Restraints - page 2

I have a question about something that I observed on the floor the other day. If a restraint order is set to expire at 0730 and the doctor does not renew until 0900, what do you do for those 1.5... Read More

  1. by   MunoRN
    Quote from elkpark
    There is a huge different between life-sustaining medical treatment and restraints.
    In a way, yes of course there is a huge difference, but they are also two interventions that directly ensure the patient's safety, the paperwork that reflects those interventions is not. If you realize the renewal is late you have two choices; remove the restraints and directly expose your patients to harm, or get the order renewed, the choice seems pretty clear.
  2. by   MunoRN
    Quote from chare
    The expectation, once the order has been written, is that the nurse and physician determine the continued need for restraints and ensure that the order has been renewed in a timely fashion. When the restraint order is written, it should include criteria for removal. If or when these criteria are met, the nurse should remove the restraints, and either discontinues the order per protocol, or if not allowed to do so, notify the physician that the order needs to be discontinued.

    Regarding an expired order; if the nurse caring for the patient continues the restraints, as is likely to happen, he or she needs to be aware that the patient is no longer compliant with current restraint guidelines and should have the order renewed/rewritten as soon as possible as there is no grace period for compliance once the order has expired.
    I completely agree that the nurse needs to get the order renewed as quickly as possible, but the solution is not to instead remove the restraints avoid needing the renewal.
  3. by   Nurse Beth
    Quote from MunoRN
    I completely agree that the nurse needs to get the order renewed as quickly as possible, but the solution is not to instead remove the restraints avoid needing the renewal.
    It's true nurses should not allow a restraint order to lapse. Neither should providers. But it happens.

    CMS considers a remove/re-apply as a second, distinct episode (unless they are briefly removed for purposes of supervised ADLs or circulation/skin checks).

    If I came to work and my patient was in restraints without an order (expired), and there was a delay in getting the provider to respond, the restraints could be discontinued/observe the patient/re-apply if neededed= second episode, rationale: restraints were applied for safety and the provider has one hour to call back.

    Not ideal, but the patient is safe.
  4. by   Esme12
    In cases like these I feel there is a systems failure. Where I have worked I have facilitated "RESTRAINTS RENEWAL" in the OE to flag to the MD that the order needs to be renewed.....BEFORE the order expires.

    If I came in to an expired restraints order and I feel the patient is in need of them....I call the MD and get the renewal order.
  5. by   Here.I.Stand
    Quote from elkpark
    There is a huge difference between life-sustaining medical treatment and restraints.
    Not if the pt would be trying to self-extubate or rip out their lines while unrestrained. Not always the case, but for some pts it is a true safety issue. Personally I'd rather defend my use of the restraints than defend my failure to keep my now-dead or anoxic pt safe
  6. by   PixieRN1
    Quote from Here.I.Stand
    Not if the pt would be trying to self-extubate or rip out their lines while unrestrained. Not always the case, but for some pts it is a true safety issue. Personally I'd rather defend my use of the restraints than defend my failure to keep my now-dead or anoxic pt safe
    NurseBeth’s excellent solution makes all this a moot point. D/C the restraints prior to expiration...closely observe your patient. If the patient is that unsafe that one would consider illegal restraints, we would know quickly. Keep the patient 1:1 in arms’ reach until they show you they need restraints again. Then immediately reapply the restraints. This creates a new event and you now have a brand new hour to secure an order for this new restraint event. PIA? Maybe. Inconvenient? Sure. But I’d rather keep the patient safe AND be legal in my practice. You can be both in this scenario.

    With NurseBeth’s suggestion, the patient is now completely legally restrained, no one has broken the law or violated the patient’s human rights...both of which are quite important when you want to keep your patient safe while not jeopardizing your nursing license. The BON cares a great deal about illegally restraining patients, even the critically ill ones who are trying to self-extubate.

    The BON is not your friend; they do not care one iota that you kept your patient safe if you did so illegally and outside of the boundaries of the laws that serve patient protection. They will discipline that license.

    Moral of the story: nobody needs to go down in flames over this one...no patients need to die from neglect and no nurse needs to face a Board hearing.

    Nurses just need to be hyper-aware with their restraint orders. Period. Know when they expire and don’t wait until the last hour to get them renewed. “I couldn’t reach the doctor” won’t hold up in court if you waited until an hour before it expired to try to reach the MD. “I was busy and could not get to it in time” won’t work either.

    I’ve faced the BON and I will do everything in my power to never, ever visit them again. So when it comes to restraints, I do whatever I need to to keep things perfectly legal.

    Best wishes.
  7. by   Accolay
    I think we need to be clear in how these restraints are being used. There are all manner of situations where I would continue restraints without an order (but getting one as soon as I can)

    In the example put forth by Here.I.stand and Muno: I agree. It makes no sense to un-restrain a sedated, intubated patient or one in critical condition simply because the order expired.

    Imagine going through that rationale with the BON:
    "Sorry they died... but the order was expired" (RN shrugs shoulders)
    An imperfect answer to an imperfect world: It's a bad grey area to be in, but we know this happens sometimes. Continue to check your orders and work with managers and teams to get a better fix. Use your best judgement and keep your patients safe.

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