Why was the policy changed?

HCFA (a federal agency) has developed new regulations regarding use of seclusion or restraint. They apply to both psychiatric and medical/surgical patients. In response, JCAHO has revised some of their standards to be compatible with these new regulations. Our policy was revised in order to meet these new standards.

Our single policy has been separated into 2 policies: one for Medically Necessary Restraint and the other for Seclusion/Restraint for Behavior Management.

What has changed?

Any use of restraint, regardless of purpose requires a physician’s order. Protocols may no longer be used.

Time frames for physician notification and subsequent examination of the patient have changed (Behavior Management policy).

Patients in Behavior Management seclusion or restraint must be continually observed, face to face.

There is increased emphasis on staff education regarding use of restraints, including safe application and use of alternatives.

The patient’s treatment plan must be modified to reflect use of restraints or seclusion and rationale for using them.

Both policies explicitly state that medications are not used as chemical restraints. The reason for prescribing and administering a medication should be consistent with the treatment goals for the patient. Consider the reason for prescribing and administering the medication. An effect may be limitation of movement, but the actual reason may be to enhance pulmonary or cardiovascular function, to help a patient regain self-control, or to help organize thought processes.

An Assessment/Order Sheet for Medically Necessary Restraint (#2201595) and a Mechanical Restraint/Seclusion Behavior Management Episode Sheet (#2201596) are available for documentation of the RN’s initial assessment of the patient and the physician’s order(s). Samples of the sheets follow each of the on-line policies.

How do the policies differ and in what circumstances is each used?

The Behavior Management policy has much shorter time frames for notifying the physician and obtaining a written order, length of time the order may be in effect, and how the patient is to be monitored.

The Behavior Management policy will be used in all cases of restraint/seclusion on the Adult and Child/Adolescent Psychiatric units and Psychiatric Emergency Services, regardless of the reason for using seclusion/restraint. It will be used on any medical/surgical unit or ambulatory care area, including Emergency Services, when a patient exhibits sudden, unanticipated severely aggressive or violent behavior.

The Medically Necessary restraint policy will be used on all medical/surgical units and ambulatory care areas, including Emergency Services. Situations in which it would apply are: a patient is actively reaching for or pulling at lines/tubes/dressings; a patient is getting out of bed or chair unassisted when independent transfer is unsafe or the patient is unable to make independent judgments about the safety of ambulation; or when restless movement threatens to dislodge medical devices, disrupt treatment, or possibly cause the patient to fall out of bed.

How are the new forms used?

The RN assessing the patient and identifying the need for seclusion or restraint fills out upper portion of the appropriate sheet. (Seclusion is only used in Psychiatry.)

Assessment/Order sheet is to be placed on the patient’s bedside flowboard on med/surg units.

When the physician is notified, he/she may give an initial phone order for seclusion/restraint. The physician must examine the patient and provide a written order within the timeframes specified in the policies.

Duration of the order depends on the policy in use. If the Medically Necessary policy is being used, the renewals of the order are written on the assessment/order sheet, and the sheet may be used for a maximum of 7 days. It is intended that renewal of an order would depend on discussion between physician and nurse as to the continuing need for restraint.

Use of medically necessary restraint for 7 consecutive days should lead to two actions: 1). Begin a new Assessment/Order sheet (reassess the patient). 2). Physician and nurse should confer regarding reasons for the ongoing need for restraint and possible alterations in the treatment plan. If possible, other members of the interdisciplinary team should be included in this discussion.

The Medically Necessary Assessment/Order sheet includes 2 plies. The original is placed in the patient’s medical record. The second sheet is sent to Nursing CQI (Amy Hofing, RN, D4202 MPB/0718) for inclusion in the ongoing data collection. This sheet will eventually replace the 3^rd week of each month data collection currently done.

The Behavior Management Episode Sheet is used for a maximum of 8 hours for adults or 4 hours for children <17 years. If the need for seclusion/restraint continues, a new sheet is started, but Section 1 is not completed. The sheet covers all aspects of the episode including staff and patient debriefing, revising the treatment plan, and notifying unit leadership in case of prolonged use of seclusion/restraint.

The policies apply to ambulatory care settings, and the forms should be used as appropriate to the situation.