1. Hospital-Wide Restraint Initiative

2. Committee Members Vickie Geha Cathy Klotz Barb Kvale Deb Hanson Cathy Benninghoff Kathy Boyk Caryn Flournoy Kerri Rahman Ad hoc member: Deana Sievert

3. Plan – Current Situation Many different accreditation bodies have developed standards around the use of restraints. Most have to do with restraint reduction – following the philosophy that inappropriate restraint use could result in patient harm, including death The FDA now estimates that approximately 100 deaths per year are from restraint use

4. Plan – Improvement Goal Reduce restraint use against external benchmark throughout the hospital Use of external benchmarks as available Increase staff awareness regarding the standards, use of least restrictive alternatives, and the goals of restraint reduction Improve documentation of restraint use

5. Benchmarks Med/surg benchmark - 3.4 Rehab benchmark - 3.4 ICU benchmark - 24.3 Continue with internal benchmarks for psychiatric units

6. Plan – Opportunity Statement Meet compliance regarding documentation of restraint/seclusion use Maintain or decrease restraint/seclusion in all hospital areas as reasonable Meet all compliance standards for restraint/seclusion use

7. Measure - Indicator Various indicators were used M/S: number of restraint episodes (any time an order is written) ÷ number of patient days x 100 MCCU/Rehab: number of hours in restraints ÷ number of patient hours x 100 Child Psych: number of hours in seclusion/restraints ÷ number of patient days x 100 Geri-Psych: number of hours in seclusion/restraints ÷ number of patient days/24 hours x 1000 Documentation indicators

8. Analyze - Results Geripsych is almost 100% restraint free Kobacker continues to make program changes to become restraint free Increased awareness of staff in the use of restraints There has been some improvement in documentation, but 90% compliance is not met

9. Actions Purchased least restrictive devices such as lap buddies, chair alarms, Velcro waist wrap, activity aprons, wedge cushions, and side-rail protectors Continue with the Family Sitter Program Use of 1:1 Added new committee members Integrated restraint education in hospital orientation Revised the documentation tool to include all required elements

10. Actions Added the use of freedom splints in the ICUs Changed to using an external benchmark Presented to the Med/Surgical Zone yearly Independent study program offered (contact hours provided) Presented poster presentations Recognized staff nurses who documented thoroughly Counseling staff for documentation issues

11. Actions Restraint care plan revised Recognized 5CD for achieving nursing documentation standards above 90% for one month Documentation tool revised Kobacker PI project won first place at the PI fair Develop 1:1 policy Develop 1:1 Standards of Care Continue to have ACs review restraint documentation

12. Actions – Future Steps Education of physicians will occur in the area of order writing Slice/dice data further Continue to look for patterns Identify opportunities by population or unit Continuing to educate at the new employee orientation and nursing orientation

13. Actions – Future Steps Independent studies are available Include restraint education in skills labs Continue to monitor documentation compliance regarding the many required documentation elements Make some revisions to the current charting tools to streamline, including the physician order form

14. Response Restraint use as it relates to PI is complex, challenging, and often, slow moving Data collection is time-consuming and labor intensive Goals must be well defined and the team must celebrate even small successes Value and perception regarding restraint use varies, but most staff do not think about restraint use the same as a form of treatment

15. Response When you think you have the rules down – they change PI around restraint use is here to stay It is possible to achieve perfection with efforts from all Have to keep up with the monitoring to achieve perfection