Restraints

  1. 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 hours that you do not have an order? Do you leave the patient in restraints? Or do you remove them?



    Regarding the specific patient that I observed, the restraints remained in place and none of the other nurses on the floor seemed to have a problem with this. Maybe its because I am new that I am thinking this is wrong?
    Any input would be greatly appreciated.
    Last edit by emm1256 on Jul 29
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  2. 19 Comments

  3. by   emm1256
    Any advice? Should I repost this to general nursing?
  4. by   Rose_Queen
    I don't work with restraints in my setting, but as to reposting, just be patient. It's the weekend, when AN sees a lot less traffic. Additionally, this is something that your employer should have a policy on- have you checked to see what the policy states?
  5. by   emm1256
    Sorry for seeming impatient, I was just really curious. I have checked the employers policy and it is rather vague. To my best understanding, you have 1 hour after the application of new restraints to get a new order. So 'technically' I believe you have 25 hours from the initial order. However, this went into the 26th hour. I don't know. Maybe I'm just making a big deal of nothing.
  6. by   elkpark
    Someone needs to call the physician and get a new order before the previous order expires.
  7. by   AJJKRN
    My facility moved to just getting the order renewed daily. Doesn't matter of the time and DNV approves of the change in practice.
  8. by   chare
    The 1 hour that you refer to pertains to the initial order only, with the intent being that this allows you to place the restraints at the time of need, and then obtain the order; not to have an hour to leave the patient in restraints while the order is renewed. Once the order has expired the patient should be removed from restraints as you no longer have a valid order, and any period of time, other than the 1 hour grace period with initial application is non compliant with guidelines.

    Our restrain t orders used to be written for 24 hours, however there were compliance issues with renewal and lapsed orders. Our policy has now been change so that our non-violent restraint orders expire at 2359 on the second calendar day after the order was written. This, coupled with the fact that the continued need for restraints is discussed during rounds and the order renewed as needed has significantly increased our compliance.
  9. by   chiandre
    Any time that there is not a valid order for the restrain, it is illegal to continue the restraint and could be a liability issue. If any harm happens to the patient during that period without an order, the hospital and the responsible RN would be liable for improperly restraining a patient.
  10. by   MunoRN
    Remember that nursing is all about prioritizing, given the choice between keeping the patient safe and ensuring administrative compliance you keep the patient safe, and then work on correcting the paperwork issue.

    I am part of the group that works with our surveyors and this question sometimes comes up, the consistent answer is that they expect we keep the patient safe, if we don't consider it safe to remove the restraints then they expect the restraints to be used until either a new order is received or the physician orders to remove the restraints, a late renewal is not the same as an order to remove restraints.

    As an example, I often get transfers from other hospitals, sometimes on multiple high dose pressors and/or inotropes, sometimes with circulatory support devices running, there is always a period of time after arrival where I have no valid orders for the medications and mechanical treatment the patient is receiving, should I just shut them all off until the MD gives me orders? Does that seem like good nursing judgement?
  11. by   elkpark
    Quote from MunoRN
    As an example, I often get transfers from other hospitals, sometimes on multiple high dose pressors and/or inotropes, sometimes with circulatory support devices running, there is always a period of time after arrival where I have no valid orders for the medications and mechanical treatment the patient is receiving, should I just shut them all off until the MD gives me orders? Does that seem like good nursing judgement?
    There is a huge difference between life-sustaining medical treatment and restraints.
    Last edit by elkpark on Jul 30 : Reason: fixed typo
  12. by   chare
    Quote from MunoRN
    […]
    I am part of the group that works with our surveyors and this question sometimes comes up, the consistent answer is that they expect we keep the patient safe, if we don't consider it safe to remove the restraints then they expect the restraints to be used until either a new order is received or the physician orders to remove the restraints, a late renewal is not the same as an order to remove restraints.
    […]
    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.
  13. by   Nurse Beth
    Quote from chiandre
    Any time that there is not a valid order for the restrain, it is illegal to continue the restraint and could be a liability issue. If any harm happens to the patient during that period without an order, the hospital and the responsible RN would be liable for improperly restraining a patient.
    So true, it's a huge liability. Restraining a patient without an order puts your facility at risk from the state, TJC, CMS...any regulatory agency with hospital oversight.

    What you can do is discontinue the restraints if the order expires as a work around while trying to contact the provider.

    If the patient still meets criteria for restraints, you can re-apply (counts as a separate episode), which buys you one hour to contact the provider for a new order.

    This protects the patient's safety while meeting requirements.
    Last edit by Nurse Beth on Jul 30
  14. by   elkpark
    Quote from Nurse Beth
    So true, it's a huge liability. Restraining a patient without an order puts your facility at risk from the state, TJC, CMS...any regulatory agency with hospital oversight.

    What you can do is discontinue the restraints when the order expires.

    If alternatives are tried and the patient still meets criteria for restraints, you can re-apply (counts as a separate episode), which buys you one hour to contact the provider for a new order.

    This protects the patient's safety while meeting requirements.
    Everywhere I've ever worked over the years, it has been the responsibility of the RN assigned to the restrained client to be aware of when the current restraint order expires and to contact the ordering physician (or some physician, if it's a matter of someone else being on call, or whatever) and get a renewal order for the restraints prior to the expiration of the current order. Even finding yourself in the position of needing to "buy time" to get the order renewed would be considered a significant error on the part of the RN.

    It's pretty simple -- when someone is in restraints, it's the responsibility of the assigned RN to stay on top of and be proactive about the orders.

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