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Restraint Policy at a Glance

Restraint Policy at a Glance - Clinical Hub, Patient Safety, Nursing Quality and Safety Resources, Restraint Resources and Tips

Focus

 

Non-Violent and/or Non-Self Destructive Behaviors

Violent or Self Destructive Behaviors

Definition

Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely.

Behavior

Behavior that could be classified as irrational or uncooperative, such as:

  • interfere with a treatment or device (lines tubes, drains)
  • cognitive impairment
  • alcohol withdrawal

Violent or self-destructive behavior:

  • jeopardizes the immediate physical safety of the patient, a staff member or others 
  • unanticipated outbursts of severely aggressive or violent behavior  
  • is considered an emergency situation

Exceptions

  • Devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, arm boards or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests
  • Devices to protect the patient from falling out of bed (crib with or without upper shield, emergency room stretchers, specialty beds)
  • Devices that permit the patient to participate in activities without the risk of physical harm (gait belt or physical escort)
  • Forensic and correction restrictions used for security purposes. 
  • Four side rail use is considered necessary to keep a patient safe and is NOT considered restraint:
    1. During transport
    2. When using a stretcher
    3. When the bed needs to be elevated to facilitate care of the patient
    4. When a bed is used in the rotational mode
    5. When a bariatric specialty bed is being used
    6. When a low air loss mattress is being used
    7. While recovering from sedation
    8. When a neurologically impaired patient experiences frequent spasms that could propel them out of bed
    9. When seizure precautions are required
    10. Raised rails in crib or Ohio-warmer
    11. When using the Hovermatt® is inflated

Physician Notification

The registered nurse (RN) must notify the treating physician before or immediately after placing the patient in restraints and obtain an order within ONE hour.

Notify the treating physician immediately after placing the patient in restraint/seclusion and obtain an order within ONE hour after initiation of restraint and/or seclusion. 

Initial Physician Evaluation

The physician will examine the patient as soon as possible, but no later than 24 hours. 

Physician must document a face-to-face evaluation within one hour of the initiation of restraint or seclusion.  Components of evaluation include:

  • The patient’s immediate situation
  • The patient’s reaction to the intervention
  • The patient’s medical and behavioral condition
  • The need to continue of terminate the restraint or seclusion

This evaluation may be performed by a RN or physician assistant (PA) who must then consult with the physician responsible for the care of the patient as soon as possible after the evaluation.

Time Limited Orders

Orders have a one calendar day time limit.  A new order must be obtained prior to midnight of the next calendar date. 

Written orders for restraint or seclusion are limited to:

  • 4 hours for patients 18 and older
    • 2 hours for children and adolescents 9 - 17 years of age
  • 1 hour for children under age 9

Order Renewal

If a restraint is continued beyond 24 hours, a new written order based on a face-to-face patient assessment by a physician is required once each calendar day.

When the physician order expires, the RN reassesses the patient and if he/she believes the restraint/seclusion is needed, the order may be renewed by obtaining a verbal order  (follow Patient Care Policy 8.16 on verbal orders), observing the above noted time limits for renewal.  Orders may be renewed, by obtaining a verbal order, for a maximum of 24 hours.

Physician Re-evaluation

Re-evaluation in-person by the physician for the continued need or restraint or seclusion is performed at least once every 24 hours. 

Re-evaluation in-person by the physician for the continued need of restraint or seclusion is performed at least once every 24 hours. 

Patients outside of Inpatient Psychiatry: The order(s) for restraint will be provided by the physician service in accordance with this policy.  A Psychiatric Consult is strongly recommended for patients outside of the Psychiatry Unit who require restraint for the management of violent or self-destructive behavior.

Early Release

Patients may be released from the restraint prior to the expiration of the order.  Once the restraints are removed and the patient is left unattended, the restraint can only be reapplied with a new physician order.

Patients may be released from the restraint/seclusion prior to expiration of the time-limited order.   For a patient experiencing early release, the restraint may be reapplied only with a new physician order.

Family Notification

Staff should attempt to promptly notify the family of the need for the restraint.

Release from Restraint

Patients will be released from the restraint as soon as safely possible. RN’s and/or physicians may make that clinical decision.  Release is based on whether the patient is demonstrating behaviors that indicate they may be ready for restraint removal. This  may include:

  • improved mental status
  • capacity to adhere to a contract regarding expected behaviors
  • cooperative behavior
  • supervision of family/others
  • discontinuation of tubes/lines 

As early as feasible in the restraint or seclusion process, the patient is made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. RN’s and/or physicians may make that clinical decision. 

Restraint or seclusion is discontinued as soon as the patient meets his or her behavior criteria.  This may include:

  • Patient’s ability to contract for safety
  • Cessation of verbal threats

MONITORING

1. Continuous Observation

None required

The patient in simultaneous restraint and  seclusion (Inpatient Psychiatry only) is continually monitored by:

  • Face-to-face by an assigned, trained staff member or
  • By trained staff using both video and audio equipment. 

This monitoring must be in close proximity to the patient. (Note:  Continually means ongoing without interruption.)

Patient in locked limb restraints

2. Components of Required 10-minute Observer Documentation

None required

Every 10 minutes checks are provided by a RN, NA  or trained technician to:

  • Visually check the patient
  • Check respirations
  • Monitor comfort

3. Components of Required 1-hour Observer Documentation

None required

Hourly checks are provided by a RN, NA or trained technician to:

  • Provide range of motion to restrained limbs
  • Reposition as needed
  • Determine need for hygiene, food, fluids and toileting

Every hour a RN assesses:

  • Signs of any injury associated with the application of restraint including circulation
  • Changes in the patient's behavior or clinical condition.
  • Whether the restraint has been appropriately applied
  • Readiness to meet criteria for less restrictive alternative and discontinuation

When monitoring and evaluation results in the need for intervention, prompt action will be taken.

4. Components of Required 2-hour Documentation

Every two (2) hours an RN completes an assessment of the patient including the following (EXCEPT for elbow immobilizers and mitts):

  • Provide range of motion
  • Reposition as needed
  • Determine need for hygiene, food, fluids and toileting
  • Sign of injury associated with the application of the restraints
  • Whether the restraint has been properly applied
  • Readiness to meet criteria for less restrictive alternatives and discontinuation

When monitoring and evaluation results in the need for intervention, prompt action will be taken

None required

5. Components of Required 4-hour Observer Documentation for Elbow Immobilizers and mitts

Every four (4) hours an RNcompletes an assessment of the patient including the following:

  • Provide range of motion
  • Reposition as needed
  • Determine need for hygiene, food, fluids and toileting
  • Sign of injury associated with the application of the restraints
  • Whether the restraint has been properly applied
  • Readiness to meet criteria for less restrictive alternatives and discontinuation

When monitoring and evaluation results in the need for intervention, prompt action will be taken

None required