Use of Restraints on Intubated patients - ER and ICU

[MassED]

Ok, so I'm definitely unsure of the state/federal laws on using restraints for intubated patients that are used solely to prevent a patient from pulling out their ET tube. I regularly place soft wrist restraints on my intubated patients. Often we have to adjust their sedation and I once had a patient pull out her tube, so I'm very cautious.

There's an educator where I work whose specialty is geriatric psych, so I'm not sure she knows how the law/rules apply for our specific population/environment, since this type of restraint is different. She states we need an order.

I haven't been able to find the specific laws on this topic. I have been looking for resources to be able to check my own nursing practice. I'm sure I'll be called out again for this by this educator, so I just want to be sure that what I'm doing is not just "how we've done it," or is there validity to what I have been doing.

I also do not regularly see orders for an ICU patient that has "soft wrist restraints" as an order to protect ET tube.

Ideas? Thoughts? Resources?

Thanks!

[Altra, BSN, RN]

Listen, in the ED restraints are used all the time without an order, we all know that. In p&p you bet an order is "needed". Just make sure you get the order or remove them before you transfer them out.

In all other units you must get an order no matter what the reason for application is and is renewable every 12 or 24 hrs depending on policy.

I agree with what you're saying, except the implication (might just be my interpretation) that orders aren't needed in an ED setting. And that is simply not the case. Orders are needed -- it might just be that the order is being obtained as the situation requiring restraints is developing, or immediately afterward.

Bottom line, OP -- in the ED things move fast, and there will rarely be an order prior to the application of restraints. But if you put restraints on your patient and the DOH were to walk in two seconds later ... believe me ... there better be an order.

Restraints for an intubated patient fall under non-violent or non-behavioral or whatever term your facility uses.

If the providers in your ED have grown accustomed to not writing orders for restraints for intubated patients that is unacceptable -- and it is time to change that.

[sauconyrunner]

I was an ER nurse for years, you do need the order, within an hour of applying them and the MD has to assess them within that hour- which of course is usually not an issue in the ED, as the MD who intubated the patient should be right there. Most places do have protocols for intubated/sedated pts, depends on your ED. For us we use computerized entry, so the nurses usually put the order in while the MD is intubating.

[Esme12, ASN, BSN, RN]

I think we need to cognizant that not all facilities/managers/educators are as judicious in the education of their staff in the use of restraints. I don't think we need to jump to an individuals competency because their facility shortcommings or

misinformation by personally commenting on their abilities as a nurse.

MassED...if you are accredited.....you need an order. I have worked the ED for EONS and an order is required.

Federal Medicare regulations and policies, as well as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), impose restrictions on how facilities may use physical or chemical restraints. Most states also have laws regarding patient restraints. Although the statutes differ slightly from state to state, such laws generally require the restraint to be:

• Authorized in writing by a physician.
  
• Used for only a specified period of time.
  
• Applied only by a physician or other qualified licensed nurse or personnel under the supervision of the physician.
  

The liability risk in using restraints can be reduced significantly if the hospital has a written policy that is stated clearly and followed consistently. A written policy helps hospital personnel understand when restraints can and cannot be used. Any adopted policy should:

• Strike a good balance between the need for the judicious use of restraints to protect the patient from injury and the avoidance of the misuse or overuse of such restraints.
  
• Provide that restraints be used sparingly and only when no less restrictive means is available.
  
• Never be used for a period greater than 24 hours without the attending physician's reassessment of the patient's condition and need for further restraint.
  
• Prohibit the use of PRN or as-needed patient restraint orders.
  
• Require the physician to make the determination a restraint is needed. If an oral order is the basis of the restraint, the physician should evaluate the patient and sign the order within 24 hours. In all cases, the physician should certify in writing that the patient's life or health could be seriously jeopardized unless restraints are used, and that no less restrictive alternative is realistically possible.
  

A patient should never be restrained solely for the convenience of the hospital staff or as punishment. Such punitive or convenience restraint use is prohibited expressly by most state laws, Medicare regulations and JCAHO standards.

Liability risk for restraint use can be further reduced by having the incompetent patients guardian or family member sign a release form: Understanding Patient Restraints -- A Hospital's Decision to use Restraints

For the most part....this summary of the direct impact elements of performance (EP). All direct impact requirements for this subject are Category A of The Joint Commission

• EP.03.05.01 focuses on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.
  
• EP.03.05.03, EP.1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.
  Suggestion: Implement a well-designed education program that aligns practice across the organization. Provide documentation/competencies of the education. Remember that the medical staff needs restraint education as well. This can be an abbreviated educational document provided to physicians. Don't forget about security guards or other non-licensed personnel that observe patients in restraints or assist with the application of restraints. EP.03.05.05, EP.5 applies only to restraint used for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours. Remember, EP 4 defines the age specific time-limited orders.
  
• EP.03.05.05, EP.6 requires renewal of medical (non violent) restraint according to hospital policy. A single instance of a missing order could generate a direct impact RFI.
  Suggestion: Consider the use of protocol orders with specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day, but you must follow your policy.
  
• EP.03.05.11, EP.1 requires a face-to-face evaluation of violent or self-destructive patients by a responsible physician or an appropriately trained RN or physician assistant (PA) within one hour of the application of the restraint/seclusion.
  Suggestion: Ensure that all RNs who staff the emergency department or the behavioral healthcare unit have documented training and competencies in evaluating violent or self-destructive patients.
  
• EP.03.05.11, EP.2 requires a nurse or PA who performs the one-hour face-to-face evaluation of violent or self-destructive patients to consult with the responsible physician as soon as possible after initiation of restraint.
  
• EP.03.05.11, EP.3 specifies the content of the one-hour evaluation of violent patients.
  Suggestion: Hard code this documentation into forms or computer templates. Include the four required components of the face-to-face evaluation defined in EP3.
  
• EP.03.05.13, EP.1 requires the continuous observation of patients who are simultaneously restrained and secluded
  

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter08-18.pdf

CMS regulations is some 350 pages long but here is the link

The rules for behavioral restraint are different for medical device restraint...but both require orders. If your facility is Joint commission accredited..you have a policy somewhere. It is very common for "the usual and customary.....we've always done it this way" to be the prevalent culture ......it is not the legal one. Some states do have additional laws the supplement the federal CMS mandates so it would be best to check.

Here is one for Minnisota....Requesting The Use Of A Physical Restraint

I hope this helps.

[Merlyn]

http://oig.hhs.gov/oei/reports/oei-04-99-00150.pdf

Policy of restraints

[yiyayiya]

You certainly will never be using restraints on me. I refuse restraints for ANYTHING regardless of the consequences and also have an AD set up to that effect. If any procedure requires restraints of any kind then I refuse that procedure, even if there is a serious risk of death.

[Altra, BSN, RN]

Am I safe to assume then, that your advance directive states that you are DNI - do not intubate - in the event you stop breathing? As you wish.

[elkpark]

You certainly will never be using restraints on me. I refuse restraints for ANYTHING regardless of the consequences and also have an AD set up to that effect. If any procedure requires restraints of any kind then I refuse that procedure, even if there is a serious risk of death.

I've worked in psych settings over the years in which individuals would come in with psych advanced directives paperwork saying that they "refused" restraint or seclusion. Know what happened if they got violent/dangerous? They got restrained if necessary, same as anyone else. Let me tell ya, if push comes to shove, staff in psych settings, or any healthcare settings, will do what is necessary to keep people safe.

Advanced directives get ignored all the time in hospitals.

And, really?? You'd rather die than be temporarily restrained? How come?

[Sun0408, ASN, RN]

The sad part about AD, DNI, DNR is the paperwork shows up after the work is done. It shows up after an accident and the DNI is now intubated and sedated. The DNR paperwork shows up after the code.. Family is not real quick at bringing the paperwork in plus I have yet to see a pt that had their AD on them in a time of emergency. EMS is not looking for it in an accident, fall, etc either...

OP, yes we have to have an order q24h. The MD must be notified within the hour and the fact the restraints are for ETT protection does not matter, we still must have an order. Mittens at my current facility is not a restraint as long as they are not tied down so no order needed for them. My last facility mittens were restraints and we had to have an order..

[yiyayiya]

Yes - DNI. Can use non-invasive ventilation but nothing more. If my wishes / AD was ignored in a hospital, the people responsible would be in court for battery and false imprisonment as well as up in front of the Medical council so I would suggest they get trained in an alternative career. What so called medical professionals keep forgetting is that they are not god. If a person is "competent" or has an AD they cannot by law go against this regardless. The more people realised this and kept control of what is done to them the better it would be.

[yiyayiya]

If intubation is done re an accident and the AD was not known then fine but this would be rectified as soon as it was discovered - eg extubation. Again - refer to previous post, anyone not following my wishes - ad would end up in court / medical council.

[emtb2rn, BSN, RN, EMT-B]

If intubation is done re an accident and the AD was not known then fine but this would be rectified as soon as it was discovered - eg extubation. Again - refer to previous post, anyone not following my wishes - ad would end up in court / medical council.

To prevent the accidental intubation, I suggest getting DNI tattooed across your upper chest. Solve the potential issue right quick.

[Esme12, ASN, BSN, RN]

You certainly will never be using restraints on me. I refuse restraints for ANYTHING regardless of the consequences and also have an AD set up to that effect. If any procedure requires restraints of any kind then I refuse that procedure, even if there is a serious risk of death.

This thread is about a year old and is about the US regulations/requirements/laws regarding the use of restraints in the hospitals settings and the documentation necessary for healthcare workers.

I know you have issues with being restrained for any reason as you have indicated in many posts. It is good that you have taken steps towards making your personal wishes clear for the healthcare providers. Here in the US not all states recognize Advanced Directives/living will as legally binding but as a list you what the patient wishes in the event they are unable to decide for themselves.

If in the event you are rendered unconscious in an accident and clinging to life....the EMS/paramedics will not be looking for paperwork about your wishes for intubation...they will save your life first and if they happen across your documents later will take them under advisement .......but will not necessarily remove your from life support because you don't like restraints.

Here in the US we are obligated to protect you and others from self harm (Danger to himself or others) until you are able to make "rational" decisions. Each state here in the US have their own criteria as to what constitutes "imminent danger to self and others"in which the medical staff can restrain and hold someone against their will. Danger to Self or Others Guide - Colorado.gov

A person may be dangerous to self and others when he or she have recently threatened or attempted suicide or some serious bodily injury. He or she may have demonstrated danger of substantial and imminent harm to himself and/ or others through some recent act, attempt or threat of the same. ‘Dangerous to self’ may also include a situation where a person is unable to cater to his nourishment, shelter or self protection without supervision or assistance of another person. Without such supervision and adequate treatment, it is probable that the mentally ill individual may succumb to death, substantial bodily injury or serious physical debilitation or disease.

An example of Missouri Law. Mo. Rev. Stat. 552.040.9 “No committed person shall be unconditionally released unless it is determined through the procedures in this section that the person does not have, and in the reasonable future is not likely to have, a mental disease or defect rendering the person dangerous to the safety of himself or others.”

Every effort is always made to follow a patients wishes when they are alert and oriented and no patient that is in control of their faculties is ever forced and restrained for any procedure that they refuse.

When restraints are used in the US in healthcare facilities there are certain laws/guidelines that must be followed as required by law. Which is what this thread is about.

Lets stick to topic please....:)