Date
of Last Review: 5/19/08
SME: Associate Director of Nursing
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Seclusion is an involuntary confinement of a person alone in a room where the person is physically prevented from leaving. |
| Restraint is any method of physically restricting a person's freedom of movement, physical activity and normal access to the body. For examples of devices used for mechanical restraint see Acceptable Mechanical Restraints |
The following are policies regarding seclusion/restraint at UTHCPC:
| Hospital staff embraces the organization philosophy of Limiting Seclusions/Restraints (See Philosophy of Limiting Seclusion/Restraint Use) |
| Seclusion/Restraint is used for emergency management intervention when a patient demonstrates a threat of harm to self or others, and when least restrictive /non physical interventions have proven unsuccessful |
| Dignity of the patient is always maintained |
| Seclusion/Restraint is not to be used as a punitive action, for the convenience of staff, or in a manner that causes undue/physical discomfort harm, or pain to the patient |
| Seclusion/Restraint is used for the shortest period of time necessary to provide safety for the patient |
| Patients may not be restrained in a prone position and never place a towel, bag, or cover over a patient's face |
Clinical justification is required from a Physician and/or Registered Nurse
Seclusion/Restraint are limited to emergencies which pose an imminent risk of a patient harming self / others and nonphysical interventions were not effective.
Behaviors may include but not limited to the following:
| Confusion, disorientation, or extremely restlessness to the degree that the patient is not responsible for safe decision-making and may accidentally or purposefully harm self. |
| Agitation, hostility, or aggression toward others in the form of overt actions of biting, scratching, hitting, kicking , etc., |
| Self-injurious actions |
| Attempting to ambulate without assistance when assistance is required for safety |
| Risk of falling |
If patient has history that could be contraindicated for Seclusion/Restraint:
| Notify the physician |
| Document physician's consideration of this fact |
Staffing levels (e.g. 1:1 coverage, direct observation) and assignments are established to minimize circumstances that may cause seclusion as well as maximize safety when seclusion is required. Staff qualifications, acuity, patient's needs, etc., are considered in staff assignments. One to One staffing may be an alternative to seclusion/restraint.
Patient (s) will be assessed for the following at the time of admission regarding information that could minimize the use of seclusion/restraint.
| Triggers(s) that would place patient at risk of being secluded/restrained. |
| Prevention strategies that would help patient control behavior |
| Preexisting conditions ( e.g. physical disabilities, hx of sexual/physical abuse) that would place the patient at risk |
| Authorization for family notification |
| Mental Health Advance directive |
The following are necessary elements for seclusion/restraint orders:
| Each and every seclusion/restraint episode requires a physician's order, see Physician's Orders for Seclusion/Restraint form |
| In an emergency situation, the Registered Nurse may authorize the use of seclusion/restraint. A physician's order (written/verbal) for seclusion/restraint must be obtained immediately following, or no later than one hour following the initiation of seclusion/restraint. The RN consults with the physician regarding the patient's physical/ psychological condition and release criteria |
| Seclusion/restraint orders are time-limited as follows: |
 | (18 on up) - 4 hours |
| 9 to 17 - 2 hours |
| Ages under 9 - 1 hour |
| Orders include: |
| for seclusion/restraint |
|
|
| Type of Restraint |
| Release criteria |
| The physician must see and evaluate the patient face-to-face, as well as sign the order for seclusion/restraint, within 1 hour of the application of the seclusion/restraint |
| The treating physician is consulted as soon as possible if the seclusion/restraint is not ordered by the patient's treating physician. |
If seclusion/restraint is required beyond the time-limited order, a new order is obtained
Patients/Families/Significant others are educated about the hospital's Seclusion/Restraint philosophy via the Patient's Guide at the time of admission.
Based on the patient's authorization, the family/significant other are notified of the seclusion/restraint incident.
Nursing staff relay the following information to the patient at the time of seclusion/restraint:
| Reason(s) |
| Timeframe |
| Expected Care ( rounds, toiletry, etc.,) |
| Release criteria |
| Remove other patients from the area and provide reassurance |
| Open the seclusion room door and conduct a safety check |
| Escort the patient into the seclusion room |
| Exit and lock the room door |
| Remove all the patient's personal items, which could be used to injure self or others (ex. Belts, shoes, smoking materials, etc.) |
| Document items removed in the medical record |
| Remove the other patients from the area and provide them reassurance |
| Carefully place the patient on a hospital bed in a supine position |
| Securely hold each of the patient's extremities as another staff member applies cuffs |
| Adjust the cuffs so two finger widths fit between the cuff and patient for optimal circulation |
| Place the restraint belt through the loop on each extremity, allowing one inch of leverage |
| Secure the belt to the bed frame (side rails are contraindicated for patients in restraints.) |
| Checks each restraint for correct application and circulation. |
This table describes how nursing staff observe patient's to ensure physical safety:
Stage |
Description | ||||||
1 |
Seclusion Monitor the patient continously through 1.1 observation in person. After the first hour, video equipment may be utilized to monitor the patient. Document observations every fifteen (15) minutes Restraint Nursing staff observe and treat the patient under restraint as follows:
| ||||||
2 |
Assessment includes as appropriate: signs of injury, nutrition/hydration, vital signs, hygiene, elimination, readiness for release, etc., | ||||||
3 |
Staff assist patient in gaining control of behavior to return to the milieu. | ||||||
4 |
Reevaluation Discuss the use of seclusion/restraint in the next treatment planning session to include but not limited to the following:
|
This table describes the documentation process when seclusion is implemented:
Stage |
Description | ||||||||
1 |
A registered nurse (RN) documents in the nursing seclusion/restraint progress notes of the patient's chart. The following is included in the notes:
| ||||||||
2 |
Nursing staff monitoring the patient continuous document on the Seclusion/Restraint Checklist making entries a minimal of every 15 minutes. | ||||||||
3 |
Nursing staff completes Special Team/Physical Intervention form as appropriate. | ||||||||
4 |
The RN completes a Seclusion/Restraint PI monitor after each occurrence. | ||||||||
5 |
The RN attaches the completed PI form to the pink/yellow copy of the Seclusion/Restraint Checklist (white copy goes in chart) and forwards to the Nursing Supervisor's office along with the 24-Hour Report. | ||||||||
6 |
The Nursing Supervisor forwards the completed PI monitor to the Nurse Manager. | ||||||||
7 |
The Nurse Manager reviews the forms and forwards them to Nursing Administration. |
This table describes the steps involved in releasing a patient from seclusion/restraint:
Step |
Action | ||||||||
1 |
The RN may discontinue use of seclusion/restraint if the patient's behavior meets the release criteria prior to the expiration of the physician's order | ||||||||
2 |
If the patient falls asleep in seclusion, the door must be unlocked and opened within the nearest 15-minutes of monitoring. | ||||||||
3 |
If a patient falls asleep in restraint, restraint(s) are removed as behavior permits. | ||||||||
4 |
Adequate nursing staff are present to ensure control/safety of the patient when released from seclusion/restraint. | ||||||||
5 |
Debriefing Nursing staff process with the patient post-seclusion ( no longer than 24 hours post the episode)to include the following:
| ||||||||
6 |
Emergent Medical Condition- If an individual experience an emergency medical condition while in restraint or seclusion, the staff member ptoviding continous face to face observation of the individual or other staff must release the individual from restraint or seclusion as soon as possible as indicated by the emergency medical condition. |
This table describes staff reporting responsibilities for any patient requiring seclusion/restraint:
Stage |
Person Responsible |
Description | ||||||||
1 |
Nursing staff |
Use the 24-Hour Supervisor Report Sheet to notify:
| ||||||||
2 |
|
Investigate all unusual patterns of seclusion/restraint use | ||||||||
3 |
|
Completes a Seclusion/Restraint Consultation Request form on any patient secluded three or more times during a given admission or two or more times in 12 hours or remains in seclusion for more than 12 hours
Consultation finding(s) are discussed at the next treatment planning meeting and integrated into treatment as appropriate | ||||||||
4 |
|
Reports to the appropriate regulatory body (e.g. HCFA, JCAHO) any death that occurs while a patient is secluded or where it is reasonable to assume a patient's death is a result of seclusion |
Seclusion data is collected and aggregated a minimal of twice a year. Data components include but are not limited to the following: shifts, units, staff, timeframe, date, day, time, age, gender, whether injuries were sustained, debriefing data
The clinical leader team review data to identify improvements as well as opportunities to redesign care processes. Annual summary/recommendation(s) are reported to the PICC/PIC
All direct care staff participate in ongoing education and training designed to encourage creativity and innovation in providing less restrictive or non-restrictive alternatives.
Staff demonstrates competency via SAMA training the following elements:
| Identifying underlying causes of threatening or aggressive behavior,including those that may be related to non-psychiatric medical condition |
| Staff responsibility on how their behavior can affect the behavior of the patient |
The use of de-escalation, mediation, self-protection and other non physical techniques
| Assess for signs of physical distress during physical intervention. |
Staff demonstrates competency via Skills Lab the following competencies;
|
The initiation of seclusion |
|
Applicant of personal restraint |
|
Application restraint or seclusion |
| Monitoring of patients in restraint or seclusion |
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Management of emergency medical conditions including CPR and relief of foreign body airway obstruction. |
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Proper documentation of seclusion and restraint episodes |
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UTHCPC maintains documentation of training of each staff member. |
Proper documentation of seclusion and restraint episodes
This table describes the types of mechanical restraints and how they are used:
Type |
Description |
How to use... | ||||||||
Anklet |
A cloth band fastened around the ankle or leg |
| ||||||||
Wristlet |
A cloth band fastened around the wrist or arm |
| ||||||||
Mitten |
A cloth or foam rubber covering |
The device must be the proper size for the patient | ||||||||
Helmet |
A plastic, foam rubber, or head covering (ex. various sport helmets) |
|
The application of restraint depends on the reason(s) for the restraint. The following table describes the method of restraint and how it is applied:
Method |
How restraint is applied... | ||||
2 point |
| ||||
3 point |
| ||||
4 point |
All four limbs | ||||
To minimize the risk of aspiration, the head of the bed must be elevated and the patient must be positioned to freely rotate his/her head to the side. | |||||
Philosphy of Limiting Seclusion/Restraint
Related to regulatory standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
