Joint Commission

2. Joint Commission The Joint Commission: A patient entering a behavioral health unit requires an assessment upon admission of the patients risk of hurting self or others. The staff must then determine interventions that could minimize the use of restraints or seclusion.

3. Get Help When placing a patient in restraints or seclusion, never attempt to do so alone. Always call for assistance and use a team approach.

4. Time Restraints CMS and Joint Commission Time Limit 4 hours for adults 2 hours for ages 9 – 17 1 hour under age 9 Note: Be sure to document in the patient record the time limit of the original order and any renewal orders. Pt’s in restraint/seclusion must be assessed every 15 minutes.

5. Debriefing Once the pt. has been released from restraints or seclusion conduct a briefing with both the patient and the staff. Remember, this event has been traumatic for both parties involved. Debriefing also allows for dialog of the lessons learned from the experience.

6. Seclusion The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. A patient is not considered in seclusion if: The patient is confined to an area with others or the pt. is locked in a room for their own protection but can open the door from the inside.

7. Seclusion Seclusion can only be used for the management of Violent or Self-Destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.

8. Restraints What restraints are, and what they are not. According to CMS (Center for Medicare/Medicaid Services): mechanical restraints include any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. The most commonly used restraint devices are wrist and ankle ties.

9. RESTRAINTS “For years, there was a belief that restraints were a necessary component of care. But it is now clear from evidence-based studies that restraints must be avoided whenever possible. Not only do they not address the underlying problem, they may actually worsen it.” Elizabeth Capezuti, PhD, RN, FAAN

10. Side Rails Considered a Restraint when preventing voluntary movement out of bed. This could actually differ depending on the patient’s situation. It really depends what the side rail means to the patient.

11. Medications Considered a Restraint if used to manage the patient’s behavior or restrict the patient’s freedom of movement, and is not a standard treatment or dosage for the patient’s condition.

12. Restraints The Joint Commission states that restraints are any method (chemical or physical) of restricting the patient’s freedom of movement, including seclusion, physical activity or normal access to his or her body that is not a usual and customary part of a medical, diagnostic, or treatment procedure to which the patient (or his or her legal representative) has consented; is not indicated to treat the person’s medical condition or symptoms; or does not promote the patient’s independent functioning.

13. What Restraints Are Not (CMS) Side rails if they are raised during patient transport Prescribed Devices: eg. (sling, helmet) Other methods that physically hold a patient for the purpose of conducting routine physical examinations or tests. (VS Machine) Methods that protect the patient from falling out of bed. Methods that permit the patient to participate in activities without the risk of physical harm (does not include a physical escort) Medications are not restraints if used within parameters set by FDA and the manufacturer; follow national practice standards; are used to treat a specific condition; or are standard treatment that would enable the patient to function properly.

14. What Restraints Are Not (JCAHO) Adaptive supports such as postural supports, orthopedic devices and appliances or slings, used in response to assessed patient’s need Helmets Standard practices such as surgical positioning, IV boards, X-ray procedures, protection of surgical sites in pediatric patients Limitation of mobility or temporary immobilization related to medical, dental, diagnostic or surgical procedures including post-procedure processes

15. Forensics Note: Both CMS and The Joint Commission agree that forensic devices applied to prisoners; and handcuffs, shackles or other restrictive devices applied by outside law enforcement officials are not considered restraints

16. A Question of Behavior ? Evidence shows that some caregivers believe restraints can address aggressive or combative behavior. In fact, the opposite is often true. There are many studies that prove that restraints and side rails can actually increase the risk of injury or aggressive behavior, and in fact may represent a failure in treatment. If we are to reduce the use of restraints, then we must be proactive and meet our patient’s needs, rather than react to troublesome behavior. And, we must remember to respect our patient’s basic right to dignity and freedom of movement.

17. Conditions of Participation CMS states in their C.O.P. that “a patient has the right to be free from restraints or seclusion in any form, which has been imposed as a means of coercion, convenience or retaliation by staff.” This information should always be included in the patient rights statement and given to the patient in writing upon admission. This applies to all hospitals that accept Medicare or Medicaid.

18. The Prime Directive Keep patient’s free from restraint and seclusion Then ask, “What is causing this behavior?” All alternatives to restraints, all efforts to figure out what’s happening with the patient, what the cause of the behavior is, why the patient is acting in a particular way needs to be fully investigated. A complete assessment needs to be done, and a solution to those problems for the patient need to be sought.

19. Medical Conditions Medical conditions that can alter normal behavior include: Increased temperature Hypoxia Hypoglycemia Electrolyte imbalances Drug Interactions Pain Infection Dehydration Medications such as psychoactive Drugs and drugs with anti-cholinergic side effects

20. Other Factors that Trigger Restraints Fall risk Interference with therapy Agitated / restless behavior Poor safety judgment due to cognitive impairment Elopement / wandering

21. Psychological Triggers Psychiatric conditions Stress Substance use Coping skills Emotional status Social isolation

22. Milieu Factors that Trigger Restraints Environmental factors, such as: Noise levels Lighting Barriers to mobility Space for privacy and socialization Change in caregivers or routine

23. Assessments The Key To Prevention The best way to uncover potential triggers is to conduct a comprehensive assessment: The patient’s health history Medication usage Functional status Mental and psychological status Environmental factors

24. Red Flags The Following are red flags for investigation of underlying triggers.

25. Treatment Interference Treatment Interference: refers to removal or interference of monitoring devices. Assessment may uncover physical and environmental factors which manifest as psychological symptoms such as anxiety, agitation, verbal and physical aggression.

26. Fall Risk Factors Falls, especially with sudden onset, may indicate dehydration, hypoglycemia, or side effects of medications.

27. Entrapment Entrapment: most commonly seen with hospital beds with side rails. When a patient is fully or partially caught between the side rail and the mattress, and because of gravitational chest compression, is unable to inhale.

28. Entrapment Reducing entrapment: conduct a patient assessment that examines medical symptoms that may predispose a patient for entrapment such as confusion, sedation, lack of muscle control, size, restlessness, and other impairments. Additionally, a risk analysis should be completed and bed frames, side rails, and mattresses should be inspected to identify areas of risk.

29. Cultural Assessment May identify cultural and generational issues that need to be considered. These may focus on expectations of care by the patient and family, how to avoid disrespect, and recognizing diverse needs.

30. Interdisciplinary Team Nurse, physician, social worker, psychiatric technicians should work together to evaluate patient, identify triggers, and look for alternatives to restraint. Modify treatment plan as needed.

31. Combativeness Many patients become combative because they feel an invasion of personal space, a reduced sense of personal identity, loss of control, or because they feel unsafe or secure. Look for patterns that will help you determine when, where, how, and with whom the behavior occurs to determine the meaning behind the behavior, and the best intervention.

32. Documentation To comply with CMS and The Joint Commission you must document the patient’s behavior along with the condition or symptom.

33. Watch for Bias When documenting, avoid words like, “aggressive” or “agitated,” as these labels often exhibit bias by the healthcare provider based on perception or beliefs. Instead, describe the behavior in precise terms, such as “the patient remains at the desk although repeatedly asked to leave to the day area.”

34. Alternatives to Restraints Once the source for the behavior has been determined, individualized interventions can be implemented to meet the patient’s needs – without the use of restraints. There may be evidence-based techniques that can be used to redirect the patient, engage the patient in constructive discussion or activity, prevent self-injury, or otherwise help the patient maintain self control and avert escalation.

35. Alternatives The alternatives for restraint should include the following A comprehensive assessment Be part of the individualized plan of care Be fully documented in the patient record

36. Alternatives to Restraints Should be selected from these 4 catagories Physical and Physiological Interventions Psychological and Psychosocial Interventions One-on-one companionship or Observation Modifying the Environment

38. Intervention