UTHCPC Procedures - Restraint (Mechanical)

Restraint (Mechanical)

Definition

Date of Last Review 08/31/04

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.

Policies

Nursing subscribes to the following policies regarding restraint:

Restrain patients when necessary to limit their movement as a means of protecting themselves and others from harm

Maintain the dignity of the patient

Use restraints for the shortest period of time necessary to provide safety for the patient

Restraint is not to be:

A punitive action

A convenience for staff

Used in a manner that causes undue physical discomfort, harm, or pain to the patient

Patient may not be restrained in a prone position

Never place a towel, bag, or cover over a patient's face

Criteria for use

When assessing the need for restraint, note the following:

Clinical justification is required from the physician and Registered Nurse

Restraint is used only when least restrictive alternatives have failed, for example:

Modify the environment

Use verbal redirection

Reduce sensory stimulation

Carefully consider the following when assessing whether a patient is in need of restraint:

Confused, disoriented, or extremely restless to the degree that he/she is not responsible for safe decision-making and may accidentally or purposefully harm him/herself

Agitated, hostile, or abusive toward care givers in the form of overt actions of biting, scratching, hitting, kicking personnel

Self-injurious actions

Attempting to ambulate without assistance when assistance is required for safety

In danger of falling out of bed or a chair

Medical condition contradicts use of restraints

Contraindication for restraint

If a patient has a history that could be a contraindication for restraint:

Notify the physician

Document physician's consideration of this fact

Restraint order

Nursing staff must obtain a physician's order for each and every restraint episode, see Physician's Orders for Seclusion/Restraint form.

Exception: In an emergency, the Registered Nurse may authorize the application of restraints. The nurse must obtain a physician's order (written/verbal) for restraint immediately following or no later than one hour after the restraint.

An order for restraints must be time-limited, not exceeding the timeframes below for:

Adults - 4 hours

Ages 9-17 - 2 hours

Ages under 9 - 1 hour

An order must include:

Reason for restraint

Timeframe

Release criteria

The treating physician is consulted as soon as possible if the restraint is not ordered by the patient's treating physician.

Patient education

Nursing staff provide the patient with the following information prior to restraint:

Reason(s) for restraint(s)

Expected care (ex. rounds, etc.)

Release criteria

Acceptable mechanical restraints

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

Secure to a stationary object (ex. bed)

Acceptable fasteners include velcro and buckle-type devices

The device must not be secured so tightly as to interfere with circulation nor so loose as to permit skin chafing

Padding the inside of the device aids in preventing chafing

Wristlet

A cloth band fastened around the wrist or arm

Secure to a stationary object (ex. bed, chair frame, or waist belt)

Acceptable fasteners include velcro and buckle-type devices

The device must not be secured so tightly as to interfere with circulation nor so loose as to permit skin chafing

Padding the inside of the device aids in preventing chafing

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 device must be the proper size for the patient

If appropriate, a face guard may be attached to the helmet

The chin strap should not be so tight as to interfere with circulation

Method of restraint application

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

One arm and one leg on the opposite side of the body

Both arms

3 point

One arm and both legs

Both arms and one leg

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.

Restraint process

A registered nurse directs the restraint process as follows:

Responsible staff

Action to be taken...

Nursing staff

Remove other patients from the area and provide them reassurance

Provide two staff members to witness patient inventory

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

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)

Registered nurse

Checks each restraint for correct application and circulation

Physician

Sees and evaluates the patient face-to-face, as well as signs the order for restraint, within 1 hour of the application of restraint

Patient treatment

Nursing staff observe and treat the patient under restraint as follows:

Monitor continuously through 1:1 observation

Assess for circulation and skin color at least every 15 minutes, more often if necessary

Provide an opportunity for motion, range of motion, or exercise for at least 5 minutes during every hour in restraint

Assess every 2 hours for hydration, nutrition, toiletry and other needs

Assist in gaining enough control of behavior to return to the milieu

Discuss the use of restraint in the next treatment planning session to include but not limited to the following:

Alternate strategies to control behavior

Implication for family/significant other(s) notification

Treatment plan implication(s)

Documentation

Staff document the restraint as follows:

Staff responsible

Required Documentation

Nursing staff

Complete a Special Team/Physical Intervention form for all restrained patients (see Nursing Manual procedure, "Special Team/Physical Intervention" for a copy of the form)

Document every 15 minutes on the Seclusion/Restraint Checklist

Registered nurse

Document in the patient's medical record on the Nursing Seclusion/Restraint Progress Notes when restraints are implemented to include the following:

Behavior exhibited prior to seclusion/restraint

Less restrictive intervention attempted and patient's response

Behavior required for release

Patient's feelings about restraint

Complete a restraint Performance Improvement (PI) monitor after each occurrence

Attach PI form to pink/yellow copy of the Seclusion/Restraint Checklist and forward to the Nursing Supervisor's office with the 24-Hour Report

Nursing supervisor

Forwards the completed PI monitor form to the Head Nurse.

Head nurse

Reviews the PI form and forwards to Data Management.

Release of restraints

The table below shows the staff responsible for releasing a patient from restraint and the actions they perform:

Staff responsible

Action

Registered nurse

Ensures that adequate staff are present for the patient to be safely released from restraint

Releases patient from restraint under the following conditions:

Patient's behavior meets the release criteria prior to the expiration of the physician's order

Patient falls asleep in restraint (If release is not possible, document clinical justification for continued restraint)

Nursing staff

Process with the patient post restraint to include:

Patient's feelings

Identification of trigger

Alternative behavior/response to trigger

Return the patient's personal possessions/articles

Staff education

All direct care staff participate in ongoing education and training designed to encourage creativity and innovation in providing less restrictive or non-restrictive alternatives.

The competency assessment includes restraint reduction, alternatives/strategies to restraints, risk assessment, early intervention, and proper/safe application of restraint.

Reporting condition

This table describes staff reporting responsibilities for any patient requiring restraint:

Stage

Person Responsible

Description

Nursing staff

Use the 24-Hour Supervisor Report Sheet to notify:

Area Director of Nursing or designee

Head Nurse/Supervisor

Head Nurse

Area Director for Nursing

Medical Director

Investigate all unusual patterns of restraint use

Licensed nursing staff

Completes a Seclusion/Restraint Consultation Request form on any patient restrained three or more times during a given admission and every three times thereafter

Forwards the Seclusion/Restraint Consultation Request form to the Medical Director

The Medical Director reviews the case and completes the designated section of the consultation form

The completed form is forwarded to the unit and placed in the seclusion section of the medical record

Consultation finding(s) is discussed at the next treatment planning meeting and integrated into treatment as appropriate

Administration

Reports to the appropriate regulatory body (e.g. HCFA, JCAHO) any death that occurs while a patient is restrained or where it is reasonable to assume a patient's death is a result of restraint.

References

Seclusion
Sentinel and High Risk Events

Related standards:

JCAHO PI 3.1.1, PI 4-5
JCAHO PE 2.3, TX 7-7.4.1

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