1. Policy and Form Updates
Restraints (TX 10)

2. This educational program is for RN’s, LPN’s, Unit Secretaries and NA’s

3. Policy and Procedure Revisions
Restraint Policy (TX 10)
Policy and Procedure
Revisions

4. What is a Restraint?
A restraint is any method of physically or chemically restricting a person’s freedom of movement, physical activity, or normal access to his or her body.
Restraints are used to prevent injury to patients and others only after all other less restrictive, reasonable alternatives have been evaluated.

5. There are 2 Categories of Restraints:
Medical-Surgical Care Restraint
applied when the primary reason for use directly supports medical healing
limited to those situations where there is a clinical justification
Behavioral Health Care Restraint
primarily used to protect the individual against injury to self or others because of an emotional or behavioral disorder
applied when non-physical interventions would not be effective

6. Potential Consequences of Restraint Use
Restraint use has the potential to produce serious consequences, such as
physical harm,
psychological harm,
loss of dignity,
violation of an individual's rights, and
even death.

7. Reducing Risks Associated With Restraint Use:
Decrease actual use through effective preventive strategies,
Using restraint alternatives,
Following clinical care protocols and procedures that protect each patient's health and safety as well as preserving each patient’s rights, dignity, and well-being, and
Utilization of process improvements in an environment that helps staff focus on the patient's well being.

8. And ALWAYS Selecting the least restrictive, safest,
most effective method,
based on an assessment of the clinical situation,
applied only by competent staff,
under the direction of the Registered Professional Nurse.

9. Risk Management
The death of a patient while in physical or under chemical restraint must be reported immediately to Risk Management.

10. Ordering Restraints
The Restraint Order form has been revised to coincide with the policy revisions.

11. Section 1 Now Lists Side Rails Under The Medical-Surgical Care Restraints

12. When Are Side Rails Considered a Restraint?
If side rails are raised and restrict the patient’s freedom to exit the bed, they are considered restraints.
Side rails are considered a safety measure when used to prevent the patient from falling out of bed (e.g., use with stretchers, recovering from anesthesia).
Side rails that can be lowered by the patient or requested by the patient and used for security, turning, or positioning are NOT considered restraints.

13. Sections 2, 3 and 4 Have NOT Changed

14. New Section 5
As placing a patient in restraints is usually associated with a change in condition, efforts should be made to contact a designated family member when this is a NEW application.
Documentation of these efforts and the name of the person contacted will be recorded in the progress notes.

15. Verbal Orders for Restraints
If a restraint is needed, an L.I.P. is immediately called and, pending arrival, a telephone order is obtained and documented in the new Section 6.
The patient MUST have an in-person evaluation within 1 hour of restraint placement, at which time the verbal order is cosigned.

16. In-Person Evaluation Attestation
A physician or a nurse practitioner MUST attest that an in-person evaluation was completed and all aspects of restraint use were appropriate.
A P.A. or R.N. may complete this 1 hour in-person evaluation ONLY if advanced competency for restraint evaluation and initiation has been achieved at Kaleida.

17. Page 2 of 2 Has NOT Changed (Used for Behavioral Care Restraint Orders)

18. Placing Restraint Orders Into PowerChart

19. Under “Add Orders,” Search for “Restraint Tracking”

20. Apply Date and Time

21. Select “Restraint Type” From The Multi-Select Field

22. And Do The Same For “Reason For Utilization” and “Duration of Orders”

23. When Discontinued, Enter “Reason,” “Date,” and “Time”

24. Additional Key Points:
Med-Surg Restraint orders are only good for 24 hours.
The R.N. may direct the release of restraints, or the reduction in restraint level, as the patient’s condition warrants.
When a restraint has been successfully discontinued, the order covering the restraint becomes inactive.
If the patient must again be restrained, a new order must be obtained, without regard to the previous order being less than 24 hours old.

25. Revisions To The “Adult Patient Care Record”

26. The Restraint Care Section Has Been Revised to Meet New Restraint Requirements

27. If restraints are not used, check the upper left hand corner
If restraints are not used, check the upper left hand corner. When restraints are used, enter the codes for Restraint Device, Alternative Interventions Attempted, and Continued/Not Re-Applied in lines 1,2, and 3. The nurse entering this data MUST enter initials in line 4.

28. The next 7 lines, indicated by the gray vertical “Initials Required” bar, are ONLY to be documented by the initials of the appropriate caregiver. Restraint release care (every 2 hours) and Med-Surg safety checks (every 30 minutes) may be initialed by Unlicensed Assistive Personnel performing them.

29. NOTE: For Med-Surg safety checks, be sure to initial EVERY 30 MINUTES
NOTE: For Med-Surg safety checks, be sure to initial EVERY 30 MINUTES. For Behavioral Health Care Restraints, safety checks are at least EVERY 15 MINUTES and are to be documented on the “Behavioral Health Care Restraint Flow” sheet.

30. Until the Critical Care Flow Sheets are Revised…
Until the Critical Care Flow Sheets are Revised…. Be sure to divide each hour block into 2 and initial Med-Surg safety checks every 30 minutes.

31. Initial Restraint Note
An initial restraint note must be written in the Progress Notes. Two examples follow.

32. Example 1 of Initial Restraint Note:
“Patient in need of posey vest as least restrictive restraint measure at this time (note must contain that this is the least restrictive restraint at the time). Patient is attempting to get out of bed and is unsteady on his/her feet. Patient is at risk of injury to self (or patient has gotten out of bed unassisted and has fallen). Verbal de-escalation, reality orientation, diversional techniques and environmental modifications have been unsuccessful alternatives (need to state what alternatives were attempted). There are no other alternatives at this time. Spoke with patient’s daughter, Mary Jones, and informed her on the necessity of the restraints and explained the need to her. She stated that she agreed and would be in shortly to stay with her mother.” (Document to whom you spoke and of what the conversation consisted.)

33. Example 2 of Initial Restraint Note:
“Patient in need of bilateral (Right or left, as one side may be flaccid) wrist restraints as the least restrictive restraint measures at this time (your note must contain that this is the least restrictive device at the time). The patient is attempting to pull out (or has pulled out) lines (IV, TLC etc.) and tubes (NG, ET, foley, GT etc.) and is at risk for injury to self. Validation techniques, reality orientation, pain management and diversional techniques have been unsuccessful alternatives (need to state what alternatives were attempted). There are no other alternatives at this time. The family (husband, Frank and son, Joseph,) have been made aware and understand the need of restraints at this time. (Document to whom you spoke and of what the conversation consisted.)

34. PLEASE NOTE: This program was only a summary of
the changes made to the
Restraint Policy & Procedure.
Please review the entire document, which is posted in your work area.

35. Restraint Re-Demonstration
For those employees who have direct hands-on patient care responsibilities, you need to attend a Restraints Skill Lab, where you will be required to re-demonstrate the correct procedure for applying restraints.
Check with your site’s Clinical Education Department for a schedule of these labs.