MUSC Health Patient Restraint and Alternatives

1. MUSC Health Patient Restraint and Alternatives Ramona Smith, MSN,RN Mary Allen, BSN, RN Celeste Phillips, MN, RN Sept 2008

2. MUHA Policy on Seclusion and Restraint This presentation is based on MUHA Policy C-22 Restraint and Seclusion If you would like to review this policy go to this link MUSC Policy C-22 Policy

3. MUSC Philosophy on Seclusion and Restraint to protect the patient�s health and safety preserve the patient�s dignity, rights and well being to reduce, prevent or eliminate the use of restraints.

4. CMS Definitions of Restraints Any manual method of head or extremity immobilization which prevents movement Does not include immobilization for procedures. Does not include orthopedic or protective devices

5. CMS definition of Seclusion The involuntary confinement of a patient, alone in an area, to prevent harm to self or others. Seclusion may only be used for management of violent or self destructive behavior.

6. Restraints are used only As a last resort After alternatives to restraints are used To promote medical healing To prevent imminent risk of injury to the patient or others

7. Initial Assessment All patients are assessed on admission Assess for risk of potential injury that may require the use of restraint or seclusion.

8. Educate Patient and Family If patient is deemed at risk for restraints educate patient and family about: Behaviors leading to restraint Alternatives to restraint Types of restraint Info in �Patient Safety Brochure� Patient rights related to restraint and seclusion.

9. Involve Patient and Family in Plan of Care Patient�s family notified no later than 24 hours after restraint/seclusion initiated

10. Restraint Policy Highlights Physician or medical provider order required. May never be written as PRN order. Seclusion and restraint are never initiated for: staff convenience as a substitute for staffing to monitor patients or as a punative action

11. Restraint Policy Highlights The patient�s face is NEVER covered The airway is NEVER obstructed during seclusion or restraint For example, with a patient who is spitting, the staff should use personal protective equipment such as gowns, goggles, gloves.

12. Release of Restraints Restraint or Seclusion must be discontinued at the earliest possible time regardless of length of order. Restraints should be removed when Patient is no longer interfering with lines/tubes/dressings Patient is able to consistently follow directions

13. Alternatives to Restraints Physical Distraction Regular physical exercise Control of pain Call light near Frequent toileting Environment Room at conformable temperature Nightlight or bathroom light on Minimize noise

14. WHAT IF Restraint ALTERNATIVES FAIL?

15. TYPES OF RESTRAINT ORDERS AT MUSCHealth

16. 2 Types of Restraint & Seclusion Orders Restraint for Acute Medical and Post Surgical Care Any device used to improve a patient�s well being and promote medical healing regardless of diagnosis or setting eg. wrist or vest restraints Seclusion and Restraint for Behavior Management Interventions used in emergency situations when there is imminent risk of harming self or others

17. Restraint Order Forms Medical/Post Surgical Order Form banded in blue Seclusion/Behavior Management Order Form banded in red Complete one of these forms for restraints

18. Restraint Order for Medical/Post Surgical Restraints

19. Medical/Post-Surgical Restraint Order Form

20. Medical Post Surgical RN may initiate restraints in emergency Must obtain order within 1 hour Order must be signed within 24 hr Attending MD must be notified as soon as possible within 24 hours.

21. Medical/Post-SurgicalPatient Assessment Patient assessed at least every hour for nutrition, hydration, pain, toileting needs Restraints removed every 2 hours and patient assessed for range of motion, skin integrity These actions are documented on the Restraint Documentation Form

22. Restraint DocumentationHard copy or Clin Doc

23. PRN RESTRAINT ORDERS?

24. Behavioral Seclusion/Restraint May be initiated by RN Notify physician within 30 minutes Verbal orders signed within 30 minutes Patient seen by physician within I hour Strict time limits - maximum time for adults is 4 hours Patient must be assessed every 15 minutes

25. Seclusion/Restraint Order for Behavioral Management

26. Behavior Management Order Form

27. PRN RESTRAINT ORDERS?

28. Length of time for restraints The length of time patient is guided both by our restraint policy AND on individual patient assessment Patient�s should not automatically be placed on restraints for the full time allowed by the policy. Times should be individualized.

29. Restraint Alternatives

30. Hospitals are required to use the least restrictive restraints available When selecting restraint devices, the least restrictive should be tried first.

31. Restraint Devices at MUSC Health

32. Not this!

33. And not this

34. Side Rail Protectors Must be used on any patient in restraints not receiving constant observation Specialty bed companies have side rail protectors. Be sure to request when you order bed. Prevents injury Fills gap between bed and rails

35. Dangers of Not Using Side Rail Protectors The following slides show the dangers of not using side rail protectors when patients are restrained in split rail beds and not under constant observation.

41. Restraint Products at MUSC Health

42. Alternative to Restraint Hospitals are required to use restraint alternatives whenever possible.

43. Activity Apron: A restraint alternative ESI 1511 Bright colors and texture variation provide visual and tactile stimulation; zipper and buttoning buttons aids improvement of fine motor skills. Download Instructions Posey Activity Apron

44. Restraint Devices The following slides will show restraint devices available at MUSC Health for Prevention of Tube Pulling Prevention of Falls Restraint devices are presented from least restrictive to most restrictive devices.

45. Prevent Tube Pulling Shown from least to Most Restrictive Freedom Splint Peek a Boo Mit Limb Holder Twice as Tough Cuff

46. Posey Freedom Splint Arm Splint ESI # 2587 Adult ESI # ? Peds These multi-purpose arm Splints offer a gentle reminder to restrict arm movement, without resorting to rigid arm splints. To download instructions and see application video: Posey Freedom Splints

47. Posey Peek a Boo MIT Posey Peek-A-Boo Mit ESI # 2588 The Posey Peek-A-Boo Mitts feature a double-padded design that provides safety and comfort. The Quick-Check flap enables circulation checks, without having to remove the Mitt.  To download instructions and see an application video see: Posey Peek-A-Boo Mitts

48. Quick Release Limb Holder Posey Quick-Release Limb Holders ESI# 1510 Adult ESI # 333 Child Foam padded ankle and wrist restraint secures with hook and loop and a quick-release buckle... Cuff fits pediatric or adult limb. One pair per package. To download instructions and see an instructional video go to: Posey Quick-Release Limb Holders

49. Double Strap Limb Holder ESI # 2625 Foam padded ankle and wrist restraint with double straps secures with hook and loop and a quick-release buckle. The double connecting straps allow "triangulation," which limits range of motion more effectively than a single strap To download instructions and watch application video see: Posey Double Strap Foam Limb Holders

50. Twice as Tough Cuffs ANKLE (red) ESI # 1517 Adult WRIST/ANKLE (blue) ESI # 1509 Adult For greatest limitation of limb movement. Download Instructions: Twice as Tough Cuffs

51. Devices for Patients at Risk for Falls Wrap around self releasing Posy Torso support Self releasing roll belt General Purpose Belt for bed and gurney Roll Belt Sleeved Vest

52. Posey Wrap Around Self Releasing ESI # 2708 XXL May be positioned in front of patient for self-release or in the back for assisted release. Can also be used on a bed or stretcher for temporary patient positioning. Download instructions Posey SR Wrap-Around

53. POSEY TORSO SUPPORT ESI # 1505 Large ESI # 1506 Med Helps prevent tilting, leaning and forward sliding. The Torso Support is self-releasing and provides soft, broad support around the chest and over the shoulders. Allows the caregiver to determine method of release and the front hook and loop fastener allows "self-assisting" patients to open it themselves. Download Instructions Posey Torso Support

54. Roll Belt � self releasing Posey SR Roll Belt ESI # 2622 Adult Reg The Posey SR Roll Belt allows patients to sit up in bed or roll from side to side. Self-releasing with quick-release buckle closure. Ends tie to bed frame or are available with quick-release buckles. Machine washable. One per package. To download instructions or see application video go to: Posey SR Roll Belt

55. Posey Roll Belt (Quick release buckle) ESI # 2595 Adult XL ESI # 2596 Adult The Posey Roll Belt is a less restrictive restraint that allows the patient to sit up or roll from side to side in bed. Helps prevent the patient from falling or getting out of bed unassisted. Straps attach to bed frame out of patient's reach. Download Instructions: To download instructions or see application video go to: Posey Roll Belt

56. Posey Sleeved Jacket http://www.posey.com/poseystore/ProductInfo.aspx?productid=3360 ESI # 1982 Adult SmallESI# 1983 Adult Med ESI # 1984 Adult Large ESI # 1985 Adult XL ESI # 2593 Adult XXL ESI# 2594 Adult XXXL A versatile restraint for positioning in either bed, wheelchair or geri-chair. To download instructions and see instructional video go to: Posey Sleeved Jacket - Poly/Cotton Plaid with Quick-Release Buckle

57. General Purpose Belt - Bed ESI # 2706 90�x3� (for bed) ESI # 2707 66�x3� (for stretcher) An appropriate fifth-point restraint for use in the Emergency Department or Psychiatric Unit. May be applied at chest, waist, or leg position in bed or on a stretcher. Closes with hook and loop for easy application. Download Instructions Posey General Purpose Belt

58. Pediatric Restraints Posey Pediatric Limb Holders ESI 333 Soft, foam ankle and wrist restraints can be used on arms or legs. Helps prevent picking, scratching or disruption of IV lines or tubes. To download instructions: Posey Pediatric Limb Holders

59. Pediatric Restraints Duncan Elbow Immobilizer �No No� ESI 406 Small ESI 407 Large

60. Thank you! Remember that the use of restraints often exposes patients to more danger than it protects them from. So Use Restraints as a last resort Use the least restrictive restraint first