1. Prevention, Intervention and Postvention: Restraints and Seclusion
Battle Creek Health System
Behavioral Health Units

2. Restraint or Seclusion
BCHS
Behavioral Health
Guidelines
Centers for Medicaid and Medicare
Joint Commission on Accreditation of Hospitals
Michigan Mental Health Code
The 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.

3. Course Objectives
Define Physical Restraint, Drug or Chemical Restraint, Legal/Administrative/Forensic Restraint and Seclusion
Define patient rights regarding the use of restraint or seclusion
Identify dangers associated with placing a patient in restraint in prone position
Identify required documentation for initiating, monitoring and discontinuing restraint or seclusion
Identify least restrictive interventions
Identify the requirements for reporting a death related to restraint or seclusion

4. Physical Restraint
A 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.

5. Drug 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.

6. Legal/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.)

7. Seclusion
Seclusion 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.

8. New Terminology for Behaviors
CMS defines two types of behavior that could warrant the use of restraint or seclusion
Non-violent, Non-self-destructive Behavior
Violent, Self-destructive Behavior

9. Staff Behavioral Triggers
Staff may exhibit behaviors that trigger patient behaviors requiring restraint or seclusion
Attitude: hurried, inattentive, preoccupied, non-supportive, non-open
Routines: becoming so involved in following the routines that the patient’s needs become secondary
Rules: being too rigid with rules and not individualizing the care because it would break a rule
Personal triggers: not being in touch with own triggers or preconceptions related to patients and their care

10. Environmental Triggers
Noise
Confusion
Increased census
Overall milieu
Admissions and discharge processes
Activities happening on the unit

11. Restraint 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)

12. Patient Rights
All 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))

13. Patient Rights
Least restrictive interventions must be implemented or at least considered prior to initiation of restraint or seclusion
Restraint or seclusion use can not be based solely on the patient’s diagnosis or history of dangerous behavior
The 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?”

14. Risks Associated with Restraint or Seclusion
Use may result in strong negative physical effects such as:
Discomfort
Increased risk of pressure ulcers
Increased risk of pneumonia
Increased cardiac load
Increased risk of de-conditioning
Increased risk of injury or death
Use may result in strong negative psychological effects such as:
Increased disorganized behavior
Social isolation
Demoralization
Humiliation
Sense of being punished
Interferes with therapeutic relationship

15. Awareness of Escalating Behaviors
CPI training for each Behavioral Health staff member
Majority of restraint or seclusion events occur within the first 24 hours of admission in BCHS Behavioral Health
Escalating signs may include:
Pacing, hand wringing, clenching fists
Red faced, perspiring heavily, rapid breathing
Loud, pressured or rapid speech
Lack of eye contact

16. Least Restrictive Interventions
Re-direction
Counseling
1:1 Intervention
Decreased environmental stimuli
Increase rounding frequency
Move patient closer to nurse station
Approach patient in calm, unhurried manner
Limit setting
Quiet atmosphere
Visual suprvision
Diversional Activities
Television, radio
Games

17. Least Restrictive Interventions
Refocusing attention
Reality orientation
Pain relief/comfort measures
PRN medication
All interventions attempted must be documented
Any interventions that were considered but not attempted should be documented and the reason not implemented

18. Is 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:
Fear
History of physical or sexual abuse, past restraints
Misinformation
Symptomatic behavior related to diagnosis, i.e. paranoia

19. Initiation of Restraint or Seclusion
Assessment of patient’s needs
Addressing medical problems may eliminate or minimize the need for restraint or seclusion.
Medical problems may include:
Substance abuse, drug interaction or drug side effect
Elevated temperature and infection
Pain
Organic Brain Syndrome or delerium
Hypoxia
Hypoglycemia
Electrolyte imbalance

20. Positional 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).

21. Prone Restraint Complications
Compression or restriction of movement of the ribs (intercostal muscles) limits the ability to expand the chest cavity and breathe
Abdominal organs may be pushed up, restricting movement of the diaphragm and further limiting the available space for the lungs to expand
Further 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 chest
Agitation or aggressive struggle further increases the body’s oxygen demands and increases the heart rate
Increased heart rate and insufficient oxygen may cause a fatal cardiac arrhythmia

22. Agitated 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 struggling
Hyperthermia is often present
Described in patients with psychosis, chronic schizophrenia, mania, and high blood concentrations of cocaine, methamphetamines or other stimulants

23. Obtaining an Initiation Order
Order may be initiated prior to receiving order, if imminent danger to patient or others
Nurse 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 Problem
If order was not received from the attending or the physician covering for the attending, notify the attending as soon as possible
Behavioral Health Administrator on Call must be notified of every restraint or seclusion event

24. Restraint or Seclusion Order
Must Never Be Written as PRN
Choose Restraint or Seclusion
Include Duration (hours or minutes)
Include Duration Unit (number of hours or minutes)
Include least restrictive interventions attempted or considered/not attempted and why not attempted
Include clinical justification for use
Include type of restraint
Include behavioral criteria that must be demonstrated for discontinuation and this information is also shared with the family when authorized by the patient

25. Physician Face to Face Assessment
Must be performed within one hour of the initiation of the restraint or seclusion
RN documents on the restraint form the time the physician performs assessment
Physician documents the assessment findings in Powerchart

26. Monitoring of Restraint or Seclusion
Staff will be assigned to monitor the patient one to one
In seclusion, the staff member will remain outside the locked door to observe the patient
In restraint, the staff member will remain in the room with the patient
Documentation must be done every 15 minutes on the assessment section of the restraint form
A 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

27. Restraint or Seclusion Assessments
Document every 15 minutes
Vitals
Based on the patient’s condition
Circulation and range of motion
Checking skin color and temperature
Complaints of numbness, tingling
Asking how extremities feel
Repositioning and release of restraints
Which restraints have been released
Patient was repositioned

28. Restraint or Seclusion Assessments
Offer and document every 2 hours
Hygiene and elimination
With assistance, loosen restraints and assist patient to commode for elimination needs and or hygiene needs
Nutrition and hydration
Increased calories being used related to behaviors
Increased risk for dehydration and or electrolyte imbalance related to increased perspiration

29. Psychological Status and Comfort
Continue to offer support to the patient, focusing on what they need and how we can help them
Continue to rebuild therapeutic rapport
Continue to listen for their concerns or complaints
Continue to learn from the patient what led to the behaviors that required restraint or seclusion

30. Vulnerable Patient Populations at Risk While in Restraint or Seclusion
Pregnant
Respiratory conditions such as asthma or COPD
Cardiac disease
Seizure disorder
Fractures, arthritis
Head or spinal injury
Victim of sexual, physical or emotional abuse
Victim of rape
Cognitive limitations, language limitations

31. Assessment of Patient Distress Related to Restraint or Seclusion
Shortness of breath, coughing, choking, gasping, saying he/she can’t breathe
Changes in vital signs, changes in mental status or speech
Skin cool or cold to touch, perspiring heavily and hot to touch
Pain symptoms - guarding an area, grimacing, saying he/she is in pain, pointing to a painful area
Nausea and vomiting
Any physical changes must be reported to RN for further action up to and including calling 911 for transport to the Emergency Department
Initiation of CPR for absent pulse or respirations

32. Helping the Patient Meet the Criteria for Discontinuation
Criteria has been identified in the initial order and communicated with the patient and/or family
Offer to contact the family if that would help
Ask how we can help the patient meet his/her needs
Continue to dialogue with the patient

33. Recognition of Patient Readiness to Discontinue Restraint or Seclusion
Behavioral criteria identified at initiation of order has been met
Changes in physical activity and verbalizations
Must be discontinued at the earliest possible time, regardless of the length of time identified in the order
Once 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 discontinuation
The restraint or seclusion event must be entered on the restraint/seclusion log on the unit

34. Care 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.

35. Debriefing after Restraint or Seclusion
As soon as possible, but no longer than 24 hours, after the event hours
Includes all staff present during the event and the patient and/or family as applicable
Documentation 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

36. Death Reporting Requirements
You must report any death that occurs in relationship to restraint or seclusion to Risk Management
Death that occurs while a patient is in restraint (physical or drug/medication) or seclusion
Death that occurs within 24 hours after the patient has been removed from restraint or seclusion
Each 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 death
A PEERS must also be completed

37. Contact Required for Reporting a Death
Must be reported to Risk Management
Call operator and ask Risk Management be paged to your number
Sending an or leaving a phone message is not acceptable
You must speak to someone from Risk Management

38. Staff Training Requirements
CPI certification on initial hire and annual recertification for all staff
Staff are not allowed to participate in restraint application or seclusion procedures until CPI training has been completed
Review of this Behavioral Management training module

39. Patient 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 meetings
Report of restraint or seclusion events to Behavioral Health Quality Improvement Team monthly
Report of restraint or seclusion events to Patient Safety and Quality monthly

40. References 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 Requirements
Crisis 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.

41. References
American 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)