Patient Rights and Restraint Use at EKL

       To promote freedom from restraint while protecting the patient from injury to self or others by eliminating the inappropriate use of restraint.
       To provide a standard of practice in the use of restraint that promotes patient safety, encourages less restrictive measures and preserves patient rights, dignity, and well-being.
       Procedure for Restraint use:
       Initiation of Restraint
       Restraint order, Assessment, Face to Face Evaluation
       Care of Patient while in Restraint
       Patient Rights
       Physical Restraint
·       Medical Justifications
·       Behavioral Justifications
       Chemical Restraint
       Proper Documentation
Patient Rights
       Every patient has the right:
o      to receive care in a safe setting
o      to be free from all forms of abuse or harassment
o      to be free from physical or mental abuse, and corporal punishment
o      to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.
       Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
       Restraint imposed as a means of coercion, discipline, convenience, or retaliation by staff is prohibited at EKL.
Physical Restraint Defined
A restraint is any manual method, physical or mechanical device, material, or equipment that restricts a patient’s freedom of movement (arms, legs, body, or head) and prevents normal access to his/her body.
When Should a Restraint be Used?
To ensure the physical safety of patients, staff or others and only when less restrictive measures are ineffective or not viable.
Physical Methods of Restraint
·       Hand mitts with ties attached
·       Soft limb holders for wrists and ankles
·       Freedom splints for elbows
·       4 siderails when used to keep a patient from getting out of bed voluntarily
·       Enclosure beds
·       Holding a patient down physically (use of force)
·       Use of restraint to safely transport in an emergency situation
·       Use of restraint during physical escort
·       Drugs used to emergently control overt or violent behavior
Emergency Situation
Any instance:
       in which there is imminent risk of a patient harming himself/herself, staff, or others
       when nonphysical interventions are not viable
       when safety issues require an immediate physical response
       when a physician is not readily available to conduct an assessment to write restraint orders
Unacceptable Types of Restraint
       Restrictive Chairs
       Vests that tie patients to their chairs or beds
       Bed sheets tucked so tightly that a patient can’t move
       The placement of a wheelchair-bound patient to a wall that prevents him/her from getting up
       Seclusion (involuntary confinement in a room and the patient is prevented from leaving) is not acceptable @ EKL.
Non-Restraint Methods
       IV arm boards or supportive devices such as orthopedic appliances, positioning wedges, etc.
       Temporary immobilization devices used during medical, dental or post-anesthesia care is a standard practice for the procedure
       3 or fewer bed side rails & raised side rails on stretchers
       Physical holding for physical exams or tests (patient does have the right to refuse treatment)
       Correctional devices (shackles, handcuffs) applied by non-hospital staff or law enforcement officials for custody
       Medications to treat medical conditions
       Timeout if patient consents to being alone
       Patient or family request (prompts assessment)
Less Restrictive Measures
       IMAB techniques (Interventions & Management of Aggressive Behavior)
       Assistive devices (i.e. mittens without ties)
       Control stimuli (noise levels)
       Bed alarms
       Management of medications
       Fall precautions
       Frequent observation
       Position changes/realignment
       Family visits
Individualized Patient Assessment
       The comprehensive individualized patient assessment is critical, includes a physical assessment to identify and address medical problems that may be causing behavior changes in the patient, and is the basis for the decision to use restraint.
       After assessment, the decision to use restraint involves determining whether use of less restrictive measures pose a greater risk than use of restraint.
       If less restrictive are ineffective or not viable and restraint is chosen, CMS standards apply.
EKL’s Position
·       Restraint use is an exceptional event and not a routine response to a certain patient condition or behavior.
·       Provide a standard of practice in use of restraint that:
o      promotes patient safety
o      encourages less restrictive measures
o      preserves patient rights, dignity, and well-being
·       Promotes freedom from restraint while protecting the patient from injury to self or others by: 
o      eliminating inappropriate use of restraint
o      discontinuing restraint at the earliest possible time
Restraint and Patient Risks
·       Falls
·       Reduced Bone Mass
·       Strangulation
·       Agitation
·       Loss of Muscle Tone
·       Pressure Sores
·       Decreased Mobility
·       Depression
·       Frustration
·       Loss of Dignity
·       Constipation
·       Incontinence
·       Agitation Death
Restraints and Falls
Falls and serious fall-related injuries increase with use of restraint. If a falling patient becomes suspended in restraint when attempting to climb over, under, around, through, or between the siderails, could result in any of the following:
·       Chest compression
·       Strangulation
·       Suffocation
·       Death
Reporting Deaths
·       Hospitals must report the following information to Center for Medicare and Medicaid Services (CMS):
·       Each death that occurs while a patient is in restraint
·       Each death that occurs within 24 hours after the patient has been removed from restraint
·       Each death known to the hospital that occurs within one week after restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient’s death.
NOTE:  Staff must document the date and time that the death was reported to CMS in the patient’s medical record
Clinical Justifications -Medical-Surgical Restraint
·       Less restrictive alternatives failed.
·       Use of restraint prevents interruption of medical healing.
·       Patient attempts to remove therapeutic devices (IVs, ET tube, NG tubes, Foleys, etc.)
·       Patient behavior puts self or others at risk for injury or harm due to diagnosis recovery process or cognitive impairment.
Clinical Justifications -Behavioral Restraints
·       Use of restraint is primarily due to an emotional or behavioral disorder & intent is to protect from injury or harm to self or others.
·       Use of restraint is for an unanticipated outburst of severely aggressive, violent or self-destructive behavior or verbal threats that pose an imminent danger to the patient and/or others.
·       Restraint is applied after attempting less restrictive measures, or if less restrictive measures are not viable as when the situation is an emergency
·       Patient is unable to contract for his/her own safety.
Restraint Orders
·       Based on assessment of the patient’s condition, an RN may determine that use of restraint is necessary for the patient’s protection. The physician is immediately notified when this occurs and, if possible, prior to restraint application.
·       All orders for restraint must be written by the physician and preceded by conduction of both:
o      a comprehensive individualized assessment, and
o      a face-to-face evaluation within 1 hour. 
If a Patient Tries to Assault a staff member by throwing a garbage can. The Nurse should take the following actions:
·       Assess patient; determine cause of behavior
·       De-escalate (IMAB, provide support, empathize)
·       Communicate –answer information gathering questions; redirect challenging questions
·       If calming attempts fail or imminent danger exists, determine if additional staff is needed
·       Notify Security –Call Code White (Call “1100”) for attempt to take-down if necessary
·       Immediately contact physician to respond to the patient’s location      
Calling a Code White!
·       DIAL 1100
·       Direct operator to announce Code White, and include the location where needed
·       The operator will announce over the hospital intercom system and then contacts Security
·       Security will respond to the crisis
Use of Weapons
·       EKL & CMS do not consider the use of weapons in the application of restraint as a safe, appropriate health care intervention.
·       According to hospital policy, the term “weapon” includes, but is not limited to pepper spray, mace, nightsticks, tasers, cattle prods, stun guns and pistols.
·       The use of any weapons by security staff is considered a law enforcement action, and not a health care intervention.
·       Employees, other than security staff, are prohibited from the use of weapons
·       To view the Weapons Use policy, click here.
Assessment of Post Electrical Shock Resulting from Taser/Stun Gun
·       Patients, staff or visitors who have received an electrical shock from a Taser/Stun gun should be evaluated on a case by case basis and treated according to hospital protocol.
·       To view the Policy and Procedure, click here.
Restraint Orders: Time Limits*
·       Medical-Surgical Restraint –24 Hour Maximum Duration with renewals within 24 hours based on assessment (order expires @ 24 hours)
·       Behavioral Restraint–Up to a total of 24 Hours as determined by CMS with renewals occurring in accordance with the following time limits:
o      4 hours for adults 18 years and older
o      2 hours for children 9 –17 years of age
o      1 hour for children 0 -9 years of age
***At the physician’s discretion, a shorter length of time
       may be ordered.
Face-to-Face Evaluation
Is required to be completed by the physician within 1 hour for initial application of restraint for both Medical-Surgical and Behavioral Restraint.
Chemical Restraint
·       A chemical restraint is a drug or a combination of drugs that:
o      Emergently controls overt behavior
o      Restricts patient’s freedom of movement
o      Reduces patient’s ability to effectively interact with others
o      Is not a standard treatment for medical or psychiatric conditions
·       Chemical restraint is not part of a patient’s standard treatment
·       PRN medications for anxiety are not chemical restraints
·       Use of PRN medication orders for chemical restraint is prohibited at EKL
·       Documentation on the patient’s medical record must include:
o      the date and time of the initial restraint order, the initial face-to-face evaluation, legible signature, and consultation with attending physician.
o      the patient’s behavior that lead up to the intervention used (Physical or Chemical Restraint).   
·       that alternatives or less restrictive measures were attempted before applying restraint.
·       that the restraint intervention used was the less restrictive intervention that protected the patient’s safety.
·       that the patient’s symptoms or condition warranted the use of restraint.
·       that the patient was released from restraint at the earliest possible time.
·       that the patient’s symptoms or condition warranted the use of restraint.
·       the patient’s response to the restraint intervention.
·       that the patient was released from restraint at the earliest possible time.
·       the patient’s response to the restraint intervention.
·       If the patient was not released from restraint, documentation must support the patient’s continued need for restraint.
·       Documentation for all restraint use must be completed on the appropriate forms.
Restraint Forms
1.   Restraint Assessment & Physician’s Order Set
2.   Treatment Interference Protocol
3.   Physician Checklist
4.   Progress Notes
5.   Restraint Flow Sheet
6.   Restraint Log
Restraint Order
·       All orders for restraint must be written by the physician or LIP, preceded by an assessment and face-to-face evaluation done by the physician.
·       The order must be obtained prior to application of restraint for medical-surgical reasons and immediately (within a few minutes) for behavioral reasons.
·       The RN may accept a telephone order for restraint only in an emergency situation.
·       The RN cannot accept PRN or standing orders for restraints.
Restraint: Responsibilities of Medical Professional
·       Continuously monitor and evaluate the restrained patient
·       Document assessments
·       Document continued need for restraint
·       Release restraint as soon as possible
·       Create a culture of safety, dignity and respect for patient’s rights
·       Communicate the commitment to reduce, prevent and eliminate use of restraints
·       Be committed to the national goal to reduce usage of restraint.
·       Be informed about regulatory requirements and rationales for reducing use of restraint.
·       Be a patient advocate; respect patients’ rights. 
·       Provide care in a safe setting, and try every alternative to keep
·       Patient’s free from restraint.
Restraint Use Policy and Procedure
·       To view the Policy for Restraint Use, click here.
·       To view the Procedure for Restraint Use, click here.
Where Do I find the Restraint Use Policy and Procedure?
·       Go to the P drive on My Computer:
P:\Policies and Procedures\Nursing Services
Click on these policy numbers:
06-13-005, 06-13-005A, 06-13-005B
Any Questions?
Please Contact
Naoshia Carroll, MSN, RN
Assistant Manager/Quality Management EKL
225-354-12962087 Office
Faye S. Jones, RN, BSN
RN House Manager/Patient Safety/Quality EKL
225-358-1296 Office