Hooch

Thought I'd start a general discussion on the use of restraints, giving us the opportunity to discuss how common it is, the ethics, professional and legal implications, and what you may have come across in the course of your professional practice. As we all know there are three forms of restraints, those being chemical, physical and environmental. I always understood that the use of restraints should always be used as a last resort, and only when there's an imminent risk of harm, and it should always be the least restrictive. Here where I come from the national policy is to eliminate the use of all restraints, or if it's not possible after weighing up the risk versus harm, to use the least restrictive means of restraint. While we're told that we need to perform a full assessment on the patient before prior to any episode of restraint, do we do this? While it goes without saying that restraints should never be used to make our work easier, how often do we really question what we're doing? What kind of restraints have you come across and have you ever questioned whether the restraint that was being used was a bit OTT or necessary? While some of us have come across and accept the need for locked psychiatric units, how many of us have come across other environments where the entranceways to wards are locked? Again, where I come the entrances to the floor in ED's are generally locked to control access to the floor, with the added benefit of an electronic release button if staff, patients or relatives want to leave. So in that context, that's not really a form of restraint. However, I've also come across other environments where doors to wards are electronically locked and can only be released by members of staff. Curiously, they are not psychiatric or care of the elderly dementia units, they are wards where post-op surgical patients are getting rehab. So tell us your experience, what have you come across that led you to question, is this legal, and why are we doing it? How did management or colleagues react, if you questioned if the use of restraints was entirely appropriate?

And are you being a competent mentor if you ignore or shout at the new entrant for asking questions?

Sheer curiosity - I was reviewing the protocol for triage and it consists of a two pager Q&A that notes the method of arrival, time of arrival, presenting complaint, allergies, obs, GCS, investigations (ECG, urinalysis and tetorifice), pain score, drugs cardex, ABC's, the blaylock discharge planning risk assessment tool, and another section on patient discharge/transfer. It contrasts sharply with the realms and realms of paperwork that's you'd ordinarily end up doing on a ward - and that's in addition to having to do a written summary of the admission.

So in your experience would that mean that the triage nurse would only make a mental note of the information that would be conveyed to him/her by the ambulance crew at triage? Surely, not recording anything would leaves staff wide open legally?

Another quick question. We all know the importance of good record keeping, but would the receiving ED nurse in addition to recording the findings of their own assessment, also make a formal written record of all information that would be conveyed to him/her as part of the verbal handover from crews at triage?

Thank you - much appreciated.

You probably thought I was being smart - no I don't have a paper to write - it's just that I am trying to understand how triage operates in ED - and if there'd be a policy and protocol to guide practice. I no longer practice at the coldface (health law is more my thing) - and I never worked in ED before.

Quick question - do most ED's have triage policies and protocols in place to guide practice - and would the policy identify the locations where triage would be sited ie, majors and minors? How many triage areas are there in the unit that you work in, and were are they sited ie, is there one in major and a separate one for minors? Have any of you's ever come across two in majors? Would you consider it best practice for one nurse to be responsible for triaging arriving ambulances with the walk-in wounded together in a major trauma centre? I never worked in ED - so hence all the questions.

Try Clinical Research Coordinator.

I think this trumps it! Only three weeks ago it was a Policy with a nice shiny title which clearly delineated it as a policy, staff duly recognised and implemented it as a policy, and then suddenly within a three week time frame the "policy" magically morphs into a guideline . Despite the fact that each nurse is accountable for his/her practice, this Policy was developed by the medical directorate but the one's who are implementing it are the nurses. Now nothing wrong with that I hear you say. Unbelievably however (but not if you knew the country I was in) it now transpires this policy or guideline was drafted without due consideration to proofing it against legislation, professional standards and guidelines, evidence based practice or professional and ethical conduct. Add to that the non-application of best practice procedures which clearly stipulate that the development of policies and procedures must involve consultation with all key stakeholders, which in this instance are representative groups of the people who the policy/guidelines is most likely to affect, which is the Patient. And just when you think they couldn't be more off the wall, these geniuses also think that its entirely appropriate to evaluate this policy or guideline on a bi-annual basis, and this is despite the fact that it is clearly impacting on the fundamental rights and freedoms of the patient. Sometimes the mind boggles.....

And when you document "Nil concerns/complaints to time of report" what process of assessment do you undertake to reach that conclusion out of interest? Should there not be more detail as to what you're referring to?

We are all familiar with the standards of proper documentation that say's that any matter that affects patient care needs to be documented, and the presumption in cases of litigation that "If it isn't documented it isn't done"! Progress notes would tend to state facts like vital signs, levels of consciousness, sat levels, significant changes in the patients condition, and plans for diagnostics, procedures and discharge etc. This is a statement of facts based on your assessment and observation. However, sometimes in the documentation there is a singular reference to "No Complaints Voiced" and no explanation as to what it actually refers to. What does "No Complaints Voiced" actually mean? Is this a subjective observation or opinion, rather than it being a determined fact following an assessment? I would think that it can cover a multitude in terms of its actual meaning - from they didn't voice any complaints about having pain, elimination, mobilizing to breathing, to complaints about standards of care. But if a patient doesn't voice a complaint does that actually mean that they don't have any complaint? Should you document a blanket statement that the patient didn't voice any complaints if you didn't ask or give the patient the opportunity to voice a complaint? Are there certain groups who just don't like to complain about anything - like a generational thing - the older population being one case in point? If a patient had a problem with the standards of care they were receiving while they are still in hospital, how many are likely to complain while they are still in hospital or would they lodge a complaint post discharge? Thoughts.... Another question, when you sign documentation do you actually print your name in full or is it a signature akin to a scribble?

I used nursing as a stepping stone sideways into another career. While in training I always knew that I'd be heading back to uni - essentially nursing and my training was the catalyst to move in health policy analysis. What I would suggest, is that you need to get some post-qualification experience before you make that final decision. Its also important to be very clear on the reasons why you want to change careers because it involves a lot of commitment. Personally speaking, it helps if you've a genuine interest in, and a passion for the area the you're trying to break into. Another point to remember is that most career changes necessitate additional study - so its not as easy as making that decision and just getting a job.

Does the emergency department in which you work restrict the access that patients have to their significant other's and families, and if so, why? Patients who've attended a particular emergency department have reported that they were not allowed access to their significant other's or their families until visiting hours, and the allotted visiting times are one hour in the afternoon and one hour in the evening. They tell me that this seems to be a blanket policy that is implemented across the board, regardless of your code, or whether you are an ambulance admission or are the walk-in wounded. They did ask the nurses in the unit why they couldn't have somebody with them, and they were told that it was their policy, and it was on health and safety grounds. So there was no medical grounds for refusing access. However, in not being allowed to have access to their significant other's and families, some patient's complained that key bits of information giving the full-clinical history was often with-held from the clinical assessment phase, and often despite assurances that some family members had received that they would allowed to be present during the clinical assessment. Some patients felt totally aggrieved that they were denied the necessary emotional and psychological support without any just cause. In putting yourself in the shoes of a patient or their significant other or family member, would you tolerate this? And I am not for a moment blaming the patient or their significant other/family members either. The other question that struck me was when did significant other's and their families who accompany a relative to an emergency department become visitor's? Does anybody else think, that this might border on an abuse of power, or a failure to respect the rights of the patient?