Hi, I am an RN who worked full time in geri psych in the hospital(until recently, now on call). Restraint use is the biggist issue! JCAHO and HCFA make the rules regarding restraint use,as well as the state and the individual facility. JCAHO has a website for sure, I'm unsure about HCFA. It has been my experience that med surg units have some leeway and can use physical and chemical restraints, whereas we (mental health) have MANY stipulations and rules. We are not allowed to use restraints until every single, possible alternative, including "therapeutic holding" (or attempting to hold or hug the patient who is agitated until they calm- which if the patient is truly agitated is dangerous)has been tried and documented. Then the RN must assess the patient to determine what behavior is uncontrollable and get an order from a physician for a restraint such as vest,wrist, or seclusion; if medication is needed a one time only order for an IM, such as haldol or ativan may be ordered. However, the patient must be SEEN by the physician (within two hours I believe) and seen again if ordered needs to be renewed, and there is much paperwork, frequently the patient must be constantly monitored with documentation at least every 15 minutes and taken out of any physical restraints ASAP. If JACHO finds that documentation etc is incomplete there can be severe penalties, even including being "shut down". A year or two ago all psych staff where I worked had to become certified in a special technique in managing agitated patients called CPI, or Crisis Prevention and Intervention I believe, this was very effective with patients who are similar in size to the staff member, difficult for us to use on a 6 foot, 200 pound demented patient... The most accepted form of management is a "one to one" order where a patient has a staff member assigned to him/her 24 hours a day within arms length at all times, in hopes of heading off severe agitation episodes, or "quicker" management if patient did begin to escalate, this becomes expensive however. One of the biggest problems for us in the acute care setting is the "frequent flyer syndrome"- with our age population, and the type of patient- the demented- we see frequent readmissions due to state laws regarding the use of psychotropics. In long term care, if the patient is stable in their behaviors, the doctor must begin decreasing the dose of any/all psychotropics. My question here is- do we decrease the dose of insulin in a diabetic with stabilzed blood sugars? NO. For the episodically psychotic patient that rule is a good one, but for the chronically mentally ill, or demented patient who will only worsen, this causes frequent relapses, it is very sad and frustrating at times. I see other information posted as well regarding this issue, it is not a simple one and the misuse of a few has negatively impacted the rest, at times to the detriment of the patient. We have had to get creative about managing the environment in an effort to manage patients who become agitated. Other options to help keep a patient or his/her peers safe if the Vail Bed, Posey huggers, a gerichair with a tray, a low bed, padded side boards/rails, and for DT's a checklist of assessment designed to ID symptoms early and medicate to manage those symptoms until pt is safe with little risk of seizures. Hope this helps. It is my personal opinion that with better staffing in all healthcare facilities, the overall number of agitated patients would decrease as needs would be met and thorough assessments made for those patients who cannot express their needs and may become agitated when needs are unmet.
[This message has been edited by 505rn (edited September 18, 2000).]