1. EAST TEXAS MEDICAL CENTER
Managing Behavioral Restraint or Seclusion in the Hospital
Knowledge-Based Physician Training
Revised 2-13

2. Required Training CMS Rule: 482.13(e)(11)
Physician and other LIP training requirements must be specified in hospital policy. At a minimum, physicians and other LIPs authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.

3. Joint Commission: PC
The hospital has written policies and
procedures that guide the use of restraint and seclusion for behavioral
health purposes which include staff
competence and training

4. Texas Administrative Code:
25 TAC
Physicians authorized to give
orders for restraint or seclusion
must receive training and
demonstrate competency

5. DEFINITION OF RESTRAINT
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

6. THREE TYPES OF RESTRAINT
MEDICAL OR NON-BEHAVIORAL
BEHAVIORAL
FORENSIC

7. MEDICAL RESTRAINT Examples: Definition: Orthopedic devices Helmets
Surgical dressings
IV arm boards
Devices used to achieve body alignment
Soft foam wrist or ankle straps or hand mitts
Side rails (2) or crib rails
Safety belts
Physical escorts from which the patient can escape
Any method of holding or securing a patient for the purpose of conducting tests, exams, or procedures or to protect the pt. from falling out of bed or to prevent injuring themselves in some type of activity

8. FORENSIC RESTRAINT DEFINITION:
Application of handcuffs, ankle cuffs, or belly chains by peace officers for the purpose of security, detention, or public safety; individuals in forensic custody with these types of devices must be maintained and monitored by peace officers.

9. BEHAVIORAL RESTRAINT
Any method (physical, mechanical, or chemical) of restricting a patient’s
freedom of movement (incl. seclusion),
physical activity, or normal access to his or her body, and is not done as a part of a medical-surgical condition or procedure.

10. TYPES OF BEHAVIORAL RESTRAINTS
Physical Hold (maximum of 15 min.)
Mechanical
•Restraint Chair
•Restraint Net
Seclusion
Chemical (not used )

11. PHYSICAL HOLD RESTRAINT
The application of body pressure by another person to the body of a patient in such a way as to limit or control movement of the whole or a portion of a patient’s body. The various techniques such as “physical hold” or “take down” procedures are considered forms of physical restraint.

12. Bear Hug
Type of
Physical
Hold

13. MECHANICAL RESTRAINT
This is any device used to restrict the movement of the whole or a portion of a patient’s body. It can be in the form of ankle or wrist straps, a body net or a restraint chair.
Caution: Geri Chairs and Side rails (4) can be considered a mechanical restraint if the patient cannot control egress

14. Example Of
Mechanical
Restraint
Adult
In the
Body Net Restraint

15. RESTRAINT
CHAIR
Type of
Mechanical
Restraint

16. SECLUSION
Seclusion is the confinement of the patient alone in a locked room or alone in an identified area from which egress is prevented. Patients in seclusion must be monitored by a trained staff member at all times.

17. Seclusion Room at BHC

18. CHEMICAL RESTRAINT
Use of medication is considered a chemical restraint 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 or diagnosis. Chemical restraints are not used at BHC.

19. CRITERIA FOR BEHAVIORAL RESTRAINT
All less restrictive measures were attempted and failed
No time to attempt less restrictive measures
Must be evidence of eminent danger

20. Definition of a “Least Restrictive Measure”
This is a term that is used extensively in mental health and in patient rights issues. It simply means “the least intrusive or restrictive service or treatment that can effectively and safely address the patient’s needs and stated preferences”. All less restrictive measures must be tried and documented before a behavioral restraint or seclusion is ordered.

21. EXAMPLES OF LESS RESTRICTIVE MEASURES
Making a contract for safe behavior
Helping the patient to identify the stressor causing the behavior
Redirecting the patient’s attention by suggesting another activity
Reducing the noise level and light intensity
Allowing the patient to speak to a patient advocate, minister, supervisor, or family
Deep breathing exercise
Negotiating a solution based on options available
Offering medications to assist in reducing agitation/anxiety

22. EMINENT DANGER
There must be evidence that there is “eminent” danger to the patient or others in order to justify the need for a behavioral restraint or seclusion. Threatening to do something is not acceptable. Patients must be in the “act of” or “process of attempting” to do something that could result in injury or damage.

23. TIME LIMITS FOR RESTRAINT AND SECLUSION BY AGE
Physical Hold: 15 minutes for all ages (child-adult)
8 yrs. of age and younger: 1 hour
9-17 yrs. of age: 2 hours
18 yrs. and older: 4 hours
Patient must be released as soon as the risk of harm to self or others no longer exists.

24. MONITORING REQUIREMENTS EVERY 15 MINUTES WHILE IN RESTRAINT OR SECLUSION
Circulation
Respiration Rate
Heart Rate
Blood Pressure
Oxygen Saturation
Behaviors
Food/Fluid Needs
Elimination Offered
ROM Provided
Hygiene Needs Met
Physical Comfort Provided
Psychological Support Offered
Signs of Injury
Evaluated for Release

25. PHYSICAN REQUIREMENTS
Face-to-Face Evaluation of Patient within one hour of the onset of the R/S
Completion the Physician Order Set for a behavioral restraint
Completion of Physician Progress Note for a behavioral restraint
Notification of attending physician if physician ordering the R/S is not the attending

26. Physician Order Set For Behavioral Restraint
(located in red folder with all other physician orders)

27. Restraint or Seclusion.
Physician Progress
Note for a Behavioral
Restraint or Seclusion.

28. You have completed the physician
CONGRATULATIONS!
You have completed the physician
Training module for Restraint and Seclusion.
Please print the certificate below and sign
and date as indicated. Submit this document
to the medical staff office to be filed in your record.
Thank you.

29. Certificate of Training RESTRAINT AND SECLUSION
Physician Name______________________ Date:________
Print
Physician Signature:_____________________________