Physican restraints still being used???

TitaniaSidhe · Mar 30, 2005

When all else fails & the patient is a danger to himself or others, violent, inflicting self harm with severe intent; in these situations mechanical restraint becomes necessary.

There are those rare occasions when you have someone go off without forewarning or get in a completely psychotic/violent admission & have no other recourse but to utilize mechanical restraints.

Not all facillities have a seclusion or "quiet room". Ours does not have one.

In our facillity the only people able to decide about utilizing mechanical restraints would be an MD or an RN. One, the other or both must be present during the application to ensure correctness, circulation, etc.

This is not a decision to be made by a nonprofessional, NA, tech or whatever. Also placing an individual in seclusion is considered a form of restraint. The documentation required is just as lengthy & it requires a MD order. Even side rails in an upright position on a bed in long term care are considered a form of restraint. Keeping a patient in a gerichair with the tray table up is considered restraint if the patient is incapable of opening up the tray table & getting out of the chair. Both also require an MD order & copious amounts of documentation.

Common sense would tell you to always choose the least restrictive but viable option first. As I said previously alternatives are always utilized with mechanical restraints being a last resort.

elkpark · Mar 30, 2005

Quiet rooms (or seclusion rooms) are found on most psych units (in my state, psych units are required to have at least one). They can be used to encourage/allow clients to calm down and get into better control of themselves in less stimulating environment, on a voluntary basis without the door being locked, and with the client free to come out of the room when/if s/he desires. In that situation, use of the room is not considered a restrictive intervention by the CMS standards (and most state standards).

The room can also be used to lock the client in ("locked seclusion"). Psych staff are mandated (by Federal and state regs and by standards of practice for physicians and nurses) to use the "least restrictive setting" necessary to protect the client from harming her/himself or others. Locked seclusion is considered a less restrictive setting/intervention than restraints, because the person is still free to move about the room and is not strapped down in one position (which also involves some real physical risks to the safety of the client). Often, people are placed in locked seclusion because they are unable to be safe in the general milieu of the unit at that particular time, and they are able to use the peace and quiet of the closed (locked) room (and any medication they may have gotten) to get back into control, be able to process with staff, and be able to return to the larger milieu. However, if someone is placed in the seclusion room and is noted to be attempting to harm her/himself (e.g., beating her/his head against the wall) and is unwilling or unable to stop that and be safe, that's the kind of situation in which someone would have to progress to physical restraints. There are also situations in which locked seclusion represents a greater safety risk to the client than physical restraints (e.g., a confused, frail elderly person who is lurching around the seclusion room and at real risk of falling and breaking something); in that kind of situation, restraints might be the better, safer intervention for that client.

I'm kinda surprised that all of this stuff hasn't already been reviewed in your psych nursing course ... ??? :confused:

Lawnurse · Mar 30, 2005

I'm kinda surprised that all of this stuff hasn't already been reviewed in your psych nursing course ... ???

I understand the theory behind it and I'm researching the law, but I want to know how this actually plays out on the unit. The shortcoming in all of "the law" is that it can't dictate what is lawful in every single situation.

Is there such thing as a standing prn order for restraints?

What about when a patient needs immediate restraint to keep from hurting self/others - can you restrain and then page the MD for an order, or do you actually have to wait for the order first?

If standing orders aren't allowed, does the MD have to assess the patient before making the order?

Nurse Ratched, RN · Mar 30, 2005

RN can initiate restraints and MD has to OK and visually assess (read: in person, regardless of whether it's 3am) within one hour. Can renew by phone at 4 hours, and need to have MD see pt in person every 8 hours while in restraints. A trained staff member must be assigned 1:1 with any pt in restraints. Additionally, on admission, all pt's complete a "behavioral advance directive" stating what measures they prefer for de-escalation should they become agitated (1:1 with staff, meds, pacing, isolating in a quiet room) however this does not mean they will not be restrained should the need arise, only that other measures will always be attempted first unless safety is immediately compromised. Finally, a debriefing form is completed anytime a pt is restrained to review the situation and see if restraints could have been avoided.

I feel quite comfortable in my legal standing as long as I follow my facility's policies/procedures to the letter. It's a rare pt who *isn't* threatening to sue me in the middle of the restraint process. Hasn't happened yet (knock on wood.)

Edited to add: there is no such thing as a PRN restraint order. I might also add that these rules are for behavioral restraints. Medically necessary restraints are another animal and fall under different guidelines.

elkpark · Mar 30, 2005

I understand the theory behind it and I'm researching the law, but I want to know how this actually plays out on the unit. The shortcoming in all of "the law" is that it can't dictate what is lawful in every single situation.

Please understand that I was not being critical of you at all -- you can only learn what you are being taught. I'm just surprised and curious because, when I was in nursing school, the legal requirements in my state as well as how restraint and seclusion issues played out "in real life" on psych units was discussed thoroughly in class, and when I was teaching psych nursing, I reviewed all of this thoroughly in class with my students.

Is this now another one of those things that we don't bother to teach students in nursing school anymore?? Because it's pretty important stuff to know ...

Lawnurse · Apr 1, 2005

For our last session of Civil Law & Psychiatry we are visiting an in-patient mental health setting - a pretty large facility - where we will have a chance to Q&A with patients. Not sure if I'll be able to Q&A with staff members. In any case, this will give me another perspective to compare with my experience at the Cleveland Clinic.

BTW, is it standard practice to hide the psych unit? At CCF it is in one of the surgery buildings, and there is no signage whatsoever to indicate it is a psych ward.

z's playa · Apr 1, 2005

The title of this thread makes it look like you are restraining physicians!

I know :rotfl: I read the title a few times and curiosity got the best of me! I had to come see where these unruly physicians were!

CharlieRN · Apr 12, 2005

While my facility does have locked leather 4 point restraints we usually use a restraint "bag". This is actualy a flannel lined canvas sheet with sewn in wooden battens. The patient is placed on the sheet, it is zipped closed then wrapped tightly to conform to the patient's body and strapped in place. A bagged patient is on 1:1 constant observation and the staff doing the 1:1 is checked q15mins by another staff. Bag restraint is rarely longer than one hr. The nurse in charge is the usual person to order the initiation of physical restraint but the on call MD has to come in and assess the patient within one hour. Under normal circumstances the restraint bag would not be used until a telephone order for it had been obtained. Patient safety might cause variation from the ideal. I'm not going to put a patient at risk because the DOC's beeper is malfunctioning.

We have found that patients generally feel less exposed and powerless in the cocoon-like restraint bag than they do spread eagled on a bed in 4 points.

Lawnurse · Apr 12, 2005

thank you for the reply - that is very interesting. Do you know who manufactures this or is it unique to your facility?

other question - so a pt in 4 point restraints is restrained to a bed? How are they restrained for bathroom privileges? like I said earlier, I never saw these being used in my psych rotation.

elkpark · Apr 12, 2005

We have found that patients generally feel less exposed and powerless in the cocoon-like restraint bag than they do spread eagled on a bed in 4 points.

It's also possible to buy "papoose boards" (I'm sure they have some official name, but I don't know it), that are used for procedures with infants and small children in peds settings, in sizes up to adult (6'). I've found, in working with kids and adolescents, that kids who have been sexually abused typically feel much safer and more comfortable wrapped in a papoose board than they do in conventional restraints on a bed, because of the abuse history and the feelings aroused by being restrained in a vulnerable position on a bed. (I'm sure the same would be true of adults with a history of sexual abuse, although I haven't worked in an adult setting that used the boards.) An additional benefit of the papoose board is that you can carry it to where the patient is, restrain her/him on the board, and then carry the patient on the board to the patient room or seclusion room (wherever you restrain people) instead of having to drag/wrestle the combative person to the room with the restraints ... That makes life a lot easier ... :)

lil'nurse · Apr 12, 2005

I worked in facility for the dev. disabled and we used 6 point restraint when someone became violent towards others. It was often neccessary because we were unable to use PRN meds in a non-acute setting like you can in the hospital. It was used as part of a behavior program that was made specifically for the individual. You had to use it as a very last resort and an MD needed to notified within the hour of application. Specific guidelines for release where used i.e. 15 min of calm behavior. Quiet rooms were not allowed. Also needed basket holds, two man escorts, etc. written into the program before they could be used on someone.

Lawnurse · Apr 13, 2005

What is a baskethold?