Restraints for acute patients...

elainelisa · Jul 9, 2000

Hi..I want to find out if you should put a patient who is actively going thru alcohol withdrawal and having DT's into restraints, if they are also at risk for having a siezure. I cared for a patient who had a siezure after dialysis, who also needed to be restrained because he was disoriented and climbing out of bed while going thru ETOH withdrawal. Meds were not working with him because of his poor liver and kidney function... restraint use was literally our last option and we could barely keep control of him with those on! What have you heard or found out? Please reply. thanks

LAS · Jul 10, 2000

JoJo

I work in acute care, so I do not have much experience in Mental Health. I am currently heading up our institutions restraint task force. The Joint Commission and HCFA which are both regulatory agencies that certify a facility for Medicare reimbursment. Currentl the standards are becoming more strict. Restraints can only be used when all least restrictive measures have been attempted and failed. And the documentation must be complete and the assessments must be ongoing. In long term facilities restraints are not alternatives. The philosphy of our facility is that confusion is a symptom that needs to be treated. Hope this is helpful. I would interested to learn about your restraint practices.

------------------

jojo · Jul 12, 2000

Hi Las

Thankyou so much for your reply. This information is very useful.

What I am really looking for are descriptions of what is actually permitted by the current rules what these rules are and who is responsible for formulating these.

The restraint practices in the UK are a little different and the reason for my enquiry.

Since 1959 all forms of artificial restraint devices are banned. Restraint may be used legally to prevent injury to the patient, other patients and property but this takes the form of physical contact, holding the patients wrists usually. In extreme cases several nurses may assist in physical restraint. Clearly this is a short term measure though.

Isolation rooms are still used in some hospitals but these may only be used for a maximum of 1 hour after which a doctor must attend.

In the past 10 years this physical restraint has been gradually phased out, except to protect other people from harm and then only sufficient to remove that harm. 'Cot sides', rails applied to the side of beds and chairs which have special tables which can be secured to make standing up difficult are now outlawed.

The result has been that actual violence is comparitively rare in most psychiatric hospitals. My own experience from working in forensic (legal), long stay, mentally acute and elderly is that I have rarely if ever been attacked with the exception of elderly confused and in this case any such attacks usually ammount to grabbing, throwing something, or an agressive gesture and are easily resisted, usually by diverting the patients attention.

I should say that there are a few hospitals where old habits amoung staff do surface but over the last 20 or so years these old hospitals have been closed down.

Now this is very important. I discovered the existence of restraint practices in US psychiatric hospitals while reading some articles on the internet. I have discussed this with some colleagues and the consensus is this:

Care of the mentally ill is a social matter. While progessive approaches are to be applauded such progress is a matter for the local society and it is not our place to criticise or place judgement upon another society's practices. Clearly, in the UK society has a more developed attitude to mental illness than in other countries but this is down to UK society and any lack of progress in this regard is not an criticism of psychiartic nurses elsewhere, though it may be a criticism of leadership.

Secondly, we are all jointly interested in the approach curently used in the US. We appreciate that many issues are currently a mater for local debate. I have managed to access some American Nursing Magazines and down-loaded articles on reforming the current practices in relation to restraint. However we are very interested in learning what the current regulations and practices are and the equipment used.

I hope you can help. If you want any further information from our side of the pond, please don't hesitate to ask.

Jojo

jojo · Aug 25, 2000

Thanks to all who have replied.

I suppose that there are no overall guidelines for the use of restraints in the US, a point which I find surprising since the US tends to regulate most things.

However, thanks again.

If I can be of any help to anyone looking for information on mental health nursing in the UK then please put in another reply.

505rn · Sep 18, 2000

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).]

blindog45 · Jan 7, 2001

Hello,

I have worked in psych for 13 years. First as an orderly in a psych hospital here in Ohio. Now I work on a psych unit for a "normal" hospital. I know the use of restraints is our last option, and seclusion is a last option as well. We try timeouts for an our at times with some success. Other times sitting with a pt seems to work. Other times, if they are violent towards others or themselves, restraints come into practice. I know the DR. needs to see the pt. in 1 hour after they are placed into restraints. I work 3rd shift an the DR's will NOT get out of bed to come in and see there pt., so we are given T.O. to let the pt. out of restraints in 59 minutes. In emergencies where we cannot let them out our house DR. can come and see them in the hour allotted.

As far as meds, we try to the prn before the pt is out of control, Ativan, Haldol, and sometimes Benadryl works well. Cutting the stimulation down on the unit seems to help also. Some of the schiz. and manic pts. cannot handle too much stimulation and this helps as well.

For the most part, good assessment skills are your biggest assett. Not neccessarily assessment skills we are taught in school, but behavoiral assessment skills. Being able to see a crisis coming is the biggest alternative to restraints that I know of, because intervention and prevention can come into place.

blindog45 · Jan 7, 2001

Hello,

I have worked in psych for 13 years. First as an orderly in a psych hospital here in Ohio. Now I work on a psych unit for a "normal" hospital. I know the use of restraints is our last option, and seclusion is a last option as well. We try timeouts for an our at times with some success. Other times sitting with a pt seems to work. Other times, if they are violent towards others or themselves, restraints come into practice. I know the DR. needs to see the pt. in 1 hour after they are placed into restraints. I work 3rd shift an the DR's will NOT get out of bed to come in and see there pt., so we are given T.O. to let the pt. out of restraints in 59 minutes. In emergencies where we cannot let them out our house DR. can come and see them in the hour allotted.

As far as meds, we try to the prn before the pt is out of control, Ativan, Haldol, and sometimes Benadryl works well. Cutting the stimulation down on the unit seems to help also. Some of the schiz. and manic pts. cannot handle too much stimulation and this helps as well.

For the most part, good assessment skills are your biggest assett. Not neccessarily assessment skills we are taught in school, but behavoiral assessment skills. Being able to see a crisis coming is the biggest alternative to restraints that I know of, because intervention and prevention can come into place.

Callan · Mar 4, 2001

To go back tot he gal who was questioning the need for restraints with someone in withdrawal, seizures, etc. We have, at times, had severe heroin withdrawal patients who are so confused and thrashing about while they have a peripheral line in for hydration purposes. We have, on the medical floors, restraint protocols. We do not have any in the psych unit. I fsomeone is at risk for harm to themselves-ie, pulling out a line, the doc orders a protocol.

\

On the AODA unit, we use soft posey wrist restraints for the severe heroin withdrawals. We do not restrain for those going in DT's. We have a staff member with them all the time. (We must justify staffing, too!) If the folks are adequately medicated to be free of these withdrawal effects, you should see a decrease in theses symptoms. For those of you who treat heroin withdrawal, it can be nasty!

With the new HCFA rulings on restraints, we do see a decrease in the # of restraints on my unit for mental health. Planning ahead is the best intervention!!-even if it means staffing up. Administration must be supportive of this as well.

BarbRPN · Mar 28, 2001

Originally posted by jojo:
Looking for information on use of restraints for acute patients in psychiatric nursing in USA.
What sort of restraints are available
What are the rules?
What are the feelings of American nurses reguarding the use of restraints?
What is the ethical position?
What is the legal position?
Any information and references, especially web references. Thanks.

I'm a registered practical nurse in Canada and I must say I was a bit surprised at the replies you've received (from the original questions). I've worked in a large provincial psych hospital for sixteen years in geriatrics, chronic care, rehab and admissions. Over the years I have seen a fair bit of change in management of disturbed behavior but none so positive as has been described here. Certainly there is much less use of passive and active restraint in our facility but restraints are still utilized frequently. Our policies have become tighter, with higher degree of monitoring by physicians.

Currently we use "special observation rooms" when a client becomes dangerous to himself or others. If the person is at risk of self harm, seclusion is not permitted. They are either monitored at least every fifteen minutes OR if they are more critically suicidal, they are monitored on a constant one on one protocol. Clients with self harm/suicidal ideation are NEVER secluded (locked in a seclusion room). Agressive/threatening/hostile/abusive clients are secluded, monitored every fifteen minutes and when escorted to the washroom or shower they are on constant observation by two or more staff. Most times when a constant observation client is out of seclusion the physicians will order that they must wear three point OR wrist to waist restraints. These are applied before bringing the person out of seclusion and then ALWAYS removed before seclusion resumes. Wrist to waist to chair orders are less and less frequently used, ankle to ankle restraints are also used less frequently in recent years. The type of restraints we use are cloth and velcro wrist to waist restraints (which I personally don't care for since most clients can easily remove them) and the older version of plastic keylock cuffs with leather belt. These have an archaic appearance but when used are far superior IMHO. When a client is completely out of control and use of medications is limited or ineffective, or if the person is at serious risk of suicide even with constant observation, we have a specially designed bed that is used in combination with the leather and plastic cuffs, to prevent imminent harm of the client or others. I work in an acute admission ward so we use this means of restraint a few times a year. In any of the described cases, the expectation is to use the restraint for the least length of time as possible and encourage the client to regain control of his/her actions. Other restraints used previously were the "Posey Company" restraints. These generally were used in chronic care and geriatrics to restrain clients in bed or in a chair. They were generally used with clients suffereing from dementia where the client was unaware that they could not ambulate and would be at risk in the night of getting out of bed. The "vest" type of bed/chair restraint have been banned due to strangulation accidents that occurred in our facility and others around the world. We still use belt restraints for this type of client. It is secured to the bed/chair with a magnet and around the patient's middle with a magnet. When applied properly these restraints are quite effective in preventing falls. These again are used less and less but are effective in certain situations such as dementia clients who are post surgery and don't realize they are not to be walking.

I can't comment on your question about detox and seizures, as I have not worked in this kind of situation. Our clients have to be physically cleared in a general setting before they can be admitted, so if they were in detox we would return them to a general hospital.

------------------

Barb

Registered Practical Nurse

Psychiatry

Ontario CANADA

psych-rn · Mar 29, 2001

WOW

I can not believe the use of restraints. What happenned to risk management? If a client is a risk for violence why not call in extra staff to assist? We have two ten bed closed units at my hospital, no jackets and no wrist restraints. We have the most abusive and violent clients come in. When an admission comes in, a risk assessment is done before their arrival. Staff from other areas are called in to assist and when the client enters the ward admissions area they are greeted by 5 or more staff members. When they are yelling/screaming we give them the opportunity to talk, modelling to them the behaviour/interaction we are wanting. When these skil;ls don't work we let the client know firmly the expectations of their behaviour. When this does not work we expklain to the client that they are going to get medication to help their agitation. If they refuse they are then given an opportunity to chose how they want the medication, either injection or orally. The next step is that staff restrain him/her, placed in seclusion and medicated IM. Throughout the process we re-emphasize it was his/her decision to have the injection, what medication is given and what the expeceted outcome will be. We also explain to them the legal implications of what is happenning so that the client can understand this is treatment and not punishment. When the client is asleep, the seclusion door is oipened and trhe client upon awakening finds him/herself in a corridor where he/she can come to the nurses station window to speak to staff. Haldol is being less used, and a combination of zuclopenthixol and midazalam are being used, less side effects and quite sedating (short-term).

------------------

[This message has been edited by psych-rn (edited March 28, 2001).]

TopazStone · Apr 16, 2001

I worked for an unlocked psych crisis unit; a bizarre setup. If the client was a risk to self/ others we had to put them on an involuntary hold--but could not lock them in a room!! On a typical night the police would bring in a suicidal client (in cuffs) who wanted to go back out and finish the job. The cuffs would come off and the client would run. They would go to the "restraint room"; I'd jump on the phone with the doc and the police would assist in the restraint. We used a combination of chemical/ mechanical restraints. Clients would get one on one observation, nursing checks q15 mins, and the doc had to be called after 2 hours for another order. After 4 hours, the doc had to come in. Usually after an hour, the meds would kick in and the patient could be released. There were nights when I had tandem restraints, and several people detoxing!! I'd run from one room to another with my equipment and juice and snacks and a notepad to keep track of myself LOL! Luckily I had good docs and great social workers-- the police were a big help too.

The state department of mental health created guidelines for the use of restraints (we always used leather, except for children-- then it was the "burrito bag", but very rare). Our first duty was to keep the client and ourselves safe from harm until they could transfer to the hospital. The order for involuntary hold could be completed by the police, court, probate officer or doctor. Careful documentation to validate the need was essential. There were times we had to let the person run and then call the police to bring them back and write the order.

[This message has been edited by TopazStone (edited April 16, 2001).]