Presentation on theme: "Prevention, Intervention and Postvention: Restraints and Seclusion"— Presentation transcript:
1Prevention, Intervention and Postvention: Restraints and Seclusion Battle Creek Health SystemBehavioral Health Units
2Restraint or Seclusion BCHSBehavioral HealthGuidelinesCenters for Medicaid and MedicareJoint Commission on Accreditation of HospitalsMichigan Mental Health CodeThe following course addresses meeting the requirements of CMS, the Joint Commission and the State of Michigan Mental Health Code related to the implementation of restraint or seclusion.
3Course ObjectivesDefine Physical Restraint, Drug or Chemical Restraint, Legal/Administrative/Forensic Restraint and SeclusionDefine patient rights regarding the use of restraint or seclusionIdentify dangers associated with placing a patient in restraint in prone positionIdentify required documentation for initiating, monitoring and discontinuing restraint or seclusionIdentify least restrictive interventionsIdentify the requirements for reporting a death related to restraint or seclusion
4Physical RestraintA physical 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.
5Drug or Chemical Restraint A drug or medication, or a combination, when it is used as a restriction to manage the patient’s behavior, restrict the patient’s freedom of movement, or to impair the patient’s ability to appropriately interact with their surroundings and is not standard treatment or dosage for the patient’s condition.
6Legal/Administrative/Forensic Restraint Corrective restraints used for security reasons and administered by forensic personnel.(Use of handcuffs, manacles, shackles, other chain-type devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are considered law enforcement restraint devices to patients at BCHS.)
7SeclusionSeclusion 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.Timeout is not considered seclusion – patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving.
8New Terminology for Behaviors CMS defines two types of behavior that could warrant the use of restraint or seclusionNon-violent, Non-self-destructive BehaviorViolent, Self-destructive Behavior
9Staff Behavioral Triggers Staff may exhibit behaviors that trigger patient behaviors requiring restraint or seclusionAttitude: hurried, inattentive, preoccupied, non-supportive, non-openRoutines: becoming so involved in following the routines that the patient’s needs become secondaryRules: being too rigid with rules and not individualizing the care because it would break a rulePersonal triggers: not being in touch with own triggers or preconceptions related to patients and their care
10Environmental Triggers NoiseConfusionIncreased censusOverall milieuAdmissions and discharge processesActivities happening on the unit
11Restraint or Seclusion Interventions “Seclusion and restraint when used properly, can be life-saving and injury-sparing interventions. These emergency measures aim to protect patients in danger or harming themselves or others and to enable patients to continue in treatment successfully and effectively” (Success Stories and Ideas for Reducing Restraint/Seclusion, p.3)
12Patient RightsAll patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, or retaliation by staff. 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.(CMS (e))
13Patient RightsLeast restrictive interventions must be implemented or at least considered prior to initiation of restraint or seclusionRestraint or seclusion use can not be based solely on the patient’s diagnosis or history of dangerous behaviorThe type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.Asking the patient who is demonstrating the behavior “what would help you right now at this moment?”
14Risks Associated with Restraint or Seclusion Use may result in strong negative physical effects such as:DiscomfortIncreased risk of pressure ulcersIncreased risk of pneumoniaIncreased cardiac loadIncreased risk of de-conditioningIncreased risk of injury or deathUse may result in strong negative psychological effects such as:Increased disorganized behaviorSocial isolationDemoralizationHumiliationSense of being punishedInterferes with therapeutic relationship
15Awareness of Escalating Behaviors CPI training for each Behavioral Health staff memberMajority of restraint or seclusion events occur within the first 24 hours of admission in BCHS Behavioral HealthEscalating signs may include:Pacing, hand wringing, clenching fistsRed faced, perspiring heavily, rapid breathingLoud, pressured or rapid speechLack of eye contact
17Least Restrictive Interventions Refocusing attentionReality orientationPain relief/comfort measuresPRN medicationAll interventions attempted must be documentedAny interventions that were considered but not attempted should be documented and the reason not implemented
18Is it Time for Restraint or Seclusion? Behavior that precipitates a decision to restrain or seclude a patient should first trigger investigation and treatment aimed at understanding and eliminating the cause of the behavior.Underlying causes of threatening behavior may include:FearHistory of physical or sexual abuse, past restraintsMisinformationSymptomatic behavior related to diagnosis, i.e. paranoia
19Initiation of Restraint or Seclusion Assessment of patient’s needsAddressing medical problems may eliminate or minimize the need for restraint or seclusion.Medical problems may include:Substance abuse, drug interaction or drug side effectElevated temperature and infectionPainOrganic Brain Syndrome or deleriumHypoxiaHypoglycemiaElectrolyte imbalance
20Positional Asphyxia and Restraint or Seclusion The prone position (face down) should not be used for restraint as it may lead to positional asphyxia“Positional asphyxia is insufficient intake of oxygen as a result of body position that interferes with one’s ability to breathe”(Mohr & Mohr, 2000, p.289;National Institute of Justice Program [NIJP], 1995, p.1)As a consequence of the restraint application respiration is compromised causing insufficient oxygen in the blood to meet the body’s oxygen needs or demands (hypoxia) which then results in a disturbed heart rhythm (cardiac arrhythmia)(Patterson,et.al., 1998, p.62).
21Prone Restraint Complications Compression or restriction of movement of the ribs (intercostal muscles) limits the ability to expand the chest cavity and breatheAbdominal organs may be pushed up, restricting movement of the diaphragm and further limiting the available space for the lungs to expandFurther restriction of the chest cavity may come from a staff person pressing a hand or knee into the patient’s back or leaning body weight into or against the back or chestAgitation or aggressive struggle further increases the body’s oxygen demands and increases the heart rateIncreased heart rate and insufficient oxygen may cause a fatal cardiac arrhythmia
22Agitated Delerium and Sudden Death Involving Restraints Condition of extreme mental and motor excitement characterized by aggressive activity with confused and unconnected thoughts, hallucinations, paranoid delusions and incoherent or meaningless speech.Display extraordinary strength and endurance when strugglingHyperthermia is often presentDescribed in patients with psychosis, chronic schizophrenia, mania, and high blood concentrations of cocaine, methamphetamines or other stimulants
23Obtaining an Initiation Order Order may be initiated prior to receiving order, if imminent danger to patient or othersNurse initiated order is for 30 minutes. If physician was not notified prior to restraint or seclusion, within a few minutes contact the psychiatrist or physician to obtain an order for up to 4 hours.In Powerchart – click Add an order – and then choose Restraint/Seclusion Behavioral ProblemIf order was not received from the attending or the physician covering for the attending, notify the attending as soon as possibleBehavioral Health Administrator on Call must be notified of every restraint or seclusion event
24Restraint or Seclusion Order Must Never Be Written as PRNChoose Restraint or SeclusionInclude Duration (hours or minutes)Include Duration Unit (number of hours or minutes)Include least restrictive interventions attempted or considered/not attempted and why not attemptedInclude clinical justification for useInclude type of restraintInclude behavioral criteria that must be demonstrated for discontinuation and this information is also shared with the family when authorized by the patient
25Physician Face to Face Assessment Must be performed within one hour of the initiation of the restraint or seclusionRN documents on the restraint form the time the physician performs assessmentPhysician documents the assessment findings in Powerchart
26Monitoring of Restraint or Seclusion Staff will be assigned to monitor the patient one to oneIn seclusion, the staff member will remain outside the locked door to observe the patientIn restraint, the staff member will remain in the room with the patientDocumentation must be done every 15 minutes on the assessment section of the restraint formA simultaneous combination of restraint and seclusion (restrained alone in a room that the patient would not be able to leave if he/she were not restrained) is not practiced at BCHS Behavioral Health
27Restraint or Seclusion Assessments Document every 15 minutesVitalsBased on the patient’s conditionCirculation and range of motionChecking skin color and temperatureComplaints of numbness, tinglingAsking how extremities feelRepositioning and release of restraintsWhich restraints have been releasedPatient was repositioned
28Restraint or Seclusion Assessments Offer and document every 2 hoursHygiene and eliminationWith assistance, loosen restraints and assist patient to commode for elimination needs and or hygiene needsNutrition and hydrationIncreased calories being used related to behaviorsIncreased risk for dehydration and or electrolyte imbalance related to increased perspiration
29Psychological Status and Comfort Continue to offer support to the patient, focusing on what they need and how we can help themContinue to rebuild therapeutic rapportContinue to listen for their concerns or complaintsContinue to learn from the patient what led to the behaviors that required restraint or seclusion
30Vulnerable Patient Populations at Risk While in Restraint or Seclusion PregnantRespiratory conditions such as asthma or COPDCardiac diseaseSeizure disorderFractures, arthritisHead or spinal injuryVictim of sexual, physical or emotional abuseVictim of rapeCognitive limitations, language limitations
31Assessment of Patient Distress Related to Restraint or Seclusion Shortness of breath, coughing, choking, gasping, saying he/she can’t breatheChanges in vital signs, changes in mental status or speechSkin cool or cold to touch, perspiring heavily and hot to touchPain symptoms - guarding an area, grimacing, saying he/she is in pain, pointing to a painful areaNausea and vomitingAny physical changes must be reported to RN for further action up to and including calling 911 for transport to the Emergency DepartmentInitiation of CPR for absent pulse or respirations
32Helping the Patient Meet the Criteria for Discontinuation Criteria has been identified in the initial order and communicated with the patient and/or familyOffer to contact the family if that would helpAsk how we can help the patient meet his/her needsContinue to dialogue with the patient
33Recognition of Patient Readiness to Discontinue Restraint or Seclusion Behavioral criteria identified at initiation of order has been metChanges in physical activity and verbalizationsMust be discontinued at the earliest possible time, regardless of the length of time identified in the orderOnce discontinued, a new order must be obtained if restraint or seclusion needed again (releasing for hygiene or elimination needs is not discontinuation)A final assessment documentation must be performed 15 minutes after discontinuationThe restraint or seclusion event must be entered on the restraint/seclusion log on the unit
34Care Plan Modification The use of restraint or seclusion must be in accordance with a written modification to the patient’s plan of care.Use of restraint or seclusion constitutes a change in a patient’s plan of care.The change in the plan of care should be based on assessment and evaluation of the patient.
35Debriefing after Restraint or Seclusion As soon as possible, but no longer than 24 hours, after the event hoursIncludes all staff present during the event and the patient and/or family as applicableDocumentation in the EMR should indicate any injuries the patient sustained and how the patient perceived the restraint or seclusion. Document if the patient identifies something else that could have been done to help he/she regain control and avoid restraint or seclusion.Postvention form needs to be completed after each restraint or seclusion event and should be submitted to the Nurse Manager or the Educator for use in staff training and for Performance Improvement
36Death Reporting Requirements You must report any death that occurs in relationship to restraint or seclusion to Risk ManagementDeath that occurs while a patient is in restraint (physical or drug/medication) or seclusionDeath that occurs within 24 hours after the patient has been removed from restraint or seclusionEach death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the patient’s deathA PEERS must also be completed
37Contact Required for Reporting a Death Must be reported to Risk ManagementCall operator and ask Risk Management be paged to your numberSending an or leaving a phone message is not acceptableYou must speak to someone from Risk Management
38Staff Training Requirements CPI certification on initial hire and annual recertification for all staffStaff are not allowed to participate in restraint application or seclusion procedures until CPI training has been completedReview of this Behavioral Management training module
39Patient Safety and Quality Performance Indicators Every restraint or seclusion event in Behavioral Health will be audited through concurrent chart reviews at the unit level and reviewed at staff meetingsReport of restraint or seclusion events to Behavioral Health Quality Improvement Team monthlyReport of restraint or seclusion events to Patient Safety and Quality monthly
40References BCHS Restraint & Seclusion Policy # TX-70 CMS Manual System. (2008). Pub State Operations Provider Certification (e)Standard: Restraint or Seclusion, (f)Standard: Restraint or Seclusion: Staff Training Requirements, (g) Standard: Death Reporting RequirementsCrisis Prevention Institute, Inc Instructor manual: Nonviolent crisis training program. Brookfield, WI: Compassion Publishing, Ltd.Michigan Association of CMH Boards. (2001). Michigan’s Mental Health Code. Lansing, MI.
41ReferencesAmerican Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems Success stories and ideas for reducing restraint/seclusion in behavioral health.DeLacy,L.C.(2001). Seclusion and Restraint Standards: A platform for creating safety for patients and staff. Journal of the American Psychiatric Nurses Association, 7 (4)Mohr & Mohr, 2000, p.289;National Institute of Justice Program [NIJP], 1995, p.1.Myers, R.E., Williams, J.E. (2001). Relationship of less restrictive interventions with seclusion/restraints usage, average years of psychiatric experience, and staff mix, 7 (5)