Key points for the Medical Staff July 2020 CMS the Joint Commission and the State of CA State have specific requirements for safe use of restraints in hospital settings including staff and provider training appropriate ordering monitoring and clinical documentation ID: 1002977
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1. Restraint Management for ProvidersKey points for the Medical StaffJuly 2020
2. CMS, the Joint Commission and the State of CA State have specific requirements for safe use of restraints in hospital settings including staff and provider training, appropriate ordering, monitoring, and clinical documentation. Compliance will be closely scrutinized during surveys.Providers authorized to order restraints are expected to have a working knowledge of the hospital policy regarding use of restraint and seclusion (CPM 4-25).Restraint/Seclusion management is performed by competency validated staff. Legal Issues Regarding Restraint Use:
3. RCHSD supports the right of each patient to be free from restraint.Restraints are only used when less restrictive means to protect the patient, staff or others from harm are determined to be ineffective.If used, restraints are removed at the earliest possible time once the unsafe situation ends regardless of the duration of the order. Patient Rights and Restraints
4. Non-violent Restraints are used to protect the patient from compromising lines, tubes or other necessary medical therapies. Elbow immobilizers (No-No’s), Posey (Net) beds, soft restraints, or neoprene locking restraintsViolent/Self-Destructive Restraints are used to manage behavior that jeopardizes the immediate physical safety of the patient, staff or others. Neoprene locking restraints are used exclusively.Fundamentals of restraint use:
5. SeclusionSeclusion – Seclusion is 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 self-destructive behavior. Note: A patient physically restrained alone in an unlocked room does not constitute seclusion.
6. Restraint and Seclusion Orders may only be entered by physicians, psychologists, or Nurse Practitioners who have received training in restraint and seclusion management.A provider order must be in place before restraints are applied, or immediately thereafter, if it was an emergent application.The attending provider must be consulted as soon as possible if the attending did not order the restraint.No PRN orders, standing orders or protocol orders are allowed for restraints. -a “trial release” is PRN and is not permitted. Ordering Restraints or Seclusion
7. Non-Violent Restraint orders must be renewed within 24 hours if still needed.Each unique episode of restraint application requires a new order. For example, if a parent comes to the bedside and the RN determines that the patient is safe without the restraints s/he should discontinue the use of the restraints. Later, when the parent leaves, if restraints are necessary again, a new restraint order is required. Requirements for Non-Violent Restraints
8. Examples of Non-Violent RestraintsElbow immobilizer (no-no’s)If both arms have an elbow immobilizer in place, this is considered a restraint. If one arm has a mobility restriction due to a medical device (e.g., arm board, cast, etc.) and the other arm has an elbow immobilizer, the immobilizer is a restraint.Soft Wrist Restraint - used to tie down an ankle or wristMitt - ONLY If it is tied down, it is a restraintNet Bed - If all zippers are closed, it is a restraint
9. Ordering Non-Violent Restraints
10. Notification of the Attending is required for Non-Violent Restraints. If the ordering user is not the Attending, an automatic cosign request will be sent to the Attending. If you are the Attending, choose “Attending placing order.” If your patient has a non-violent restraint order that will be expiring that day, you will see this banner in the Summary to remind you to re-order the restraints. Clicking on the banner will take you to Manage Orders.
11. Nursing Documentation Requirements for Non-Violent RestraintsNursing staff will:Educate restraint discontinuation criteria, an explanation of the criteria, the patients response.Reassess and document every 2 hours the patient for circulation, skin integrity, range of motion, hydration, nutrition, elimination, and injuries
12. Require a Provider Order.Restraint orders for violent/self-destructive behavior MUST be renewed based on the patient’s age: -every hour for patients < 9 years old. -every 2 hours for patients 9-17 old. -every 4 hours for patients > 18 oldRequirements for Violent/Self-Destructive Restraints or Seclusion
13. Examples of Violent/Self-Destructive Restraints
14. Ordering Violent/Self-Destructive Restraints or SeclusionWhen the provider starts to place an order for Violent/Self-Destructive Restraints, they will receive this BPA:
15. Ordering Violent/Self-Destructive Restraints or SeclusionIn the Violent/Self-Destructive restraint order itself there are process instructions based on the patients age on the duration and renewal of the order as well as information regarding the face to face assessment.
16. The ordering provider must notify the attending of the use of Violent Restraints or Seclusion ASAPRequirements for Violent/Self-Destructive Restraints or Seclusion
17. Requirements for Violent/Self-Destructive Restraints or SeclusionIf you answer “No- will notify Attending ASAP” you will see this message upon signing the order:You will not be able to sign the order until the answer to the order question is “Yes”. Please Page or send secure message to Attending
18. In the order, there is a specific question about when the Face to Face was doneOrdering Violent/Self-Destructive Restraints or Seclusion
19. The provider must conduct a face-to-face assessment before or within one hour of initiation. Documentation must be timed to occur within that hour. (Back-timing is OK) -Telephone calls or telemedicine assessment is not permitted.In the CAPS unit only, RNs who have been competency-verified may conduct the face-to-face assessment if a physician is not on site.Requirements for Violent/Self-Destructive Restraints or Seclusion
20. Requirements for Violent/Self-Destructive Restraints or Seclusion The purpose of the face-to-face assessment includes: -An evaluation of the patient’s immediate situation -That alternative less restrictive measures were ineffective -The patient’s reaction to the intervention -The patient’s medical and behavioral condition -The need to continue or terminate the restraint
21. Select Create Note to open the Restraint Face to Face Documentation Smart Form. The required elements for assessment are built into the note template. Documenting the Face-to-Face Assessment for Violent/Self Destructive Restraints or SeclusionOnce signed, the note will be filed in the Progress Note tab in the Notes Activity.
22. If the face to face assessment is not documented , the MD will be prompted with this alertA Hyperlink can take the provider directly to the restraint smart formDocumenting the Face-to-Face Assessment for Violent/Self Destructive Restraints or Seclusion
23. Clinical leadership must be informed when a patient remains in Violent/Self Destructive restraint or seclusion related to behavioral health for more than 12 hours, or experiences two or more separate episodes of any duration within 12 hours.In the unusual situation that a patient remains in violent/self destructive restraints 24 hours after initiation, the provider must conduct another face-to-face re-evaluation before writing a new order for continued use of restraints.Requirements for Violent/Self-Destructive Restraints or Seclusion
24. Nursing Documentation Requirements for Violent/Self-Destructive RestraintsNursing staff will:Educate at least once per order the restraint discontinuation criteria, an explanation of the criteria, and the patient’s response.Reassess and document every 15 mins if Violent/Self-Destructive Restraints are still neededReassess and document every 2 hours the patient for circulation, skin integrity, range of motion, hydration, nutrition, elimination, and injuries.
25. Death or disability related to use of restraints/seclusion must be reported to your supervisor/attending physician immediately, AND a Safety Report filed. Quality & Risk Management will evaluate the event, and provide appropriate documentation in the patient’s medical record, and notification of external agencies.The reporting requirement extends to deaths or disability:-While patient is in restraint/seclusion-Within 24 hours after restraint/seclusion is discontinued-Within 1 week of restraint/seclusion use if that death or disability was related to use of restraints or seclusion. Reporting of Death or Harm Related to the Use of Restraints or Seclusion
26. One last reminder: Please make sure you time the restraint order for when the restraints were actually applied.
27. Questions?