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Restraints Q and A

Hello, everyone. I was just doing some research on restraint and seclusion issues for an upcoming story and thought that you might be interested in the information below. The following are from the Q and A period from our Interpretive Guidelines audio conference just a few months ago, with Susan Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety for the Via Christi Wichita (KS) Health Network.

If you’re interested, the full audio conference is actually available for download (along with other recent accreditation programs) here. Susan is also joining AHAP’s own chairperson, Jodi Eisenberg, for a more indepth look at restraints from both the Joint Commission and CMS angle in March.

Q: If a patient is in restraints and it looks like he can do without them, and I take them off, can I then put them back on, if after 30-40 minutes it looks like he is going to need them after all?

Susan Hendrickson (SH): No, you may not. That is called a trial release. And trial release constitutes an as-needed (PRN) situation. Once a staff members ends an order to restraint intervention that the staff member has no authority to reinstate, without a new order. Using that example, if the patient is released because the staff assess that he or she didn’t need to be in restraint and later the patient exhibits that behavior…They have to go back and get an order, then you are using PRN, which is absolutely prohibited by both the CMS and The Joint Commission.

Q: What if the patient is removed from the restraints before the time limit for the physician to come in and assess them? Does the physician still have to come in and assess them?

SH: No, you can go ahead and remove the restraints. The physician is going to have to come in and assess that, in order to give the order. That’s the one thing about the time limit. The time limit is maximum time and it’s not minimum time. Actually, you are better off if you are able to get the patient out of restraints before the time limit ends. So no, that’s fine to take the patient out of the restraints ahead of time. The physician is going to have to document and agree with you that that short period of time where the patient was in restraints that he or she also agrees that was okay with the patient.

Q: If a patient has been assessed for needing a chemical restraint and you cannot order a chemical restraint as PRN, does the nurse have to call every four hours if they feel they need it or would the doctor write an order for a chemical restraint?

SH: The nurse would have to call. That is correct. The doctor doesn’t have to come in. The order can be removed for up to 24 hours so the physician wouldn’t have to come back in each and every time the nurse would have to call.

Q: With regards to education requirements, does the CMS want to see specialized training for the people who would provide restraint education to staff across the facility?

SH: Yes, you’re going to have to show that the staff member who is providing the training is competent.

You can develop training within your own hospital that’s not specific but you are going to have to show that staff maybe have education. Maybe you sent them for some specialized education, maybe they have completed some kind of course, something like that. It is not prescriptive as to what you have to do. But you need to be able to delineate that in your policy as to what makes a person confident. It may be that you do a train-the-trainer kind of thing.

Distinguish Between Medical and Behavioral Restraint

From Bud Pate, REHS, Vice President of Content and Development for The Greeley Company:

Surveyors commonly misapply the behavioral health rules to medical restraint. In fairness, the Joint Commission standards and CMS regulations are a more than a little confusing, even when you study them carefully. But the rules for behavioral health restraint are vastly different than those for medical restraint, so your definition should be crystal clear.

Regardless of the location, behavioral health restraint rules should only be applied to address violently aggressive or self disruptive behavior. We recommend that your policy clearly apply the medical restraint rules to the following situations:

– a patient who is in the critical care unit after a suicide attempt and is being restrained to avoind accidental extubation due to twitching or trying to sit up in bed;

– a patient experiencing involuntary thrashing during acute withdrawal syndrome;

– a confused patient who is interfering with nursing care.

“But wait,” you say, “we should use the behavioral health care rules because we are caring for patients with clear emotional disorders.” Or you may say “The confused patient is trying to hurt the nurse, shouldn’t the behavioral health rules apply?”

But remember, all restraint (medical and behavioral) is implemented to address behavior. And if you truly believed the behavioral health care rules applied you would already be staffing these situations with psychiatric nurses. Ask yourself, “would a debriefing be helpful to see how a future episode would be avoided?” I don’t think so.

There will certainly be those who object to this position. If you are one of them, then I encourage you to fully (and I mean fully) implement all the behavioral health care rules to these situations, including: continuous observation, 15 minutes assessments by a staff member with psychiatric training, post-restraint debriefing with the patient, and all the other very restrictive rules. If you don’t feel these measures are clinically necessary, then you agree with me: these are not behavioral health restraint. So define them as medical restraint in your policy.

Remember: we can debate the fine points of a policy with regulators all day long without reaching an adverse conclusion. However, you will definitely be guilty of an infraction if you violate your own policy. In other words: say what you do and do what you say.

Restraint benchmarking survey

Hello, all. I just wanted to share with you some results from our recent benchmarking survey:

Managing the use of restraints and complying with related requirements continue to be major challenges for accreditation professionals throughout the country. And one of the biggest areas of concern is the use of medication restraints, according to AHAP’s most recent benchmarking survey.

According to the members-only survey, conducted in June and July 2008, 46% of accreditation professionals find medication restraints the most troublesome under CMS’ updated restraint Interpretive Guidelines (24% listed soft limb restraints as most troublesome, while 17% listed “other,” 7% listed zippered comforter restraints, and 6% listed low bed restraints).

The number for medication restraints seems high, says Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, member of the AHAP advisory board, healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor. “Perhaps the organizations need to review their definitions of chemical restraint,” she says. “They may, in fact, not be following the CMS/Joint Commission definition—theinappropriateuse of a sedating psychotropic drug to manage or control behavior. To give a medication may in fact be medical management of the patient’s condition and not inappropriate use.”

When asked how they used medication restraints, 51% of survey respondents said they use them to de-escalate aggressive, destructive behavior. Thirty-seven said they use medication restraints to manage behavior, 25% said they use them for other purposes, and 7% said they use them to restrict freedom of movement.

Hope you found this useful. Go to to download the full 11-page report, as well as other benchmarking reports from this year.

AHAP Conference, Day 2

Hello again from Las Vegas!

I wanted to send you an update from Day Two of the AHAP conference. Members got a chance to learn about a few different topics–restraint and seclusion, the top 10 most frequently cited Joint Commission standards, and the 2009 updates to The Joint Commission’s Leadership standards.

During the restraint and seclusion session, Lisa Eddy, RN, CPHQ, senior consultant for The Greeley Company, discussed some of the changes to CMS’ requirements, as well as the differences between what The Joint Commission and CMS require.

Kurt Patton, MS, prinicpal of Patton Consulting, discussed the 10 most frequently scored Joint Commission standards. The top three of these include MM.2.20 (medication storage), NPSG # 2C (critical tests and values), and NPSG # 2B (unapproved abbreviations). MM.2.20 is so highly cited because of its 15 EPs, with the largest problem being the storage of medicatons.

Lisa Eddy spoke during another session on the updates to The Joint Commission’s Leadership standards for 2009. Some of the updates include new language as far as conflict management, leadership relationships, and leaders’ responsibilities in creating a culture of safety.

Lastly, attendees participated in roundtable sessions in which they got the chance to network with their peers on many topics, including critical test results, medication reconciliation, unannounced surveys, National Patient Safety Goals and suicide risk assessment. Attendees discussed their own barriers and successes in these areas and others.