Restraints Seclusion - Crozer-Keystone Health System - PA

Restraints/Seclusion: What's to Know Before Implementing

October 2009

The Crozer-Keystone Healthcare System is committed to providing quality patient care in a safe environment and ensuring dignity of care. At times, staff is presented with a concern for patient safety as well as a concern for the safety of others. Interventions may be necessary to achieve that goal by using a restraint on a patient. There may be times when a restraint may be necessary to allow needed treatment to be administered such as to administer IV therapy, prevent falls, prevent pulling of tubes and/or monitors, and to prevent patients from causing injury to themselves or another. However, it should be understood that restraints are a “last resource” when all other resources have been exhausted. Restraints must be applied per safe protocol and in compliance with The Joint Commission Standards and Centers for Medicare & Medicaid Services (CMS) regulations. All CKHS staff involved with restraining or secluding a patient receives appropriate education.

Joint Commission Defines Restraint

The Joint Commission defines restraint as:

The direct application of physical force to a patient, with or without the patient’s permission, to restrict his or her freedom from movement. The physical force may be human, mechanical devices, or a combination thereof.

CMS Defines Restraint

In 2007 CMS defined a restraint as:

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 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.

Note that both the Joint Commission and CMS define restraint by the function of the device-- not by the type of device. If equipment is used as an assistive device for a functional, coherent patient then it may not be considered a restraint; however, if it is used to immobilize or control someone’s movement, then it is considered a restraint. Note that in long term care settings, the use of devices to keep a resident from falling out of bed is considered a restraint use. 

The residual of restraining patients has the potential for both emotional and physical harm to a patient. Additionally, it can provide a sense of frustration, hopelessness, and anger by patient’s family and guilt by healthcare providers (Joint Commission “Preventing Falls”). 

ECRI Institute (March, 2008) reports the risks associated with restraint use include: increased risk of falls, injuries, and death, loss of muscle tone and strength, decreased respiratory efficiency, pressure sores, urinary incontinence, new onset cognitive impairment, and depression and aggressive behavior. Additionally they identify certain patient characteristics such as obesity, heart disease, general poor health, use of illicit or prescribed medications, and/or drug intoxications that increase the risk of fatality or injury from or during a restraint.

CKHS has an administrative policy address restraints/seclusion. It provides the definitions of physical restraint and chemical restraint. Examples of physical restraints include: wrist/ankle restraints, regardless of how many limbs are involved, hand mitts, posey vest, geri chair with tabletop in a locked position, bilateral, full siderails used to restrict a patient in bed, belt to confine patient in a chair which cannot be easily released. The policy also provides examples of medical immobilizers used for patient safety during procedures which are not considered restraints, i.e., intravenous arm board, surgical positioning, safety belt during transport, and use of siderails during transport. In terms of seclusion, note medical isolation or voluntary separating is not considered seclusion. 

Restraints are acceptable and appropriate if there is need to restrict a patient’s movement during a procedure (dental, diagnostic, or surgical).  It is the policy of CKHS to respect patient’s right to be free from restraint of any form that is medically unnecessary or is used as a means of coercion, discipline, convenience or retaliation by staff.  Restraints are limited to those situations where less restive interventions have been ineffective in improving the patient’s well being or adequately protecting the patient’s safety or the safety of others.  

Restraints may be warranted for medical/surgical continuum of care after all other resources have been attempted and failed. Patients who repeatedly attempt to remove their IV lines, endotracheal tubes, feeding tubes, and foley catheters or those with cognitive ability which severely limit their ability to ensure safe, therapeutic care may necessitate a restraint. Additionally, patient’s behavior which is aggressive or violent and presents an immediate, serious danger to self or others may warrant the use of a restraint or seclusion. Specific policy and documentation must be adhered.  

Prior to a restraint in an acute medical/surgical care setting the patient should be evaluated to identify physiological factors that may cause the patient’s behavior.  Non restrictive measures such as liberalizing family visitations, providing diversionary activities, and placing the patient in rooms which provide better observation should be considered. Once all less restrictive measures have been exhausted, then restraint measures may be considered. However, only a physician may order restraints--a physician assistant cannot order a restraint nor nurse practitioner. If the ordering physician is not the attending physician, then he/she should be notified as soon as possible. Additionally, for the rare occasions which necessitate an emergent use of restraint an appropriately trained staff member may apply a restraint prior to physician order; however, the order must be obtained during the application or immediately thereafter.

Documentation of a restraint is critical for patient safety, continuum of care, and regulatory purposes. The following should be reflected in the patient’s respective medical record if a restraint is ordered:

  • Date/time of order
  • Type of restraint applied and/or drug given and date/time of application
  • Rationale for use of physical/chemical restraint
    Specific time period during which the order is valid (time limited order)--not to exceed 24 hours and NEVER a PRN order.
  • Behavior that must be demonstrated in order for the restraint to be removed.
  • Communication with family if patient consented for such communication.
  • Monitoring of patient’s physical/psychological well being such as respiratory and circulatory status, skin integrity, and vital signs.

Restraints must be reassessed at regular intervals to monitor patients’ condition, provide for physical/emotional needs, and ensure that privacy and dignity are maintained. Policy dictates that patient is monitored at least every two hours by observation, interaction, and direct examination by qualified staff.  

While no restraint order should exceed 24 hours a new restraint order may be initiated on a daily basis, if appropriate/justified after physician examination and assessment. The goal is to discontinue a restraint at the earliest possible time, based on patient assessment. However, if a restraint was discontinued prior to the order expiring for other than caring for a patient’s needs (feeding, toileting, range of motion) and the patient requires reapplication of a restraint then a new order is necessary.  

Restraints are a very serious measure not to be taken lightly. If staff use a restraint in an unsafe manner or without physician order and/or justification then it is considered false imprisonment. Education and communication are key to the reduction and/or elimination of restraint use.  

Restraint use is monitored and audited to ensure safe practices and appropriate utilization. A mandatory reporting requirement by the Patient Safety Officer to the Dep’t. of Health involves any death while a patient is restrained/secluded, deaths within 24 hours of such event, or deaths of patients within one week of event where it is reasonable to believe that there was a contributory factor in the death.

Restraints/Seclusion: What's to Know Before Implementing  October 2009

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