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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 Page 1 of 12 Restraint and Seclusion Patient Care Policy 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. Page 2 of 12 Restraint and Seclusion Patient Care Policy 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: Page 3 of 12 Restraint and Seclusion Patient Care Policy 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 Page 4 of 12 Restraint and Seclusion Patient Care Policy 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 Page 5 of 12 Restraint and Seclusion Patient Care Policy 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, Page 6 of 12 Restraint and Seclusion Patient Care Policy 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: Page 7 of 12 Restraint and Seclusion Patient Care Policy 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); Page 8 of 12 Restraint and Seclusion Patient Care Policy 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. Page 9 of 12 Restraint and Seclusion Patient Care Policy 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 Page 10 of 12 Restraint and Seclusion Patient Care Policy 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 Page 11 of 12 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 Page 12 of 12 Every 4 hours Restraint and Seclusion Every 8 hours Patient Care Policy