new restraint regs

  1. hello from florida- we are frustrated with the regs our hospital psych unit enforces. Chemical and physical restraints, the patient must be evaluated by a doc within 1 hour. Physical restraint orders are good for 4 hours, renewable x 1. this means on night shift, when there are no docs around, we cannot use restraints. I understand this has evolved from overuse, but help! Is anyone else having this problem? thank, PGH 70
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    About PGH70

    Joined: Oct '01; Posts: 16
    psych RN


  3. by   jajnurse
    We are not even allowed to use physical restraints in any case only chemical restraints. And that is probably why we have so many serious staff assaults. We were informed that we could wear helmets. I informed them that I was trained to be a nurse not a punching bag or a member of the National Guard.
  4. by   PGH70
    The helmet offer is the wildest I've heard in a while. What has happened to the rights of the nurse, or the medical staff. We are so concerned about patient rights that nurse safety rights have been ignored. Can you use chemical restraint without the patient's consent? We need the patient's consent for any psychotropic meds, or a court ordered mandate.
  5. by   jajnurse
    When the patient is first admitted we have them sign a sheet listing all the psychotropic meds that may be given during their stay. So we do have the right to restrain patient with an injection at our disgression. We are allowed after taking a patient down to blanket roll them but there is no use of even arm restraints. And this facility is a very high acuity psychiatric hospital. We, of course, have a very high rate of turnover in staff.
  6. by   Aerolizing
    The conditions you describe are unsafe to you and to your patients. If a patient is bent on self destruction or your destruction, they will accomplish their goal even if medicated. Ativan is only supposed to last for four hours. This is so crazy. I can't believe that this is going on in a hospital setting.
    As for a solution, there is always someone on call. There has to be a doc in the ED or on a Med/Surg floor who can come see the patient and order restraints and be done in only a few minutes including the paperwork. I would find it hard to believe that there are no docs available at all during night shift at any hospital.
    I am shocked that your administration did not back you up at all. This is so unsafe. Would they like it if you just closed down the psych unit while there are no docs there to cover? Sorry, all psych patients have to go home til the docs come in the morning. How can you be recertified by JCAHO when you don't have a doc available for emergencies? I am sitting here shaking my head. I just don't understand how this can happen. I would talk to my immediate supervisor and demand a solution before working again. If they offer you no answers, I would take it up as high as it goes. I would also call my state department of mental health. The states often have much stricter guidelines re: inpt psych units than JCAHO.
    What happened to the forcing of medication when a patient is a harm to himself or to others? With or without a patient's consent on a paper. Geeze. This is crazier behavior than the patients display.
    I love the wearing of helmets. What about full body armor? How insane. What state is doing this to its nurses? I would be getting myself a lawyer as well as my own malpractice insurance. Do either of you have a legal department? If so, I would contact them at once and ask them your rights in this situation.
    I would also start pressing charges against all who offend. Each and every time I would press charges. I would also highly encourage all those who are assaulted at work to do the same. When you start spending more time in court than working, maybe the administration would get the hint. I would also have each and every assault checked out by the emergency dept. That would mean that administration would have to cover the already unsafe working conditions til other help could arrive. How many administrators want to work psych? The last time I went to the ED for eval of work related patient inflicted injury it took me four hours to be seen. A patient had kicked out the safety glass with wires window from his door and somehow landed on my shin. I was out for five days as it somehow damaged my bone and five years later, I still have large overgrowth of bone on my shin where this happened. I would also encourage staff to take time to recoup from their injuries, making workman's comp claims when appropriate.
    Or, you could just find another job that is safe and then report the unsafe working conditions to anyone who will listen including JCAHO, state dept of mental health, county dept of mental health, any local investigative reporters.
    Get out before you get hurt.
  7. by   morghan
    Hello to all my Psych colleagues out there!
    This restraint issue is really the biggest mess... a prime example of big government interfering with patient care; however, this
    became necessary due to a number of deaths while patients
    were restrained. So, the Feds got involved. The order must be
    written by a physician, the client must be seen face to face within one hour, and bedrails and geri-chairs are also restraints in
    hospitals now. The big problems arose, not from who gave the order, but from rather substandard monitoring after the patient was restrained. Unfortunately, it will take the death of nurses
    or other psychiatric health care workers, before something is done to reverse this idiocy. There have already been some lawsuits filed by the Health Care Industry, whom do not have
    MD coverage 24/7 like some large teaching facilities do. We in Psych may not give meds against the patients wishes unless
    the person is court committed, and appropriate documentation reflects the needs for involuntary medication administration or
    unless the person is endangering self or others. Our facility gets really sick, forensic type persons, too. The other piece nobody has talked about is the pondorous documentation! This is a great forum. Some of my fellow students and I just finished
    writing a paper on this issue.

    PsychRN (Wichita, Kansas)
  8. by   Aerolizing
    Hi Morghan,
    Are there really hospitals out there who have no MD on site 24/7? Even in small community hospitals in our area (71 beds) there is an on call house officer. Even if they are not psychiatrists, they still have to be aware of these regs and I am sure write restraint orders on med/surg pts. Please tell me of any hospitals without 24/7 MD coverage so I can be sure never to get sick there.
  9. by   PGH70
    dear fellow psycho nurses: thanks for responding to my concerns about restraints. Morghan, I would love to read your paper about this topic, and to learn more about the lawsuits.
    Dear aerolizing: I love your passion, and your enthusiasm for what is right. My hospital, about 300 patients, has 1 or 2 ER docs that respond to Code Blues, and occasionally cover a restraint order if the patient is coming from the ER. THe problem is with the attending psychiatrists, who will not come in to assess the patient. If we need to continue to restrain, we write an incident report against the doc, to cover our own you know what.
    We have a big psych unit, 50, alot of geri's, and a hospital administration that lives in fear of losing their accreditation. When I'm charge, occasionally, I must admit I break the rules to protect the patient. I have decided if this puts my job in jeopardy, then so be it. I have never been hurt, and I don't want to be responsible for someone else getting hurt. But how do we fight this regulation?
  10. by   morghan
    Hi back to PGH in Florida (was that it??) I'm kinda brain fried....
    writing another paper... and work tomorrow. If you want to email me your mailing address privately (
    I will mail u a copy of our paper The position we took was that
    Advanced Practice Nurses with specialty training should be able to assess, write the order and do the face to face. My other cohort had the stuff on the lawsuits (this was a joint paper),
    but it's all in the public domain.. get out that surfin' finger and roam the web just type in "restraints" I got a lotta stuff that way. Good luck. and also. do what u have to do to keep all
    the patients and yourself safe. These stupid regs were not written by anybody who worked 11-7 shift in a forensic psych unit I betcha.
    PsychRN in Wichita
  11. by   canoehead
    I would call, have them refuse to come in and write those incident reports, nightly if necessary.

    This is a medical staff problem, not a nursing problem. If the patients need restraints and the docs refuse to evaluate them when they are mandated by regulation to do so they should be disciplined by their regulating body, be it hospital or state based. I also think your supervisors should support the use of necessary restaints even if the doc refuses to come in.

    The problem can be drawn as a parallel to a patient crashing on a medical unit. If you call and inform of the signs and symptoms, and the doc refuses to come in it is a medical staff issue, not a nursing issue. You need to go through channels, up the medical staff ladder to find someone who will respond appropriately, and then through admin channels with the incident report. Give initial life/health saving treatment as any prudent nurse would (parallel the 1st dose of nitro or a fluid bolus with initiating restraints).

    Perhaps your nursing board and hospital policies would assist you in what life/health saving treatments can be initiated without an MD order. And once they are initiated I cannot see anyone objecting to a reasonable and prudent action of continuing those measures, especially when the health of not only your patient, but those around him/her is being threatened. Just document all the evidence indicating that chaos would result if you dared D/C the restraints.

    Do not get taken in by the guilt trip of impending suits without an order for restraints. When it comes down to patient care or paperwork, always siding with patient care is the best action and the most defensible action. Just make sure you are going through channels EVERY TIME, and DOCUMENT.

    I really do not envy you some of the late night conversations you ar going to have in the next few weeks. It would be nice too if the other nurses are united in their approach
  12. by   morghan
    Reply to Moderator Re: restraint issue

    That's precisely what we have been doing... writing them up each and every time they refuse... but this issue still is a big problem.
    The problems with deaths in restraints have nothing to do with who writes the order or does a face to face assessment. The problems lie in 1.) really violent/ill psych patients (ie mental
    health reform) state hospitals closed 2.) substandard care delivery 3.) Shortage of qualified/skilled nursing staff that know how to de-escalate a situation and possibly divert a restraint
    episode 4) shortage of qualified nurses to monitor these
    patients while in restraints; now restrained patients are supposed to be 1:1's (try staffing for 7 or 8 1:1's on your 11-7 shift!!; or any other shift for that matter) I don't really know
    what the answers are, but I do know that more government
    intervention/interference is worse not better for health care.

    I really do enjoy the opportunity to comunicate with my colleagues out there... to my colleage in Fla... I'll type that paper in RTF and email it to you

    Hope everyone has a happy Thannksgiving!
  13. by   Aerolizing
    I have gotten my undies in a bunch over this whole issue. I just took a job where the policies and procedures book has not been updated in a few years. It is not management's top priority although my safety is MY top priority. I work nights on the weekends. When would you send your most drunk and disorderly patients for admission but on my shift?
    Our unit was built for little old depressed people, not high, psychotic ,young, and strong people. There are typically three staffers on nights but you know how that goes, so and so did not show up so you have to work short or there are other units with needs to so you lose. The supervisor only comes when there is adequate staffing so you won't ask her to cover for your lunch. I am finding out quickly that my license is the only one on the line here.
    I am finding great resistance to change. Forgive me if I don't think it makes sense to give a psychotic man a razor with a promise to return it when he is done. What happens to his roommate who is suicidal when he gets this razor because his brain dead formeldahyde smoking roommate forgot to turn it in? I will tell you that no one under my supervision will do it on my shift, under my license, policy or not.
    One of the first nursing horror stories I heard was from an old nurse who told me never let a razor out of your site. She used to work for my employer and she saw blood rushing out from under the door where she let a stable patient shave himself. He had slashed his wrists the right way and they had to call a code on him. He really was in bad shape but he lived.
    That is just one of the policies I am trying like heck to change.
    Also, anyone here heard of giving a locked seclusion patient a bed side table? Has anyone ever seen how much damage a caster from that table can do to glass windows? Even safety glass?
    It is getting pretty scary these days when only one nurse is on duty with 20 patients. All of them under my care. I am soooo lucky that I work with great support people.
    I am trying to keep things positive and tell myself that this is a great opportunity to change policy (management willing) and to improve staff morale and make long lasting changes for the safety of patients and staff.

    ps I work prn at a local gero psych facility where the LPN I worked with told me that it is part of the job to get hurt by patients. She lost her second tooth to a patient punch. I told her I would hold a patient's hands if he were trying to punch me. She told me, no, that is patient abuse. I argued that no one has to put up with being battered on the job. She told me that was their right to hit me. She has been doing this too long I think.
  14. by   PGH70
    dear aerolizing : its 11 PM, a night off, and here we are discussing night shift on the psycho ward.
    I hope you have some power, your unit sounds like it needs some changes. Do you pass JACHO inspections?
    We have 3 levels of precautions, and yes, on the best level, level 1 we allow the pt to have a razor briefly. Level 2 and 1 patients
    must be observed.
    I guess I am lucky. Our staffing is not too bad most of the time, and we have a brand new unit, not perfect, but OK. We have monitors in quiet rooms, public rooms, hallways and nurses stations(3 of them)
    Do all of your staff get mandatory crisis intervention training yearly. and personal defense classes, and how to subdue a violent patien? Of course, with the monitors and everything is video taped, for critiqueing by the big boys, after the fact. We do not always respond as trained, and we are gently criticized for that.
    I wish you success in trying to change an unsafe unit. But I feel that as a staff nurse, I have very little power.