1. North Campus
1211 Wilmington Avenue
New Castle, PA 16105-2595
Telephone: 724.658.9001
South Campus
1000 South Mercer Street
~Ii=. Jameson New Castle, PA 16101-4673
'9 W Health System Telephone: 724.658.9001
Continuing the Tradition of Leadershzj}
in Community Health '"
Dear Physician:
Physician education for use of restraints/seclusion are part of the requirements from the
Department of Health and Joint Commission, respectively. This will involve:
A. Completing a self-learning module every year.
This is approved for 1 CME Category I credit.
Instructions for completion include:
1. Review information in the booklet
2. Complete the written exam.
3. Complete CME requirements (completion of evaluation and written
exam).
4. Return written exam and CME forms to Lori Graham.
5. Upon receipt of written exam, a certificate of completion will be sent to P.
Eppinger in the Medical Staff office in order to pursue credentialing of
this service on your behalf. A copy will be sent to you only if requested.
6. CME credits will recorded in·the database.
Thank you,
Jayne Sheehan, RN, MSN, CRNP
Director of Professional and Allied Health Education
Lori Graham, MSLS
Health System LibrarianiCME Coordinator
0112010
rsharesoncmeendmat
useofrestraints
FOR CREDIT:
MUST COMPLETE AND RETURN PAGES 29-32
(LAST FOUR PAGES) TEST AND EVALUATION
TO LORI GRAHAM -- NORTH -- LIBRARY OR TO
JHSLIBRARYCME@GMAIL.COM
2. North Campus
1211 Wilmington Avenue
New Castle, PA 16105-2595
Telephone: 724.658.9001
South Campus .
1000 South Mercer Street
~ Jameson New Castle, PA 16101-4673
""=i' W HealthSystem Telephone: 724.658.9001
Continuing the Tradition ofLeadership
in Community Health'·v
Dear Physician:
Joint Commission regulations require that physicians complete a periodic
review of our restraint policy and procedure. (A self-learning module has been
developed to enable you to complete this requirement.)
Please note the following changes to our policy which directly impacts your
area of responsibility as it relates to the management of a patient in Behavioral
Restraints.
• The requirement for a licensed independent practitioner to
conduct an in-person evaluation of the patient within one hour of
the initiation of restraint or seclusion is going to be performed by
a trained RN. (A form was developed for the RN to complete
which includes key points/requirements as per eMS guidelines.)
o This trained RN will then consult with the physician as soon
as possible after evaluation.
• The licensed independent practitioner is then responsible to re
evaluate the patient in person for continued need for restraint or
seclusion for behavioral health purposes at least once within the
following time frames:
o Every 8 hours for patients ages 18 and older
o Every 4 hours for patients ages 17 and younger
Sincerely,
Charlane Verdi, RN, BSN
Director, Community and Staff Education
CVjdmh
Attachment
3. USE OF RESTRAINTS/SECLUSION
To receive CME credits for this test, you must mark your answers,
complete the evaluation/enrollment information, and return to Lori
Graham, CME Coordinator.
Accreditation Statement
Jameson Health System is accredited by the Pennsylvania Medical
Society to sponsor continuing medical education for physicians.
This CME activity was planned and produced in accordance with
ACCME Essentials and Standards.
Designation Statement
Jameson designates this educational activity for maximum of 1 AMA
PRA Category 1 credit(s)™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
Disclosure Statement
Dr. Ali and CME Committee Members have no real or apparent
conflict of interest or other relationships related to the content of this
presentation. Disclosures are on file.
We encourage participation by all individuals. If you have a disability,
advanced notification of any special needs will help us better serve
you.
Approved by: Dr. M. Ali 12/09
Released 12/09
Expires 12/11
4. Continuing Medical Education
Elder and Care Recipient Abuse
Use of Restraints/Seclusion
Mohamed Ali, M.D.
President, Medical Staff
OBJECTIVES: At the completion of the self-learning module the
participant will be able to:
1. List factors contributing to the need for use of any
type of restraint.
2. Identify alternatives to use of restraints.
3. Identify guidelines for use of restraints or seclusion
according to hospital policy and procedure.
Approved by Dr. M. Ali 12/09
Released 12/09
5. 1
JAMESON HOSPITAL
NEW CASTLE, PENNSYLVANIA
USE OF RESTRAINTS/SECLUSION
___________________________________
President/CEO
___________________________________
President, Medical/Dental Staff
___________________________________
Nurse Executive
___________________________________
Director, Quality Management Services
___________________________________
Director, Community & Staff Education
Signatures are on file.
6. 2
JAMESON MEMORIAL HOSPITAL
NEW CASTLE, PA
TITLE: USE OF RESTRAINTS/SECLUSION
DATE: April 23, 1993 (new)
January 22, 1996 (revised)
August 19, 1998 (revised)
February 22, 1999 (revised)
May 2001 (revised)
July 2001 (revised)
October 2002 (revised)
March 2003 (revised)
November 2004 (revised)
February 2005 (revised)
April 2005 (revised)
October 2006 (reviewed)
August 2007 (revised)
October 2008 (revised)
July 2009 (revised)
SUBJECT
Restraint and Seclusion
PURPOSE/PHILOSOPHY
Congruent with the Jameson Memorial Hospital=s mission and values and with the recommendations
of external regulatory and professional agencies, the Hospital staff will advocate for seclusion and
restraint reduction. Non physical interventions should be considered before restraint or seclusion is
used. Interventions will be instituted to prevent emergency situations that may lead to restraint and
seclusion use. Restraint and seclusion will only be used with an order from a physician (including
use of the approved protocols for acute med/surg restraint) and will be limited to situations in which
there is an assessed need for its use. Patient=s rights, dignity and well being are protected during
restraint or seclusion use. Patient=s safety needs will be individually evaluated and the least
restrictive, effective type of restraint will be utilized.
There are two types of restraint recognized at Jameson Hospital. The type of restraint is not specific
to the setting the patient is in, but to the situation the restraint is being used to address. Restraints
may be used 1) in response to emergent dangerous behavior, or 2) acute med/surg which includes
the approved protocols.
DEFINITION(S)
1. Restraint - A 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; or a
drug or medication 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.
a. Examples of medications that could be used as a chemical restraint include but are not limited to
the following:
Antipsychotic Medications
First Generation
Generic Brand
Chlorpromazine Thorazine
8. 4
2. Seclusion -Seclusion is the involuntary confinement of a patient alone in a room or area from which the
patient is physically prevented from leaving.
May only be used for the management of violent or self-destructive behavior that jeopardizes the
immediate physical safety of the patient, a staff member, or others.
EXCEPTIONS
The following are not governed by this policy and are not considered to be a restraint:
1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are
considered forensic restrictions.
2. Orthopedically prescribed devices and other adaptive support devices used in response to assessed
physical needs of the patient, i.e. postural support.
3. Other methods that involve the physical holding of a patient for the purpose of conducting routine
physical exams or tests, or to protect the patient from falling out of bed.
4. Surgical dressings or bandages.
5. When a staff member physically redirects or holds a child, without permission, for 30 minutes or less.
6. Situations in which timeout is used.
7. Use of protective equipment, such as helmets.
8. Use of safety equipment, i.e. Pediatric Crib Bubble, high chair safety belt, etc.
9. To permit the patient to participate in activities for therapeutic benefits without the risk of physical harm
i.e. occupation or recreational therapy.
ASSESSMENT OF PATIENT/FAMILY IDENTIFIED CONTROL TECHNIQUES/ALTERNATIVES
TO RESTRAINT/SECLUSION USE
The following is a listing of patient identified techniques/alternatives to be utilized prior to placing a patient in
restraint or seclusion:
Χ Speak to the patient in a calm, reassuring voice
Χ Always treat the patient in a dignified and respectful manner
Χ Assess the patient=s comfort level and give care as needed. Do they need a position change? Do they
want to get up in a wheelchair, or be put back to bed? Does the patient need pain medication? Is the
patient too hot/too cold?
Χ Assess physical care needs. Is the patient hungry or thirsty? Do they need to use the bathroom? Are they
clean and dry?
Χ Is medication intervention necessary? Check PRN medications available and discuss symptoms and
behavior with the patient=s physician as needed
Χ Explain procedures carefully and assess understanding
Χ Attempt to redirect agitated patients to another topic. Reminiscence is often effective with cognitively
impaired patients.
Χ Monitor the patient closely to provide for safety and increase staff contact.
Χ Play soothing music.
9. 5
Χ Assess television to see if it has a calming or agitating affect on the patient.
Χ Place the patient in the hall close to the nursing station. Assess whether this has a calming or agitating
effect.
Χ Provide the patient with a safe diversional activity, such as an activity apron or folding washcloths.
Χ Use verbal redirection techniques.
Χ De-escalation techniques such as non violent crisis interventions.
Χ Assess environment and decrease stimuli.
PREVENTING RESTRAINT/SECLUSION USE
1. The use of non-physical techniques are the preferred method for intervening to manage patient behavior.
These techniques include redirecting the patient=s attention, verbal de-escalation, etc. Restraint or
seclusion is to be used only if the patient is at risk for physically harming himself, staff or others.
2. Staffing levels and assignments will be established to minimize circumstances that may increase restraint
or seclusion use. Staffing should be adjusted to maximize the safety of the patients who are in restraint
or seclusion. When developing staffing levels and/or assignments, at least the following factors will be
considered:
Χ Qualifications of the staff
Χ Physical layout of the unit/department
Χ Patient-specific factors including diagnoses, age, co-occurring conditions, and
developmental/functional level
Guidelines When Using Restraint or Seclusion
1. Behavior management restraint/seclusion use is limited to emergencies in which there is imminent risk
of harm to self and/or others.
Χ During the first hour of restraint and seclusion use, the patient is monitored by 1-1 staff.
Χ Must get patient=s permission to use audio/visual equipment to monitor the patient after the first
hour.
2. Acute medical surgical restraint is limited to situations in which the restraint directly supports the
medical healing of the patient. The patient=s behavior is non-violent and non-aggressive.
3. Restraint will be implemented in the least restrictive manner.
4. The use of restraint/seclusion will be addressed in the patient=s plan of care and/or treatment plan.
5. If the patient is in a physical hold for Behavioral Health purposes, another staff person who is trained
and competent in the use of restraint and seclusion and who is not involved in the physical hold is
assigned to observe the patient.
PHYSICIAN=S ORDERS
1. Orders for restraint and seclusion must be either written or verbally given by a licensed physician or
Trained Allied Health Professional..
2. Orders can never be written as a PRN or as a standing order.
10. 6
3. If the restraint/seclusion is not ordered by the patient=s treating physician, he or she must be consulted
as soon as possible after the restraint/seclusion is applied.
4. Orders for restraint/seclusion must contain the following elements:
Χ Date and time
Χ Reason for restraint/seclusion
Χ Type of restraint
Χ Duration (time limit) for restraint
Χ If phone order, signature of RN writing order
Χ The physician or trained allied health professional signature
5. The time limits for restraint and seclusion orders are as follows:
Χ For acute medical/surgical restraint = up to 24 hours (TCU - 30 days)
Χ For behavior management restraint =
Up to 4 hours for adults 18 yrs and older
Up to 2 hours for ages 9-17 yrs
Up to one hour for children under 9 yrs
6.
Χ Evaluate the immediate situation
There must be a written physician=s order for a protocol generated restraint.
7. For acute medical/surgical restraint, a physician must be notified as soon as possible of initiation and a
written or phone order must be obtained. If the restraint was initiated due to significant changes in
the patient=s condition, the physician must be notified immediately.
8. When applying restraints for behavior management, the physician, trained allied health professional, or
trained registered nurse must see the patient face to face and evaluate the need for restraint/seclusion
within one hour after initiation of the intervention. Purpose of this evaluation:
Χ Evaluate patient=s reaction to the intervention
Χ Evaluate the patient=s medical and behavioral condition
Χ Assess the need to continue the restraint or seclusion
Χ If evaluation is done by the trained allied health professional, the physician responsible
must be consulted ASAP after the completion of the evaluation.
If the patient recovers quickly and is released from restraint/seclusion within the first hour of use,
the physician must still complete the one hour face to face evaluation.
a. If the restraint or seclusion is discontinued prior to the expiration of the original order, a new
order must be obtained prior to re-initiating seclusion or reapplying restraint.
PROTOCOLS (for use with acute medical/surgical restraint only)
1. A protocol has been developed for use of restraints during the treatment of certain specific
medical/surgical conditions or the use of certain clinical medical/surgical procedures.
2. Our protocol includes guidelines that address:
Χ Criteria for applying restraint
Χ Criteria for monitoring the patient in restraint
Χ Criteria for reassessing the need for restraint
11. 7
Χ Criteria for the termination of restraint
3. The use of restraint requires an individual physician=s order. Reference is made to what protocol is in
use in the patient=s medical record. A copy of the protocol
INITIAL ASSESSMENT OF THE
as well as evidence of the physician=s order
will be on the chart. Additionally, a face to face evaluation by a licensed physician within 24 hours of
initial order must be completed. This order must then be renewed once each calendar day.
Χ Techniques, methods or tools that would help the patient control his or her behavior.
BEHAVIORAL MANAGEMENT PATIENT
1. During the initial assessment of the patient, the following information will be determined:
Χ What pre-existing medical conditions or physical disabilities/limitations exist that may place the
patient at risk during restraint or seclusion?
Χ If there is a history of physical and/or sexual abuse that would place the patient at greater
psychological risk during restraint or seclusion.
2. The patient will be informed of the organization=s philosophy at the time of admission unless the
patient=s behavior prohibits this discussion.
RESTRAINT APPLICATION
The following restraints used at Jameson Hospital are listed from least restrictive to most restrictive:
Χ seclusion
Χ 3-4 siderails
Χ mitts
Χ waist belt
Χ gerichair
Χ vest
Χ soft limb - 2 extremities
Χ soft limb - 4 extremities
Χ (Locked) restraints
Please see related procedures for the appropriate application of these restraints.
If restraint or seclusion is being applied for behavioral management,
Χ the patient=s family is to be notified promptly following application IF the patient has consented to this
notification prior to the episode.
REASSESSMENT
1. Restraint and seclusion should be ended at the earliest possible time.
2. The patient must be made aware of the expected behaviors or criteria that will result in the removal of
the restraint or seclusion.
3. A face to face re-evaluation by a physician or trained allied health professional must be conducted at
least every 24 hours for the patient in med/surg restraint.
12. 8
4. The continued need for the use of restraint and seclusion will be reassessed and documented at the
following frequency:
Χ for med/surg restraint - every 2 hours
Χ for behavior management restraint - every 15 minutes
5. For the patient in a behavioral management restraint (for violent or self destructive behavior), the
licensed independent practitioner must conduct an in person re-evaluation at least every 8 hours for
patients 18 years and older and every 4 hours for patients 17 years or younger. If provided for in the
initial order, a Registered Nurse may perform a reassessment and make a decision to continue the
original order every 4 hours up to 8 hours.
6. For the patient in a behavioral management restraint, clinical leadership will be immediately notified of
any instance when a patient is in restraint and/or seclusion for more that 12 hours or when a patient has
experienced 2 or more separate episodes of restraint and/or seclusion within a 12 hour period.
NOTIFICATION MUST OCCUR EVERY 24 HOURS THEREAFTER WHEN THE USE
CONTINUES. Clinical leadership is responsible for assessing whether any opportunities exist for the
discontinuation of use. This may be accomplished by adding additional resources, readjusting staffing
levels, etc.
MONITORING
1. Patients in restraint or seclusion are assessed and assisted.
2. A trained staff member assesses the patient at the initiation of restraint or seclusion and routinely as
follows:
a. At a minimum, the following parameters are monitored and documented:
Protocol restraint Behavioral restraint
Respirations every 2 hours every 15 min
Circulation and range of motion every 2 hours every 15 min
in the extremities
Hydration needs/nutrition every 2 hours every 15 min
Elimination needs every 2 hours every 15 min
Signs of Injury, every 2 hours every 15 min
i.e. skin integrity
Assess physical and psychological every 2 hours every 15 min
status and comfort.
Readiness for discontinuation of every 2 hours every 15 min
restraint or seclusion.
4. Hygiene needs are provided each a.m. and p.m.
5. The actual monitoring may be delegated to assistive personnel with oversight by the registered nurse.
However, the registered nurse is responsible for reassessing the behavior
13. 9
and need for continued restraint.
6. If restraint and seclusion are used simultaneously, the patient must be continually monitored either face
to face by an assigned staff member OR by a staff member using both video and audio equipment. The
staff member must be in close proximity to the patient and all areas of the room must be visible.
DISCONTINUATION AND REMOVAL OF RESTRAINTS
1. Restraints and seclusion should be ended at the earliest possible time.
2. When the patient in behavior management restraint or seclusion meets the behavioral criteria for
removal as assessed by the registered nurse, the restraint or seclusion is discontinued.
A. A new order must be obtained for any new episode.
3. Patients in medical surgical restraint, either by order or by protocol, will be continually assessed for the
opportunity for removal of restraints. This reassessment should be documented at least every 2hours.
Restraint should be discontinued when the clinical treatment is discontinued (lines removed, extubated,
etc.) or the patient=s actions no longer warrant the need for restraint.
A. A new order must be obtained for any new episode.
4. For patients in a behavioral management restraint, a debriefing session will be scheduled following
each episode of restraint or seclusion. The patient and the staff involved in the episode will meet as soon
as is possible (but no longer than 24 hours after the episode) to review the following issues:
Χ What could have been done differently to prevent this episode?
Χ Was the patient=s physical well being, psychological comfort, and right to privacy addressed
during the episode?
Χ Was there any trauma (psychological or physical) experienced by the patient during the episode?
If so, then provide counseling or treatment.
Χ What modifications to the treatment plan need to be made to help prevent another episode of
restraint/seclusion from occurring?
Information obtained from debriefing is used in Performance Improvement activities.
DOCUMENTATION
The following will be included in the documentation of each episode of restraint and seclusion:
Χ The patient=s behavior prior to restraint/seclusion
Χ Interventions used and alternatives tried and/or considered
Χ The rationale for the use
Χ The type of restraint
Χ Family/significant other notification of restraint use
Χ Revision to the plan of care
Χ Patient/family education provided regarding need for restraint/seclusion
Χ The patient=s/family=s understanding of the criteria that must be met for the removal of
restraint/seclusion
Χ Any injuries sustained during the process, if applicable
Χ Protocol in use, if appropriate
14. 10
Physician Responsibilities:
Χ Time limited order addressing reason for restraint/seclusion and device to be used
Χ Signed verbal orders for restraint/seclusion
Χ Documentation of the results of the assessment of the patient and the rationale for the continued use of
restraint. This assessment should be documented at least every 24 hours for medical surgical restraint.
For behavioral restraint: 1) Following the one hour face to face assessment and every 4 hours if patient
18 years old or older, unless physician has authorized RN to complete every 4 hour reassessment.
2) Every 2 hours if the patient 17 years of age or younger. 3) Every one hour if patient age 9 or less for
behavior management restraint. This documentation includes the physical and psychological status of
the patient, any changes to the treatment plan, and any guidance to the staff for helping the patient gain
control.
ELECTROCONVULSIVE THERAPY
Electroconvulsive and other forms of convulsive therapy are used with adequate justification, documentation,
and regard for patient safety.
PATIENT AND STAFF SAFETY
1. Food and Nutrition Therapy products are distributed and administered in a safe manner.
2. The patient environment should be free of all objects in room that have potential for harm to
patient or others.
STAFF EDUCATION
Only an RN can make decisions about, implement and oversee the monitoring of restraint use.
All direct patient care staff are trained, oriented, receive ongoing training and are competent to minimize
the use of restraint/ seclusion and when restraint use is indicated, to use them safely.
PHYSICIAN EDUCATION
Physicians are educated about the Restraint and Seclusion policy.
EMERGENCY MEASURES
A. If an emergency health situation (e.g., seizure) occurs, the patient must be immediately released
from restraint or seclusion as soon as possible as dictated by the emergency.
B. Procedures to ensure proper management of these patients during evacuation for disasters are in
place.
C. All staff who have direct care responsibility receive bi-annual training in CPR.
PATIENT AND FAMILY EDUCATION
The patient and family, when appropriate, are educated on the use of restraint. Patient and family
education includes:
1. An explanation of the patient=s behavior that may cause restraint use;
15. 11
2. An explanation of how restraints may be used to maintain needed therapies;
3. A discussion of the alternatives to the use of restraints;
4. Possible patient and family participation in the care that could limit or halt restraint use;
and
5. The patient=s preferences should be incorporated whenever possible.
PERFORMANCE IMPROVEMENT
1. Restraint use is high risk and problem prone; therefore, reducing the frequency of restraint use is a
high priority. Administrative staff will analyze aggregate data relating to restraint use, including
audits on every episode to trend restraint data, e.g. which shift, reason for restraint, which staff
initiated, etc. Information obtained from this audit will be used to determine what measures are
likely to be effective in reducing restraint use. As appropriate, Performance Improvement tools will
be utilized to evaluate these measures and data. Administrative staff will specifically look for
triggers, such as multiple restraint episodes for individual patients and the frequency of restraint use
by types of staff. These triggers alert the staff to immediately review the patient care situation.
2. The chart of each patient in restraint/seclusion is monitored by Administrative staff. A
restraint/seclusion log and review form is completed and becomes part of the computer database.
Results from the monitoring activities are reported to the appropriate hospital committees.
3. If a patient dies while in restraint or seclusion, within 24 hours after restraint removed or death
within 1 week - restraint/seclusion contributed, or it is reasonable to assume that the patient=s
death is a result of the restraint or seclusion, the event will be reported to the Risk Management
Department and to the appropriate authorities, including the PA Department of Health and
Patient Safety Authority within 24 hours. The event will also be reported to the Sentinel Event
Committee for consideration as a reportable event to JCAHO.
(R:Allnursinghwptcarerestrseclpolicy)
Attachments:
Physician Restraint/Seclusion Order Sheet - (See Softmed)
Restraint/Seclusion Observation FlowSheet - (See Softmed)
Artificial Airway and Invasive Line Restraint Protocol for Medical/Surgical Symptoms
Patient and Family Guide to Restraint (See Softmed)
Debriefing Documentation Form - (See Softmed)
Debriefing Documentation Procedure (See Softmed)
Restraint Monitor Definitions (on units)
Restraint Monitor (on units)
16. JAMESON HOSPITAL
NURSING
PROTOCOL/ ORDER
Artificial Airway and Invasive Line Restraint Protocol for Medical/Surgical
Symptoms
PURPOSE: To outline staff responsibility for assessment, intervention and evaluation
LEVEL: Independent
POLICY:
Based on assessment of needs and in accordance with the Restraint Policy, this
protocol is instituted for all patients who meet the following criteria whom under the
circumstances, the potential risks of restraints are felt to offset by the potential benefits
of patient outcome.
PROCEDURE:
This protocol is instituted when the following criteria are met:
A. Presence of one (1) of the following:
1) Artificial airway
Endotracheal tube
Tracheostomy
2) Maintenance of invasive lines / medical / surgical interventions on
patients who lack ability to comprehend danger and/or benefit.
The following are examples but are not limited to:
a) Swan Ganz catheter
b) Central venous pressure line
c) Arterial line
d) Hemodialysis catheter
e) Peritoneal catheter
f) Keofeed/nasogastric tube used for nourishment
and/or medication administration
g) Gastric tube
h) Intravenous line needed for nutritional or medication
support
i) Urinary catheter
j) Surgical incisions, drains, ostomies
17. B. Risk of harm if invasive lines dislodged and/or loss of patient airway if airway
removed.
C. One or more of the following observed and documented regarding patient’s
status:
Inability to follow directions
Observed direct attempts to remove airway or invasive lines
Alternatives to restraints tried and failed
FOLLOWING RN ASSESSMENT, PHYSICIAN ORDER TO IMPLEMENT IS
OBTAINED.
All patients are monitored according to the Restraint Policy/Procedure with
documentation on the Restraint Observation Flow Sheet. Copy of protocol to be placed
in medical record.
All patients are reassessed by Registered Nurse for continuance of protocol as per
Restraint Policy.
Patients are removed from restraint when the protocol criteria is no longer met.
REFERENCE: Hospitalwide Restraint Policy/Hospitalwide Restraint Procedure
APPROVAL: 4/01
REVIEWED: 10/02; 3/03; 11/04; 4/05; 10/06; 10/07; 10/08; 7/09
REVISED: 7/01; 9/01
APPROVAL:_____________________________________
President Medical/Dental Staff
APPROVAL:_____________________________________
Nurse Executive
APPROVAL:_____________________________________
CEO
APPROVAL:_____________________________________
Director, Community and Staff Education
APPROVAL:_____________________________________
Director, Quality Management Services
Signatures are on file.
18. JAMESON HOSPITAL
RESTRAINT MONnOR DEFINITIONS
MR # = Medical Record Number
Patient Name= name of person in restraints
Gender = male or female
Age = age of patient
Unit = Department where restraint initiated
Day of the week = Day of week-restraint episode initiated
Shift who initiated the process =shift that initiated restraint, i.e. (7:00 - 3:00, 3:00 - 11 :00 or 11 :00
- 7:00)
Staff who initiated the process = Initials of staff member who placed the patient in restraints.
Reason= As indicated by patient condition and as stated on physician order sheet
B=Behavior (emerglency use-patient's danger to themselves or others)
(Patient is confused and cannot be re-directed and has been
observed pulling lines or tubes)
P=Protocol (patient at risk for pulling lines or tubes)
SEC = Seclusion
Type of restraint:
• L-Limb (2=2 Limb)
• M=Mitt
• W=Waist belt
• V=Vest
o S=Siderails
• G=Gerichair
• C=Chemical
• (Behavior restraint only)
• Y=locked restraint
• 4=4 Limb
Physician Order:;: order by physician or trai,ned aillied health professional on chart and complete
(utilize restraint physician order form)
Date & Time of episode Start = Date and time episode initiated
Date & Time of episode Stop = Date and time episode ended
A Written Order/Physician Exam of Patient is completed within 24 hours of the initiation of restraint.
(No phone order)/Renew order every 24 hours.
Length of episode = Number of hours patient in restraint or within each calendar day
Number of episodes =Include number of episodes (each physician order for restraint).
Flow Sheet completed properly = encompasses:
• Routine assess and monitoring parameters (q 2 hours-med surg/q 15 min-behavior)
• Patient teaching completed and notification of family
19. Protocol on chart = Protocol which contains criteria for patient pulling at lines/tube - placed in chart.
Notification of Family = Family notified as approp~iate .
Patient/Family Education = Provided to patient/family as appropriate and documented on flow
sheet.
Injuries sustained by patient or staff - note any injury sustained by patient or staff while patient in
restraints.
Death while in restraints or within 24 hours of restraint =Please note if patient expiration occurs
while patient is in restraints or if death occurs within 24 hours of a restraint episode.
NOTE: Transferred patients should be recorded on log. Example: Patients received from ER
in restraints should also be recorded in the receiving unit log as patient received in restraints.
Upon restraint removal please return restraints to ED.
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1
BEHAVIOR RESTRAINTS ONLY
Behavior Restraints only - face to face evaluation by physician or trained Allied Health Professional
within 1 hour. Requirements fo~ Behavior restraints - MD/AHP documentation/note on restraint order
form or physician progress record.
Use of Psych meds as an alternative or to enable DIG - meds used as an alternative to physical
restraints or to enable D/e of restraints
Number of episodes greater than 12 hours - Multiple instances of restraint or seclusion
experienced by a patient within a 12 hour time frame or extending beyond 12 consecutive hours.
*Includes notification of clinical leadership (peM or Administrative Supervisor) for any behavior
restraint.
Debriefing - Ensure documentation that debriefing was conducted with patient and family as
appropriate and involved staff within 24 hours of restraint episode. Utilize debriefing documentation
form to capture required elements.
Revised 3/05; 4/05; 9/05; 12/07; 3109
20. Jameson Hospital
New Castle, Pennsylvania
Patient & Family Guide to Restraint
Our Goal
While it is Jameson Hospital's goal to be as restraint-free as possible and to use the
least restrictive means of restraint possible to maintain patient safety, it sometimes
becomes necessary to use a physical device to temporarily limit a patient's
movement or access to their bodies in order to support the medical healing of the
patient.
When & Why are Restraints Used?
A physician may order a restraint to be used when patients are confused or
disoriented to the degree that they cannot make safe decisions and may accidentally
or purposefully harm themselves or others. They may be agitated, hostile or
abusive to staff and other patients evidenced by biting, hitting, kicking or scratching
others. They may grab at tubes or dressings, be at risk of falling or hurting
themselves, or unable to be managed by non-restraint methods. Some medications
or illnesses can also cause confusion. A patient may not remember where he or she
is or why he or she is there.
Whichever method of restraint is used fot our patients, our staff will provide the
most respectful and least restrictive application as possible.
What Types of Restraints Are Used?
Many types of restraints are available. Each type has a purpose. Very strict
guidelines state how a restraint can be used, and for how long. Hospital policies
permit various types of restraints. They are only used after a complete assessment
of the patient's needs has been made and are then individualized to meet the specific
needs of each patient. You may come in contact with one or more of the following
restraints during your stay:
0 Mitts
0 Soft wrist restraints
0 Wrap around belts
0 Vest restraints
0 ThreelFour bed rails
0 Geri-chair with tray
21. Our staff and physicians will use the least restrictive restraint required to meet the
patient's needs.
Health care providers should do the following:
D Use restraints only after other alternatives have been tried
D Choose the least limiting restraint possible
D Check the skin under the restraint often
D Keep the call button within the patients reach when a restraint is in
place
D Remove the restraint as soon as it is no longer needed.
D Preserve the patient's dignity.
What Are the Alternatives to Using Restraints?
Except in emergencies, our first goal is for the patient to remain restraint free.
Some examples of non-restraint methods may include:
D Bowel and Bladder assessment
D Frequent observation
D Eliminating tubes and IV's as soon as possible or covering tubes while
in place
D Family involvement
D Bed/Chair alarms
D Diversional activities such as TV, radio and activity aprons
D Other activities and programs
D Room change
D Pain management review
Family Notification & Involvement
Because we want our patients to remain as restraint-free as possible, family may be
notified when restraints must be applied. In some cases, your involvement may be
requested. Sometimes a familiar voice is all the patient needs to remain calm and
safe. Your assistance is greatly appreciated in helping us keep your loved one as
restraint-free as possible.
Reviewed 9/07
Revised 3/09
5104
22. DEBRIEFING DOCUMENTATION PROCEDURE
In an attempt to reduce the recurrent use of restraint and/or seclusion, a
debriefing session will be held with the staff, patient and , if appropriate, may
include the patient's family. The debriefing will take place as soon as appropriate
but no longer than 24 hours after the behavioral episode ends. A debriefing will
take place after each episode when multiple behavioral episodes occur. Include
the time/date of the restrainUseclusion episode and the time/date of the
debriefing episode.
1. Using the questions as cues on the debriefing form , the patient and/or
staff will be asked to respond honestly.
2. The debriefing is used to identify what led to the episode and if it could
have been handled differently.
3. Ascertain that the patient's physical well-being, psychological comfort, and
right to privacy were addressed .
4. Counsel the patient for any trauma that may have been a result of the
episode.
5. When indicated, modify the patient's plan for care, treatment and services.
6. Use the information for quality improvement opportunities.
Names of all involved in the debriefing will be noted on the debriefing form.
Additional Steps:
1. For patient transfers, i.e. to Behavioral Health, Inpatient Unit or CCU:
a. Staff involved in restraint episode to complete questions 1 and 2 on
debriefing form prior to patient transfer and document their initials
and date next to documentation followed by complete signature at
bottom of form.
b. The receiving unit staff to contact Behavioral Health staff who will
serve as facilitators to complete questions 3, 4, and 5 with patient
based on the patient's ability to participate.
2. For non-patient transfers, uniUdepartment staff to complete questions 1-5.
7/12/05
Revised 10/06; 2/08; 10/08
Reviewed: 10/09
23. JAMESON HOSPITAL
NEW CASTLE, PA 16105
RESTRAINT/SECLUSION OBSERVATION FLOWSHEET
H. Observation Behavior q 15 min Artificial Airway/lnvasive Line Protocol~ 2 hours
Date Time ROM CSM Head
of
Bed
30'
Release
Restraint
wfa
Assess
Elimination
Offer
Nutrition /
Hydration
Hygiene
AM/PM
Assess
Signs of
Injury
Assess
Resp
Comments
'Assess Physical and
Psychological Status and
Comfort
'Readiness for discontinuation
Initials
C S M
I
o Restraints continued - see Observation Flowsheet Addendum for "Behavioral Restraints ONLY" q 15 min assessments
BEHAVIORAL RESTRAINTS ONLY
Criteria for RN to Discontinue Restraints
o Patient verbally contracts with staff to ensure safety of self/others 0 Patient is re-oriented/demonstrates ability to follow
direction(s) necessary for safety
*A debriefing occurs as soon as possible fol/owing behavioral restraint but no longer than 24 hours after the episode.
Date Time RN Signature ___________~________
*If restraint/episode >12" or 2 or more separate episodes, notify Patient Care ManagerISupervisor____________
Notified by RN Signature __________________:--________DatelTime _________
General Key
v Done
- Offered and Refused
N/A Not Applicable
+ Offered and Accepted
CSM Key
Color Sensation Movement
1 Pink 1 Good Sensation 1 Able to move affected limb
2 Pale 2 Diminished/Numb/or Tingling 2 Unable to move affected limb
3 Cyanotic
25-4038 (Rev. 11/03; 12/04; 4105; 6/07; 9/09) NSG-1030
24. JAMESON HOSPITAL
NEW CASTLE, PA 16105
RESTRAINT/SECLUSION OBSERVATION FLOWSHEET
ADDENDUM
o Reassessed by _________________ RN
o Reassement Date _______
Continued use of restraints/seclusion is clinically justified because patient remains:
o High risk of injury to self 0 High risk of injury to others 0 High risk of causing substantial property damage
o Other' see nurses notes
H. Observation Behavior q 15 min Artificial Airway/Invasive Line Protocol q 2 hours
Date Time ROM CSM Head Release Assess Offer Hygiene Assess Assess Comments Initials
of
C S M
Bed
30·
Restraint Elimination
w/a
Nutrition / AM/PM Signs of Resp 'Assess Physical and
Hydration Injury Psychological Status and
Comfort
'Readiness for discontinuation
BEHAVIORAL RESTRAINTS ONLY
Criteria for RN to Discontinue Restraints
oPatient verbally contracts with staff to ensure safety of selflothers 0 Patient is re-oriented/demonstrates ability to follow
direction(s) necessary for safety
*A debriefing occurs as soon as possible following behavioral restraint but no longer than 24 hours after the episode.
Date Time RN Signature _ ___________________
* If restraint/episode> 12° or 2 or more separate episodes, notify Patient Care ManageriSupervisor---:=_-=__________
Notified by RN Signature DatelTime _________
General Key
v' Done
- Offered and Refused
N/A Not Applicable
+ Offered and Accepted
CSM Key
Color Sensation Movement
1 Pink 1 Good Sensation 1 Able to move affected limb
2 Pale 2 Diminished/Numb/or Tingling 2 Unable to move affected limb
3 Cyanotic
25-4038 (Rev. 11/03; 12/04; 4/05; 6/07)
25. JAMESON HOSPITAL
NEW CASTLE, PA 16105
RESTRAINT/SECLUSION OBSERVATION FLOWSHEET
o Initial Assessment
Assessed by _______________RN Signature
Documentation of Behavior:
Date: Time:
A. Clinical Justification For Use of Device (Check All That Apply):
o High Risk of Injury to Self (behavior)
o High Risk of Injury to Others (behavior)
o High Risk for Causing Substantial Property Damage (behavior)
o Artificial Airway/Invasive Line Protocol
(Risk of injury to self due to attempts at Removing Lines, Tubes, Equipment, etc.)
B. Assessment of Patient/Family Identified Control Techniques/Alternatives To Be Used Before Restraining
(Denote by checking "P" for Patient Identified Techniques OR "5" for Staff Generated Alternatives):
oP o S Snacks
OP oS Reduced Environmental Stimuli OP OS Provided Diversional Activity
OP OS Bowel/Bladder Assessment OP OS Assistance From Family
[ IP oS Wedge Cushion OP OS Reassessment of Medications, Labs, & Physiologics
OP oS Freedom Splint (1) OP oS Encouraged Patient to Express Concerns
OP oS Skin Sleeve OP oS Pain Management Review
oP oS Music/TV OP OS Bed/Chair Alarm
oP oS Exercise OP OS Cover Invasive Tubes
OP oS Self Release Device OP OS Patient Education
oP oS Reality Orientation OP oS Companionship
OP oS Low Bed OP OS Other
C. Reason For Use of Restraint and Teaching Tool Given To:
o Patient o Family Member
D. Type of Restraint (Check All That Apply):
[I Least Restrictive
o Lap Buddy
o 3-4 Siderails
o Gerichair
o Freedom Splints (2)
o Other
o Cloth Mitts
o Right Hand
o Left Hand
o Other (Specify):
o Physical Hold
(CriSis
Intervention
Approved)
o Soft Limb
o Right Hand
o Left Hand
o Right Leg
o Left Leg
o Waist belt
o Vest
E. o When restraint and seclusion are used simultaneously the patient is monitored:
o Verbalizes Understanding
o Locked o Seclusion
Restraints
o Right Hand
o Left Hand
o Right Leg
o Left Leg
o Waist Belt
1:1 by stafffor 151
hour; after 1 hour, audio and visual monitoring can be done with patient awareness
F. Episode Definition: Each time a physician's order is written for restraint.
G. For Behavior Restraint Only: Assure exam by physician, trained Registered Nurse within 1 hour of initiation of restraint
. . . .. . .
*If prOVided for In the initial order, a Registered Nurse may perform a reassessment and make a deCISion to continue the onglnal
order for the next 4 hours up to 8 hours.
*The phYSician then conducts an in-person re-evaluation at least every 8 hours for patients 18 and older and every 4 hours for
patients 17 and younger.
26. JAMESON HOSPITAL
NEW CASTLE, PA 16105
PHYSICIAN RESTRAINT/SECLUSION ORDER
SHEET
Restraint/seclusion may not be ordered PRN Progress Notes
1. 0 Assessment ~ertaining to need for restraint/seclusion
(includesprecautions thatplace patient at greater risk).
2. REASON:
o Artificial Airway/Invasive Line Protocol (MIL)
o Behavior
TYPE OF RESTRAINT:
o Restraint o Seclusion
3. RESTRAIN PATIENT WITH:
Locked restraints Least Restrictive
o 2-point o Mitts
o4-point o 3-4 siderails
oWaist belt o Gerichair
Soft restraints
o(L) arm o (L) leg o Other
o (R) arm o ( R) leg
oWaist belt o Vest
Chemical restraints
o Drug: (Behavior restraint only)
Name of medication:
4. RATIONALE FOR RESTRAINT/SECLUSION:
o Danger of injury to self/others (behavior)
[I High risk for causing substantial property damage (behavior)
oMIL Protocol (risk of injury to self due to attempts at removing lines, tubes,
eguipment, etc.)
o Other
5. Patient to be restrained/secluded for:
Initiation time Termination time
6. PROTOCOL (ARTIFICIAL AIRWA YIINVA SIVE LINE PROTOCOL)
024 hours (Max)
oA face-to-face evaluation conducted by a Licensed Physician within 24 hrs of
initial order
7. BEHAVIOR RESTRAINTS ONLY:
04 hours (Max. for behavioral conditions) Adults 18 years & older
o 2 hours - ages 9-17 years
o 1 hour - children under 9 years
o Face to face exam by Licensed Independent Physician/trained Advanced Practice
Professional or trained RN within 1 hour
o Qualified RN may perform reassessment in 4 hrs up to 8 hrs
o The physician then conducts an in-person re-evaluation at least every 8 hrs for
patients 18 and older and every 4 hrs for patients under 17
o Criteria for RN to discontinue behavior restraint
1. 0 Patient verba "l' contracts with staff to ensure safety to self/others
2. 0 Patient is reoriented/demonstrates ability to follow direction(s)
for safety
o Contact Nutritional Services to order "Behavior Tray"Jno utensils/chinaj
o Remove all objects in room that have potential for harm to self or others
DatelTime
Physician Signature
Revised 6/11/07; 8/7/07; 9/09 EDU-1100
27. Jameson Memorial Hospital
New Castle, PA 16105
Debriefing Documentation Form
Date and Time Restraint or Seclusion Initiated:
Date and Time of Debriefing:
1. What led to the use of restraint and/or seclusion?
2. What could have been handled differently?
3. Did the patient feel the following was addressed:
Physical well being Yes 0 No 0 If no, explain:
Did any injuries occur? Yes 0 No 0 Ifyes, explain:
Psychological comfort Yes 0 No 0 If no, explain:
Right to Privacy maintained Yes 0 No 0 If no, explain:
4. Describe any discussions/counseling done with the patient (therapeutic rapport/patient contract):
a. To avoid the use of restraint/seclusion use in the future, what can patient commit to in an
effort to allow staff to help them when they are out of control?
b. So that patient does not require restraint or seclusion in the future, list 3 things that staff could
do to help patient when they feel out of control.
5. Was the treatment plan modified to reflect the use of seclusion/restraint? Yes 0 NoD If no, explain:
Names of patient, staff and/or family (with consent) involved in this debriefing:
*Original to be placed on patient record.
*Copy sent to Quality Improvement Dept.
7112/05 Revised: 10/06; 2/08; 10/08
Signature________________ ___
Facilitator conducting debriefing session
Signature ___________________
Other staff involved in restraint episode/debriefing
28. Page left blank
Please do the next two pages, from and back of each. One is the test and the other is the evaluation.
Please return the evaluation and test to Lori Graham via Courier to the Library, email or fax.
lgraham@jamesonhealth.org
Fax: 724-656-4267 or x4267 internally
29. JAMESON MEMORIAL HOSPITAL
NEW CASTLE, PENNSYLVANIA
Use of Restraints/Seclusion Written Exam
Name: _____________________________ Date: ______________________
1. The type of restraint used is not specific to the setting the patient is in, but to the
situation the restraint is being used to address.
A) True
B) False
2. Two (2) types of restraints recognized at Jameson are:
A) Acute medical/surgical restraints
B) Behavioral management restraint/seclusion
C) A & B
3. Restraints may be used in which of the following situations:
A) Management of violent or self-destructive behavior
B) When the patient is a threat to self or staff
C) Risk of injury due to attempts at removing lines, tubing, equipment,
etc. in the acute care setting.
D) All of the above.
4. Which of the following is not an alternative to restraint/seclusion use:
A) Speaking to the patient in a loud voice.
B) Explain procedures carefully and calmly.
C) Play soothing music.
D) Use of verbal redirection techniques.
5. Which of the following is true regarding physician orders for restraint/seclusion:
A) Orders must be written or verbally given by a licensed physician or a
trained Allied Health Professional
B) Orders for restraints/seclusion can never be written as a standing order
or as PRN
C) Patients in restraints for behavior management must have a face to
face evaluation within one hour after initiation of intervention.
E) All of the above.
6. If a patient recovers quickly and is released from restraint/seclusion within the
first hour of use, the physician must still complete the one-hour face-to-face
evaluation?
A) True
B) False
30. Use of Restraints/Seclusion
Written Exam
Page 2
7. The physician must document which of the following:
A) Results of assessment of the patient and rationale for use of restraints.
B) Date and time of restraint/seclusion order.
C) Type of restraint.
D) All of the above.
8. A trained RN may complete the one-hour face-to-face evaluation of the patient in
restraints.
A) True
B) False
9. For a patient in behavioral restraint, the licensed independent practitioner must
conduct an in-person re-evaluation:
A) At least every eight (8) hours for patients 18 years and older
B) Every four (4) hours for patients 18 years and younger
C) At least every 12 hours for all patients
D) A & B
01/2010
rsharecmeendmaterial
restraints
31. Both pages of the evaluation must be filled out 1
Created 11/09
CME Program Evaluation
Evaluation must be completed and turned in for certificate.
Program Title: Restraint / Seclusion (Enduring Material) Speaker/Presenter: Quality Management
Date/Time: N/A Location: N/A
Learning Objectives:
1. List factors contributing to the need for use of any type of restraint.
At the conclusion of the presentation, the participant should be able to:
2. Identify alternatives to use of restraints.
3. Identify guidelines for use of restraints or seclusion according to hospital
policy and procedure.
Please rate the following… Excellent Good Fair Poor
Overall activity…
Clarity of session content…
Relevance of content to you…
Quality of visual aids/handouts…
Presenter’s overall performance…
Presenter’s knowledge of subject area…
Presenter’s presentation skills…
Presenter’s ability to respond to questions…
Location of CME activity…
Statement of changes this program has made on your practice.
Some questions allow for more than one answer.
1. This activity will assist in improvement of:
□ Competence
□ Performance
□ Patient Outcomes
2. I plan to make the following changes in my practice by:
□ Modifying treatment plans.
□ Changing my screening/prevention practice.
□ Incorporating different diagnostic strategies into patient evaluation.
□ Using alternate communication methodologies with patient and families.
Please describe the change in communication:
□ Other.
□ None. This activity validated current practices.
3. What is your level of commitment to making the changes stated above?
□ Very committed
□ Somewhat committed
□ Not very committed
□ Do not expect to change practice
32. Both pages of the evaluation must be filled out 2
Created 11/09
4. What are the barriers you face in your current practice setting that may impact patient outcomes?
□ Lack of evidence-based guidelines
□ Lack of applicability of guidelines to current practice or patients
□ Lack of time
□ Organizational or Institutional
□ Insurance or Financial
□ Patient Adherence or Compliance
□ Treatment related to adverse events
□ Other: Explain
5. This activity supported achievement of the learning objectives.
□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree
6. The material was organized clearly for learning to occur.
□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree
7. The content learned from this activity will impact my practice.
□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree
8. The activity was presented objectively and free of commercial bias.
□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree
If you answered Disagree or Strongly Disagree to any of the statements above, please explain your disagreement with
the statement(s) in space below. Any other comments about today’s program can be made here also.
Please print your name Specialty
