New HCFA Restraint Policy

Ted · Jun 19, 2001

If these new regulations are true, it will be like being caught between a rock and a hard place. These are harmful regulations that will probably cause a lot of injuries before they are revised . . . you know, when lots of vented patients pulls out their ET tube, etc.!!! Can the patient and family sue the government for such thoughtless regulations?!?

Here's another thought. Will there be a lot of underground wrist restraints happening in the ICU/CCU settings??? :rolleyes:

TedF

ICU/CCU staff nurse.

Jenny P · Jun 19, 2001

I don't know about patients and their families suing the federal gov. if the patient is harmed because of this new regulation; but I do know we were told that we must comply with these regs. by June 26th when they are coming again to make sure we have changed our policies and procedures! My guess is that since they can make any announced or unannounced visits to hospitals, if there were "underground restraints" in ICU/CCUs; they would probably find out about it and cut off the Medicare funding for the hospitals that tried that.

Dplear · Jun 19, 2001

Jenny,

Every Hospital ICU I have ever worked at has protocols regarding the use of restraints in cases of life support equipment and they all have stated that you may use restraints as needed in cases of pt's that may accidentally pull out life supporting devices or unintentionally injure themselves while on life support. Check in the policies and I bet there is one covering that and the government has said such policies are valid through implied consent of the pt when they are unable to make those desicions for themselves due to medical condition.

[ June 19, 2001: Message edited by: Dplear ]

Barbara Rose · Jun 20, 2001

Check out the LTC regulations from Obra 87 and see what LTC has been dealing with!!!!!! Hospitals have had lots of time to see this train coming, and should have moved forward much faster, so I say (since I am from LTC) it is about time that everyone had to play by the same rules. You will be surprised at the alternatives, and the opportunity to learn about new devices, alarms, waring systems, new expensive beds, etc, etc. and will find out that in LTC lots of beds are on the floor to prevent falls. By the way, it really doesn't change the law suit environment, just the people filing; prior to the changes they suited over the use of restraints, now they sue because you don't use them, you can't win.

Jenny P · Jun 20, 2001

Dplear, in this part of the country, restraints are not used routinely when a patient has life support equipment in place. That is part of why these new regs. are so nasty-- in my 28 years of critical care in hospitals here in Mn., we have never used restraints on patients UNLESS the patient is in danger of harming himself (being confused and actually pulling at lines or trying to get out of bed) or harming someone else (violent and/or combative).

As I stated above, the policy we had in place was that a physician had to be notified and orders written within 12 hours of the restraints being applied; then those orders had to be renewed each day by the MD, and the RN could do the assessment re: the patients mentation and confusion.

Now that isn't good enough! These are brand new regulations this month, and whatever was a policy before is no longer adequate. :mad:

Barbara Rose, I am shocked and dismayed by your comments! Yes, I realize that LTC has had much different rules than acute care has had over the past few years. But for LTC and acute care to have the same rules regarding restraints? Come off it! You know which patients can become combative--you know your patients histories... you usually know what their previous behaviors were in different situations- that's why it is called LONG TERM care!

I love geriatrics, and started out as an aide in a nursing home and plan to someday go back to LTC when critical care finally gets too stressful for me. But we knew who had tendancies to wander, or hit, or harm others: we knew our residents very well. And they didn't have arterial lines or balloon pumps or other dangerous tubes and lines that, if dislodged, could cause them permanent injury or their death in less than 30 minutes. I know LTC has changed a lot since I was an aide, but you still get to know your residents much better than any acute care nurse ever could in the short hospital stay that modern health care forces on both the patient and the nurse.

The big difference is that our patients are in hospitals for such a short time that we never get to know them well enough to predict what they may do as their mentation changes (for instance, as anesthesia wears off, or how they may react to pain or meds).

I had a patient tell both the admitting nurse and his MDs that he was a "social drinker" and had a drink once a week. He went into full blown DT's on a Monday night after being hospitalized for 4 days; and it turned out that his definition of a "social drinker" was a case of beer and a quart of whiskey every Friday night! (I'm not sure what he thought all of those beers were, but to him they didn't count as "a drink!" Who knows, he may have drank a case of beer every night too!).

We do use many alternatives to restraints in acute care; we have sitters, the bed alarms and warning systems and other devices, but most of them won't work if you have someone pulling out their feeding tubes because they think it's a "buger" when you turn away from the bed for an instant (I know, they can do that in LTC also). We also use a confusion kit with lots of stuff for the patients to keep their hands and minds busy and out of trouble. :rolleyes:

I understand that LTC residents' beds may be on the floor these days, but be realistic! How do you get a fresh surgical Patient in and out of a bed that way several times per shift? :confused: Would you like to try it?

Barbara Rose · Jun 20, 2001

My comments were meant to be a little mean I guess. Not toward ICU where restraints are necessary, but to the medical floors at the hospital. I have worked just 1 year ago at the hospital, we had a policy as well, but the policy was used by nurses and aides who didn't want to check on pts. to restrain every elderly pt. on the floor. One pt. died from the stress of the restraint causing a heart attack. Where were the nurses? Not tending other pts, but at the nurses station, visiting. This is just one of many experiences I have had personally. So sorry if I upset you but there are alot of people out there using restraints as a babysitter or instead of care. That is why the regulations were changed. If you are not one of those people, you just are lucky enough to suffer with the "bad apples" but we all do that from time to time.

Now, in defense of those who use restraints right, I see that you will be more overworked than ever, and your pts. will still get the quality care they deserve because you will kill yourself to be sure that the proper procedures, etc. are followed and not abused. I am sorry that the good and bad are both suffering. My idea is now to address the time difference necessary for pt. care due to the changes and changes in the staffing numbers, grids, etc. in acute care to make up for this. I hope it can be done quickly but probably not. It is usually easier to get CNA's to work in the hospital due to better benefits, so perhaps they will at least add UAP's to help with this, who knows?

Jenny P · Jun 20, 2001

Barbara Rose, I don't think restraints are neccessary in ICU UNLESS the patient is confused or combative or agitated. We don't use them except for specific reasons, and we use sitters a lot if the nurse has 2 patients and cannot be at the bedside every minute.

Our old restraint policy was that we needed to get a restraint order within a reasonable time of using restraints and the order could remain in the chart as a PRN order until discharge. We had updated that back in December for the JCAHO visit (in Jan. or Feb.?) so that the order was in effect for a shorter period of time (I think while the patient was confused; with a new order necessary with the next confusion event; maybe?). Then after JCAHO visited (BTW, we passed with flying colors), HCFA came in March and they didn't like the restraint orders, so this visit this month was a follow-up on the visit in March. We had revamped our restraint orders so that the MD needed notification of restraints within 12 hours of restraints being applied, and daily re-ordering of restraints by the MD.

Now they are saying that that isn't good enough-- call the MD BEFORE using restraints! And the MD must do the assessments of restraints every 24 hours! It is so bizarre! In the 5-10 minutes that a doctor spends at the bedside; the patient may appear calm and co-operative; but as soon as that white lab coat leaves, he may be swinging at the nurses, or pulling lines, or trying to get out of bed again!

I think this region- and our hospital- uses restraints far less than hospitals on either coast or down south; and I do not understand why these regulations are so tough! I mean, if we were tying down every geriatric patient on a floor (as you say you have seen being done before), that would make sense to come down so hard on us; but we do use every alternative there is to try not to use restraints.

[ June 20, 2001: Message edited by: Jenny P ]

rncountry · Jun 21, 2001

We had a corporate nurse in today going over things for both Joint commission and HCFA, nothing was said about this new regulation. Maybe we will be notified later? I think personally that this bears looking into to ensure it is actually a new regulation coming in. As far as the debate on restraints in LTC vs. Acute care, please note that the two environments really are different. I have worked both ICU and LTC as a nurse. My ICU experience is Neuro. In Neuro restaint orders are very common. A closed head patient in particular could pull out lines and tubes with a nurse right in the room and within easy access to the patient. I have taken care of some closed heads that required security as well as several staff members to hold down long enought to get restraints on in order to keep them safe and be able to treat them. Not to mention the safety of the staff. Once we had a patient that was a closed head from a MVA who would have not only extubated himself and pulled every line, including a swan ganz, he would have attacked staff. He was restrained but pulled at the restraints so badly that he actually broke the handles on the bed designed for the restaints to be attached to. These were speciality beds for ICU. When we tried to keep him from extubating himself, he grabbed the hair of his primary nurse and would not let go. It was bad you guys. What we ended up having to do is to give him tracrium to paralyze him. He needed to be on the vent to blow off CO2 to help reduce brain swelling. This may be somewhat of an extreme case, but I will say that these type of extreme behaviors are not that uncommon for neuro patients. No, you are not likely to deal with this in LTC. Most issues there deal with trying to figure out a way to keep your patient from falling and harming themselves that way. And Barbara Rose you are so right, restrain them and your in trouble, don't and they fall your in trouble, both with family and the state. Damned if you do and damned if you don't. What I think the primary issue here is that nursing judgement is not being allowed for. As far as getting a physician to take a look before restraints do you not have access to an ER doc that would come up and provide that function if necessary? Seems to me that all but the smallest rural hospital has at least one ER doc in house at all times and I don't think it would be unreasonable to ask that unless the doc was in the middle of an emergency for them to make a trip to the unit in order to comply with the regs. Large teaching hospitals would have the availablity of residents in house at any given time. I may be wrong, but I know when I worked ICU there were times in the middle of the night when we had to have a doc now we utilized both of those resources. I realize not all places are going to have that resource, but is it possible where you are? Could make it function in a similar fashion as the code team does.

Not saying that this is smart, as it discounts nursing judgement. But I will agree with Barbara, some nurses use restaints in place of doing patient care. Though it has to be realized too that sometimes in an acute care setting the way things are now there are times you simply cannot be at the bedside enough to keep these patients safe. I don't think the majority of acute care settings are going to be able to have a sitter be there. While restraints should be a last resort, there are times it is necessary. I could not imagine functioning in a Neuro ICU without them. You can't even begin to reason with a closed head injured patient. The majority are extremely combative particularly in the beginning and you do get good at ducking and diving in that setting. Yet it is real hard to duck and dive and keep someone from extubating themselves at the same time. The restaint issue is a difficult one. I remember when I went into LTC and had a woman not more than 90lbs knock me upside the head on my third day on the floor when I was giving her her meds. I automatically went looking for restaints. Didn't find any and the other nurses got a good laugh when I went to the nursing station to ask them where they were. Big culture shock for me. Eventually I did learn who to watch out for, behaviour modification and all that, but in the acute care setting it is a different ballgame, and I firmly believe that staff have the right to be safe as well as having patient rights protected. Sometimes with a severely combative patient staff safety should come in front of patient rights. Particularly in the ER and critical care setting when the staff are dealing with problems that one is not likely to ever see in LTC. Paper pushers should have to follow the real provider at the bedside to get a clue what reality is all about, both in acute care and LTC.

Ted · Jun 21, 2001

I work in a ICU/CCU of a VERY small, rural hosptial. . . on the night shift. During the night, there's only one doctor in the whole house, the ER doctor who only comes up during a code situation! This means, if I understand the new restraint regulation correctly, the "on-call" MD who may live several miles a way would have to come up and sign the order before restraints are placed on a patient who is attempting to pull out the ETT, P.A line, and whatever. Doesn't seem realistic.

Please note: we very rarely use restraints on our unit! Usually, the patient, if he's agitated, is calmed down with a sitter (usually a family member), versed drip or a Propofol drip. However, there are times when I am the only nurse in the unit with one or two patients (which is another issue). If I'm by myself and I see a patient pulling on their central lines, I'm going to first try to calm the patient down and if all else fails, I'm going to place wrist restraint on . . . at least until I can find an alternative way to making sure the patient is out of harm's way. It's been several months since I last needed to place restraints on a patient. I go out of my way to avoid the use of restraints. My favorite method to help calm a patient down is to have a family member sit with the patient . . . all night long if needed. However, as you know, the restraints are needed at times.

So far within my facility, I can initiate the use of restraints (as a safety intervention in a ICU setting) and the MD can co-sign the order within 12 hours. Until I hear otherwise, I'm following this policy. . . and I hope the policy doesn't change!

Ted

[ June 21, 2001: Message edited by: Edward F. ]