physical safety of the non-violent or non-self-destructive
patient, a staff member, or others.
C. EMERGENCY BEHAVIORAL RESTRAINT – restraint used for the
management of violent or self-destructive behavior that jeopardizes
the immediate physical safety of the patient, a staff member, or
others.
D. Seclusion is:
1. The involuntary confinement of a patient alone in a room or area
from which the patient is physically prevented from leaving.
Seclusion may only be used for the management of violent or selfdestructive behavior.
Related Policies:
MHS Policy, “Pediatric Safety Measures and Fall Prevention.”
Related Forms:
MHS Form # 87-2357-7, “Non-Behavioral Restraint Order.”
MHS Form # 87-9017-3, “Non-Behavioral Restraint Nursing Documentation.”
MHS Form # 88-2203-2, “Emergency Behavioral Restraint Order.”
MHS Form # 87-9017-3, “Emergency Behavioral Restraint Nursing
Documentation.”
References:
The Joint Commission: Hospital Accreditation Standards.
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Code Of Federal Regulations: Title 42--Public Health; Chapter IV--Centers For
Medicare & Medicaid Services, Department Of Health And Human Services
482. Conditions Of Participation For Hospitals.
WAC 246-320; Revised Code Of Washington (RCW); Title 70 RCW; Public
Health And Safety; Chapter 70.41 RCW; Hospital Licensing And Regulation.
FDA Center for Devices and Radiological Health. FDA safety alert: entrapment
hazards with hospital bed side rails. August 1995. Available at:
http://www.fda.gov/cdrh/ bedrails.html.
A Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home
Health Care: The Facts. October 2000.
Maccioli, et al (2003) Critical Care Medicine, “Clinical Practice Guidelines for
the Maintenance of Patient Physical Safety in the Intensive Care Unit: Use of
Restraining Therapies – American College of Critical Care Medicine Task Force
2001-02.” 31:11.
Point of Contact: Manager of Clinical Standards
Approval By:
Date of Approval:
MHS Policy and Procedure Committee
9/07
9/07
Medical Staff Operations
PILOT
9/07
Original Date:
1/60
Revision Dates:
8/90; 5/91; 7/93; 4/95; 6/96; 10/98;
1/99; 6/00; 12/00; 5/02; 12/03; 5/06;
7/05; 9/07; 7/09
Reviewed with no Changes Dates:
X/XX; X/XX
Distribution: MHS Intranet
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Non-Behavioral Restraints
Indications
Initial
Order
Renewal
Orders
A restraint used to ensure the immediate
physical safety of the non-violent or
non-self-destructive patient, a staff
member, or others.
 An RN may initiate restraint and must
notify the LIP and obtain a telephone
or written order within 12 hours of the
initiation of restraint (immediately if
the patient’s condition has changed).
 A written order, based on an
examination of the patient by an LIP is
written within 24 hours of the initiation
of restraint even if the restraint has
since been discontinued.
 Written order every 24 hours that is
based on the LIP’s examination of the
patient.
 Within 24 hours of the initiation of
restraint, and every 24 hours
thereafter.
Initial Inperson LIP
evaluation
after the
initiation of
restraint
Emergency Behavioral Restraints
A restraint used for the management of violent or selfdestructive behavior that jeopardizes the immediate
physical safety of the patient, a staff member, or others.
 The LIP is notified as soon as possible after the initiation of
restraints.
 The patient must be seen face-to-face within 1 hour after
the initiation of the intervention by a Physician or other LIP
and a written order obtained at that time.
 Telephone and written orders are limited to:
 4 hours for patients ages 18 and older
 2 hours for children and youth ages 9 to 17
 1 hour for children under age 9
 Face-to-face evaluation within 1 hour after the initiation of
the intervention by the Physician or other LIP to evaluate:
 The patient's immediate situation;
 The patient's reaction to the intervention;
 The patient's medical and behavioral condition; and
 The need to continue or terminate the restraint or
seclusion.
 The LIP does the following:
 Reviews with staff the physical and psychological status of
the patient.
 Determines whether restraint or seclusion should be
continued and writes an order.
 Works with the patient\staff to identify ways to help the
patient regain control.
 Revises the patient’s plan for care, treatment, and
services as needed.
 The LIP or RN reevaluates the patient’s treatment plan and
LIP or
trained RN
Evaluation
On-going
LIP
evaluation
 Every 24 hours thereafter
 Safety Checks and Assessments every
2 hours;
Nursing
Patient
Safety and
Monitoring
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works with the patient to identify ways to help him or her
regain control. The patient is reevaluated as follows:
 Every 4 hours for adults ages 18 and older.
 Every 2 hours for children and youth ages 9 to 17.
 Every hour for children under age 9.
 The person doing the evaluation consults with the patient’s
provider and obtains a new order in accordance with the
age-limiting time frames for orders. The LIP must see the
patient in-person as noted below.
 The LIP conducts an in-person reevaluation at least every 8
hours for patients ages 18 years and older and every 4
hours for patients ages 17 and younger.
 Safety checks and assessments at the initiation of restraint
or seclusion and every 15 minutes.
 “Continuous Monitoring” - defined as uninterrupted inperson observation of the patient. In-person means that
the observer must have direct eye contact with the
patient; however, this can occur through a window or
through a doorway.
 If the patient is in a physical hold, a second staff person is
assigned to observe the patient.
Restraint and Seclusion
Patient Care Policy
Emergency Behavioral Restraint
Patient meets the criteria for emergency behavioral restraints.
Least restrictive restraint applied after less restrictive measures considered.
RN notifies Physician and obtains a written order or telephone order if not present.
Staff monitors patient continuously and documents safety and
monitoring checks every 15 minutes in the medical record.
Physician arrives within 1 hour of restraint initiation to conduct in-person medical evaluation.
Physician signs telephone order and determines if restraints should be continued.
Ongoing Orders
and Evaluation
time-frames are
determined by the
Patient’s Age
Patient under
9 yrs old
Patient 9-17
years old
Patient 18 years
and older
If LIP present: LIP will conduct evaluation and write an order.
If LIP not present: RN will conduct evaluation, call provider, discuss evaluation and obtain
telephone renewal for order.
Every 1 hour
Every 2 hours
Every 4 hours
In-person Evaluation by Physician. If restraint is still indicated – the physician will renew –
in writing, the order within these time frames.
Every 4 hours
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Every 4 hours
Restraint and Seclusion
Every 8 hours
Patient Care Policy