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CLINICALLY JUSTIFIED AND SAFE USE OF RESTRAINT

By Derrick Owens,2014-05-28 14:34
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CLINICALLY JUSTIFIED AND SAFE USE OF RESTRAINT

    Self Learning Program (SLP)

    The Safe Use and Proper Application of

    Patient Restraints

    Instructions:

    Obtain SLP from Staff education

    Complete all work listed in the individual SLP including the post test and evaluation

    Return the post test, evaluation, and self-addressed envelope to Staff Education

    A certificate of completion will be issued. There is 1 CE hour associated with this program.Employee Information:

    Program Title:The Safe Use and Proper Application of Patient Restraint

    Name: _______________________________________Date:____________________Employee #: __________________________________ License #: ___________________Unit/Dept: ____________________________________Title: _______________________Location: ____________________________ Signature: ____________________________Program Evaluation:

    Program EvaluationExcellentGoodFairPoor

    Attainment of stated objectives

    Organization of Content

    Clarity of Content

    Support Materials/Examples

    Overall Evaluation

    General Comments:

    1)Would you recommend this program to your colleagues? Yes No

    2)The information will help me improve my practice? Yes No

    3)Suggestions for improvement:

    4)How long did it take you to complete this SLP?

    KAISER PERMANENTE

    SOUTHERN CALIFORNIA

    Panorama City

     The Safe Use and Proper Application

    of Patient Restraint

    Self Learning Packet

    2009

    2

    The Safe Use of Patient Restraint

    TABLE OF CONTENTS

    CONTENTPAGE

    Directions and Objectives3

    General Overview4

    oWho needs to complete this learning packet?

    oKaiser’s Commitment

    Exercise # 1

    Answer Key to Exercise # 15

    Definitions6

    oRestraint

    oNon-Behavioral (Medical) Restraint

    oBehavioral Restraint

    Forensic and Correction Restriction

    Age or Developmentally Appropriate Restrictions7Seclusion

    Patient Actions to be Considered in the Application of Restraint

    Exercise #28

    Answer Key for Exercise #29

    Alternatives to Restraint10

    Outcomes of Restraint Use12Exercise # 3

    Answers to Exercise #313

    Physician Orders and Assessment Requirements for Restraint Use14

    Exercise #415

    Answers to Exercise #416

    Patient Rights17Safe Application of Restraint

    Application of Restraint Devices18

    Documentation of the Care and Monitoring of the Patient in Restraint19

    Post-test20-21

    Answers to Post-test22

    3

    DIRECTIONS

    1.Read the material.

    2.Complete the exercises as you read through the material

    3.Check your answers to the exercises as you go along. If you miss questions, go back and re-read

    the material.

    4.Complete the post test when you believe you have mastered this material. Competency is

    demonstrated by a score of 90% or greater.

    5.Turn your post test into your Department Manager or Clinical Educator.6.Consult with your Department Manager or Clinical Educator if you have any questions or need

    additional information.

    OBJECTIVES

    Upon completion of this packet the learner will be able to:

    1.Differentiate between non-behavioral restraint and behavioral health restraint.2.Determine when a device is considered restraint and when it is not restraint.3.Discuss possible alternatives to the use of restraint.

    4.Determine observed actions or behaviors that may warrant the need for restraint.5.Identify the undesired and desired outcomes of restraint use.

    6.State the physician order and assessment requirements for patients in restraint.7.State the patient rights in regard to restraint use.

    8.Describe the safe application of restraint devices.

    9.Describe the documentation of the care and monitoring of the patient in restraint.

    4

    GENERAL OVERVIEW

    Restraint is a risk management issue for Kaiser Permanente for several major reasons. Restraints can be dangerous to patients. Serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual’s rights, and even death can result from restraint use. Staff can be placed at ridk for physical injury by patients that are being restrained. Particularly, if they are not well trained on the proper application of restraint.

    This self learning packet is intended to provide education regarding the safe use of restraints. It will also address the proper documentation of patient assessment, consideration of less restrictive alternatives, care and monitoring when restraints are applied.

    WHO NEEDS TO COMPLETE THIS LEARNING PACKET?

    All direct staff and any other staff involved in the use of restraint will receive education and an ongoing review of the use of restraints. Staff includes those who directly apply or release restraints, those who perform patient assessment or monitoring, and those who evaluate the patient for continued use of restraints.

    Kaiser’s Commitment

    It is the policy of Kaiser Permanente that patients should be free from restraints of any form that are not medically necessary. The choice of safe, effective and least restrictive method of restraint is determined by the assessment of the patient by a registered nurse, in collaboration with the physician based upon the patient’s needs and behavior exhibited by the patient. Efforts are taken to develop and promote preventive strategies and to use safe and effective alternatives when appropriate. When assessment has indicated the need for restraint, the least restrictive device should be utilized.

    EXERCISE 1

    To assess your present understanding regarding the use of restraint, please complete the following exercise. After you have completed the exercise compare your responses to the correct answers at the end of this packet.

    Fact or Myth? Circle the correct response to the numbered statements.

    1.Restraint decreases falls and prevents injuries.FactMyth

    2.Restraint is for the good of the patient.FactMyth

    3.Restraint makes care giving more efficient and less worrisome.FactMyth

    4.Restraint prevents lawsuits and malpractice claims.FactMyth

    5.The healthcare facility has a moral duty to protect the patient FactMyth

    from harm, therefore justifying the use of restraints.

    5

    ANSWERS TO EXERCISE 1

    EXERCISE 1

    1.Restraint decreases falls and prevents injuries.

    MYTH:

    Non-restraining facilities experience fewer injuries from falls (37.3%) than facilities that use

    restraints (50.6%). No scientific basis exists to support the idea that physical restraints safeguard

    patients from injury.

    2.Restraint is for the good of the patient.

    MYTH:

    Research studies indicate that immobilizing or restraining older adults result in chronic

    physiologic changes. Changes are also seen in the older adult’s perceptual and behavioral

    responses to the environment.

    3.Restraint makes care giving more efficient and less worrisome.

    MYTH:

    Restraints may serve as a short-term solution. However, they actually create greater dependency

    and increase custodial care.

    4.Restraint prevents lawsuits and malpractice claims.

    MYTH:

    Death directly attributed to restraints is not uncommon. The risk of liability greatly increases with

    the misuse of physical restraints.

    5.The healthcare facility has a moral duty to protect the patient from harm, therefore justifying the

    use of restraints.

    MYTH:

    The facility does have a moral duty to protect patients from harm and minimize risk to the patient

    and to others. Restraints can increase risks and actually cause harm to the patient.

    6

    DEFINITIONS

    Restraint:Any method physically restricting a person’s freedom of

    movement, physical activity or normal access to his or her

    body.

    Non-Behavioral (Medical) A manual method, physical or mechanical device, material,

    Restraint:or equipment that immobilizes or reduces the ability of a

    patient to move his or her arms, legs, body or head freely.

    A drug or medication used solely as a restriction to manage the

    patient’s behavior or restrict freedom of movement and it

    is not a standard treatment or dose for the patient’s

    condition.

    Behavioral Restraint:A restraint used for the management of violent or self-

    destructive behavior that jeopardizes the immediate

    physical safety of the patient, a staff member, or others.

     Note : Behavioral restraint should only be used in an

    emergency that should be reserved for those occasions

    when unanticipated severely aggressive, destructive, violent

    or suicidal behaviors are exhibited that place the patient or

    others in imminent danger.

    Restraint does not include devices, such as orthopedic devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from inadvertently rolling out of bed, or to permit the patient to participate in activities without the risk of physical harm. Patient immobilization that is a normal component of a procedure is not considered restraint. For example, a safety belt might be applied to immobilize the patient during a gurney transport – this is not

    considered restraint.

    Forensic and Correction Restrictions

    Forensic and correctional restrictions used by law enforcement for security purposes (for example, the use of handcuffs by police are not considered restraints). However, the use of medical devices (e.g. limb restraint) to restrict freedom of movement, physical activity or normal access to one’s own body related to clinical care of an individual under forensic or correction restrictions is considered restraint.

    7

Age or Developmentally Appropriate Restrictions

    Placement in a crib with raised rails is an age appropriate standard safety practice for every infant or toddler and would not be regarded as a restraint. Age or developmentally appropriate protective safety interventions, such as stroller safety belts, swing safety belts, high chair lap belts, raised crib rails, and crib covers, that a safety conscious child care provider outside a health care setting would utilize to protect an infant, toddler, or preschool aged child would not be considered restraint. Seclusion

    Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self destructive behavior.

    PATIENT ACTIONS TO BE CONSIDERED IN THE APPLICATION OF RESTRAINT

    ACTIONEXAMPLE OF DEVICETYPE OF

    RESTRAINT

    Patient combative or violent due to mental stateBehavioral Health Hard Restraints

    Restraint(leathers)

    4 Point Soft

    Restraints

    Restricting movement of confused patient from removing Non-behavioral Soft Wrist Ties

    medical device (IV, endotracheal tube, catheter, drains, RestraintPosey Vest etc.)Mittens

    Confused patient attempting to climb out of bedNon-behavioral Bed Rails (4 split

    Restraintrails or 2 full bed)

    Post-op patient needs to lay on her side without rolling Not RestraintSplit Bed Rails (1-

    out of bed3)

    Protect patient from falling out of bed, using side railsNot RestraintSplit Bed Rails (1-

    3)

    Patient with poor posture while sitting in chairNot RestraintPosey Vest

    Patient sliding out of chair Not RestraintPosey Vest

    Overbed portable

    table

    Lap Belt

    Patient immobilized during MRI, circumcision, operative Not RestraintSoft Wrist

    procedureRestraints

    Safety Belt

    Patient transported via gurney or wheelchairNot RestraintSafety Belt

    Patient with head injury, at risk for fallsNot RestraintHelmet

    Patient under arrest, being guarded by Deputy SheriffNot RestraintHandcuffs

    8

    EXERCISE 2

    To assess your understanding of the definition of restraint, identify each of the following descriptions as

    Restraint or Not Restraint, and then compare your responses to the answers at the end of the packet:Description RestraintNot Restraint

    1. A post surgical patient is intubated and is unable to follow instructions to not pull at endotracheal tube. The nurse applies bilateral wrist soft ties.

    2. A safety belt is used to secure a patient on a gurney during transport to Radiology.

    3. Soft ties are used for a patient during an MRI and removed after the procedure.

    4. Patient who is extremely combative due to the influence of drugs arrives in the Emergency room. Leather restraints are applied to control the combative behavior.

    5. A confused patient continues to get out of bed and wander out of the unit after repeated instructions to stay in bed. Side rails are raised to restrict her from getting out of bed.

    6. A post stroke patient with left-sided paralysis slumps out of the chair. The nurse applies a vest to keep the patient in a sitting position.7. A patient is handcuffed while in police custody during an Emergency Room visit to have a laceration sutured.

    8. A confused patient is unable to follow instructions to stop scratching a severe skin rash. The nurse applies hand mittens.

    9. Bed rails are raised to prevent a female patient who is positioned on her side from rolling out of bed.

    10. Soft baby booties are placed on each hand of an intubated premature infant.

    9

    ANSWERS TO EXERCISE 2

    EXERCISE 2

    1.RESTRAINT: medical restraint, alternatives ineffective

    2.NOT RESTRAINT: safety belt is a

    required protective device during transport

    3.NOT RESTRAINT:: medical immobilization during a procedure

    4.RESTRAINT: behavioral health restraint for aggressive or combative patient5.RESTRAINT: the patient is physically capable of getting out of the bed and we are preventing it

    by putting up the bed rails

    6.NOT RESTRAINT: the patient is not capable of standing independently (they could not get out

    of the chair on their own) we are using the vest to support their position in the chair7.NOT RESTRAINT: handcuffs are a forensic and corrective restriction for security purposes by

    law enforcement personnel

    8.RESTRAINT: mittens (that prevent thumb opposition) keep the patient from having access to

    their own body

    9.NOT RESTRAINT: the bed rail is being used as a supportive/protective device, not intended to

    restrain from getting out of bed

    10.NOT RESTRAINT: booties do not prevent thumb opposition (the ability of the thumb to touch the

    other fingers on the same hand) and are simply safety devices

    10

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