1. RESTRAINTS

2. Current CMS Regulatory Requirements and JCAHO Requirements Staff involved with applying, assessing/monitoring &/or providing care to patients with restraints must be trained and demonstrate competency on an ANNUAL BASIS to care for a patient in restraints

3. Definition of a Restraint Restraint is 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 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.

4. Saint Joseph Health System Philosophy Minimize restraint use Maximize safety Prefer less restrictive interventions Discontinue at earliest possible times Use only in clinically appropriate and justified situations

5. Types of Restraint and Clinical Areas of Use Vest RestraintAll Clinical Nursing Areas Soft Cloth ExtremityAll Clinical Nursing Areas 4 raised side railsAll Clinical Nursing Areas ChemicalAll Clinical Nursing Areas

6. Classification of Restraint Medical Behavioral Management Chemical Side rails

7. What is a Medical Restraint? A medical restraint is used to manage a patient who presents a risk of harm to themselves and/or others and/or interferes with medical/surgical healing

8. Medical Restraint Orders The RN must notify the MD within 12 hours of initiation to obtain the medical restraint protocol order Medical Restraint orders must be renewed each calendar day

9. If the restraint is removed for a time period longer than to complete the patient’s personal needs (i.e. toileting/feeding) or for certain treatments or procedures, a new restraint order is needed.

10. A new Medical Restraint Protocol Order must be completed with each initiation.

11. Orders for restraint use are never written as a PRN order or as a standing order

12. Criteria for Discontinuation Not pulling at essential lines/tubes/dressings Movement not causing dislodgement of lines/tubes Follows directions to avoid self-injury Not attempting to get out of bed No interference with medical healing Lines/Tubes/Dressings have been discontinued

13. Medical Restraint Flow sheet Monitoring and Documentation Monitor at least every hour the patient’s: Physical and emotional well being Rights, dignity and safety are maintained Restraint has been appropriately applied Behavior that necessitates less restrictive methods or continuation of restraints or removal of restraints (nurse only)

14. Document every 2 hours That toileting, food and fluids are offered Distal circulation and skin integrity of involved extremities ROM/Rotate restraint sites, if patient condition permits Use appropriate codes listed on flow sheet

15. Monitoring/Documenting: Rehab. Therapist When caring for a restrained patient greater than 1 hour, document the restraint monitoring criteria in the progress notes as indicated

16. What is a Behavioral Restraint? A behavioral restraint is used only in emergencies when nonphysical interventions are ineffective or not viable and when there is imminent risk of a patient physically harming self or, staff or others.

17. Determine the need for Behavioral Management Restraint Mark the appropriate criteria on the Behavioral Management Restraint Order Sheet Criteria Emergency: severely aggressive / destructive behavior Behavior places staff/others in imminent danger Behavior places patient in imminent danger

18. Behavioral Restraint Orders The RN must: Notify a MD and/or LIP within one hour of application of the restraint(s). The MD and/or LIP must: Evaluate the patient within one hour of the time the restraint(s) are applied. If a physician is not available to perform a face-to-face evaluation within one hour, then contact the On- Call Physician for “Restraint Evaluation.

19. Criteria for Discontinuation 1.Able to demonstrate behavioral control 2.Responds to administered medications 3.Demonstrates no threat of harm 4.Able to respond to staff’s directions

20. Behavioral Management Restraint Flow sheet Monitoring and Documentation Continuous monitoring - Continuous means uninterrupted observation of that patient for as long as behavior management restraint is used. Observer must have direct eye contact with the patient. (This can be through a window or a doorway)

21. Assess the patient at the initiation of restraint and every 15 minutes thereafter. The assessment includes the following: Distal circulation and skin integrity of involved extremities Signs of any injury associated with restraint Offer toileting, hygiene, food and fluids Perform ROM and rotate restraint sites, if patient condition permits Physical and psychological status and comfort Readiness for discontinuation of restraint (Cont.) Behavioral Restraint Flow sheet Monitoring and Documentation

22. Documentation Use the hospital approved Behavioral Management Restraint Flow sheet Include: Date, time and type of restraint Appropriate Codes for Criteria for continuation, discontinuation or re-initiation of the restraint

23. Document Name, initials and department of staff completing care Patient/family education, if applicable, Understanding of education, if applicable Initial _______ Signature _______________ Dept _________ Initial ______ Signature ______________ Date ______ Patient/Family Education: Initials ________ Demonstrates Understanding: Initials ________

24. Side Rails Side rails are considered a medical restraint when used to: Restrict or prohibit movement Restrict access to the patients body

25. Side Rails (Cont.) Side rails on a hospital bed are not required. Side rails on a stretcher are not considered a restraint. 3 side rails are not considered a restraint. 4 side rails ARE a restraint, unless patient is: – Unable to move – Requesting side rail(s) as a mobility aid – Requesting side rail(s) as reminder not to get out of bed. – Unconscious/sedated. – Recovering from anesthesia. – Using for support purpose (i.e. obese patient) – On the Total Care Sp0 2 RT in the rotational mode.

26. Chemical Restraint Is Not considered a restraint when the behavior arises as part of a medical, surgical or psychiatric condition: Is considered a restraint when it involves the use of a medication which is not standard treatment for the patient’s condition If used as a restraint, follow the appropriate Restraint Policy

27. Patient/Family Education 1.Explain the following information to patients and family regarding the need for restraints: Promotion of safety is the goal Frequent monitoring by staff Time-limited procedure Alternatives to restraints have been reviewed Rationale for restraint use 2.Document education on the Restraint Flow sheet 3.Education information is available on Micromedex

28. Reporting Requirements Injury or death of a patient while in restraints are to be reported to the House Administrator immediately. Reminder: Remove all physical restraints with the initiation of a Code Blue

29. Transporting a Patient in Restraints Keep the patient in restraint(s) when transporting to another department (i.e. nursing unit to radiology) unless other wise indicated.

30. Proper Application of a Restraint (Add padding to support body part as needed)

31. Correct placement and position of a restraint (secure to the bed frame using the quick release buckle)

32. Correct placement and position of a restraint (secure to the bed frame)

33. Incorrect placement and fastening of restraint (tied to the bed frame and side rail)

34. Incorrect use of a restraint (tied in knot instead of quick release buckle)

35. Help me, I’m choking!!! Incorrect use of Posey (never attach straps to head of bed)

36. Has anyone seen my non-skid foot wear?

37. Wheelchair

38. Click Here to Begin Restraint Test for Radiology Tech