1. Restraint and Seclusion Updates 2014 Annual Nursing Sandy Wade RN, CNS

2. Regulatory Reminders PRN restraint orders are not allowed. When a restraint order is received, it is understood that restraint will be applied immediately, or has already been applied emergently. If the order is not carried out at that time, it becomes void. A “restraint break ” is not allowed, other than for patient care activities with a staff member in the room. – It is not permissible for family members to remove restraints for any reason. – If the staff member leaves the room while the patient is un-restrained, it is considered that restraints have been discontinued. A new order will be required if they are re-applied.

3. Indications for Restraint Terminology varies with the regulatory agency - The Joint Commission (TJC) or the Centers for Medicare & Medicaid Services (CMS) “Behavioral Health” (TJC) “Violent” (CMS) Behavioral health care reasons for the use of restraint or seclusion are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder. “The use of restraint and seclusion for behavior management is not specific to the treatment setting, but to the situation the restraint is being used to address.” (OLOL Policy OrgClin/036) “Non-Behavioral Health” (TJC) “Non-violent” (CMS) The restraint standards for medical or surgical purposes apply when the primary reason for use directly supports medical healing. Commonly referred to as “Med-Surg” restraints

4. Tips for De-escalation of Aggressive/Disruptive Behavior Remain calm Speak in a soft voice Be aware of your body language (Where are your hands?) Position self in a supportive stance (Not confrontational) Set clear, concise & enforceable limits Be an empathetic listener (Not judgmental) Do not feign attention Practice silence Repeat & reflect on what was said

5. Alternatives to Restraints Attempt these measures before applying restraints: Treat delirium Offer distraction (eg, TV, toy to occupy hands, magazine to read) Reorient patient Reduce environmental noise Offer pain relief Have family or sitter with patient Change environment (eg, room closer to nurses station, chair in hall) Explain all procedures Music offered Routine ambulation Offer toileting q2 hrs Oral hygiene Place in reclining chair “Restraint or seclusion may only be used when less restrictive measures have been determined to be ineffective to protect the patient, a staff member or others from harm.” ( CMS)

6. 1 limb, 2 limbs, 3 limbs, 4... Can be used on any floor There is a misperception that the use of 4-point restraints constitutes “behavioral” restraints, and cannot be done on a typical med-surg unit. The facts are: The number of restraints on a patient does not define the type of restraint. It’s patient behavior -- the reason for restraint -- that determines the type: – Behavioral: For management of violent behavior that threatens to harm the patient or others – Med-Surg: For management of non-violent behavior that is interfering with med-surg care/treatments Though rare, behavioral restraints may be initiated for violent behavior on a non-behavioral (med-surg) unit. It must be remembered that this type of restraint requires constant 1:1 monitoring and frequent documentation of observations.

7. Tying Soft Limb Restraints Annually, all clinical staff must demonstrate the ability to secure and release restraint with a quick-release tie or bow. Check-off will occur in your work area. Following are illustrations of acceptable quick-release tying methods.

8. The Simple Slip Knot

9. The Posey Quick-Release Tie This adds an extra step to the simple slip knot. It makes the knot more secure while still being a quick-release.

10. A Bow Is Also Acceptable

11. But This Knot... Is Not!

12. Points to Remember when Applying Restraints Secure the limb holder cuff tightly enough to prevent the patient from pulling the limb out of the cuff, but loose enough to allow adequate circulation. Allow a one-finger space between the cuff and the patient’s limb. Tie the straps to a movable part of the bed frame, out of the patient’s reach. Do not tie it to a side rail! Ensure that the bow/knot used can be released with a single pull on the tail of the straps. Maintain proper alignment of body and limbs, trying to allow enough slack to enable some limb movement without compromising the purpose for the restraint.

13. Enclosure Bed This type of restraint may be used only on: STU Neuro Rehab PICU Peds-4 Annual competency demonstration is required for nurses and CNAs on these units. Managers of these units will notify their staff of the location and times for inservicing and check-off.

14. Restraint Documentation in Powerchart

15. Obtain Initial Order from M.D. The physician should enter the Powerplan for restraints. The nurse may do so when necessary to obtain a telephone order. There are 4 restraint Powerplans:

16. Initiate the Powerplan Be sure to leave these two boxes pre-checked! They will trigger the necessary tasks as long as the Powerplan is active. The physician may initiate the Powerplan or put it in a “planned” state. The nurse will then initiate the plan.

17. 3 nursing tasks will be triggered when the Powerplan is initiated and signed: “Restraint Initiate” (Activity View) – This task is only charted once. “Restraint Observe/NV/ROM” (Activity View) – The frequency of this task is every 2 hours. – For Med Surg restraints, this task will continue until the Powerpan is discontinued. Behavioral restraint tasks have a duration associated with the order. “Check with MD regarding new orders for restraints if appropriate” – A one-time reminder the next day, charted as “done/not done”. Tasks Triggered by the Powerplan See screen prints on the following slides

18. “Restraint Initiate” Chart pre-restraint assessment and actions as well as education.

19. “Restraint Observe/NV/ROM” Use a dynamic group to create the appropriate label for the restraints being used. If bilateral limb restraints are in use, a dynamic group for each limb is required. Creating the label is only needed with the first documentation or if the location of the restraint is changed.

20. “Check with MD regarding new orders for restraints if appropriate” The task will fire at 0900 the next day to remind the nurse to obtain a new order if restraints are still necessary. This task only serves as a one-time reminder and is charted as “done/not done”. If restraints are no longer needed, the nurse should: – Document their discontinuation – Discontinue the Powerplan

21. Restraint Continuation beyond Day 1 The next day, and each day thereafter, the MD must evaluate the need for restraint and enter an order if indicated. (The nurse may do so only when necessitated by telephone order) The order to use is “Restraint Apply (Post Initiation)”. Enter this order by using “Add to Phase” on the previously initiated Powerplan for Restraints - Med Surg/Non Violent. Do not discontinue the initial Powerplan and enter a new one each day! See next slide for Post-Initiation steps

22. Post-Initiation Steps

23. “Post-Initiation” Tasks When signed, the Post-Initiation order will generate “Check with MD regarding new orders” again at 0900 the following morning. Since the Post-Initiation order is a continuation of the original restraint order, the q2hr tasks for “Restraint Observe/NV/ROM” will continue uninterrupted until the original order is D/C’d.

24. Advantages of Using “Post-Initiation” Orders It is not necessary to discontinue the previous day’s restraint orders when the new “Post-Initiation” orders are entered each day. All the restraint orders for all days of the current restraint episode will be in one location in a single Powerplan. By simply clicking on the Powerplan, you can view all the restraint orders for that episode, rather than having to scroll through the list of “Patient Care Orders” to locate them. This helps to streamline the documentation audit process!

25. And speaking of documentation audits … The following slides compare OLOL’s 2012 & 2013 restraint documentation compliance.

26. Documentation Compliance ICU Audit Item2012 Compliance 2013 (thru Oct) Compliance Timely initial order98%  97% Documentation of restraint application95%  98% Order obtained each subsequent day95%  94% Documentation q 2hrs Observe97%  92% ROM97%  92% NV check97%  92% Plan of Care addressed daily96%  91% Restraint removal documented91%  90%

27. Documentation Compliance Non-ICU Audit Item2012 Compliance 2013 (thru Oct) Compliance Timely initial order96%  99% Documentation of restraint application92%  96% Order obtained each subsequent day91% Documentation q 2hrs Observe83%  87% ROM84%  85% NV check83% Plan of Care addressed daily88%  90% Restraint removal documented83%  68% Note: Minimum acceptable Joint Commission compliance is 90% Scores below 90% are in red

28. Documentation Compliance ECU/PECU (Med-Surg) Audit Item2012 Compliance 2013 (thru Oct) Compliance Timely initial order95%  85% Documentation of restraint application84%  96% Order obtained each subsequent dayn/a Documentation q 2hrs Observe89% ROM89%  83% NV check89%  79% Plan of Care addressed daily63%  69% Restraint removal documented88%  76% Note: Minimum acceptable Joint Commission compliance is 90% Scores below 90% are in red

29. Documentation Compliance Behavioral Restraints ECU/PECUM&BH Units Audit Item20122013 (thru Oct) Audit Item20122013 (thru Oct) Timely order89%  86%Timely order100% Time-limited order74%  81%Time-limited order100%  87% Documentation of application 84%  98%Documentation of application 100% Documentation q 15 min84%  82%Documentation q 15 min100%  91% POC Revision100%  84%POC Revision100%  70% Post-restraint debriefing82%  70%Post-restraint debriefing100%  87% Note: Minimum acceptable Joint Commission compliance is 90% Scores below 90% are in red

30. But don’t let these results keep you uptight... Simply make a commitment to doing it RIGHT!

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