Published Jul 26, 2005
Working on my restraint policy at work. JCAHO guidelines a little vague on siderails. Are all 4 side rails a restraint when the patient cannot reach the release, but can crawl off the end? Does anyone know any websites with sample or actual policy or helpful hints?
Also any suggestions of a group to teach the proper way to restrain the behaviorial patient with safety of staff, patient and other patients. (In Florida)?
The first thing I would do would be pull out CMS (Medicare/Medicaid) guidelines and read pages 77-116 on Seclusion and Restraints for medical use and for behavioral health. Their rules are much more specific and black and white. You should also read your state mental health rules also. There can be differences in rules or timeframes and you must use the most restrictive of the rules to be in compliance.
When JCAHO comes calling they should know which is the most restrictive and judge you on those criteria. JCAHO standards are a little more up for interpretation as compared to CMS, which we all must follow also.
We have 3 seperate policies for restraint & yes side rails are considered restraint as well as posey vests & tray tables on geri chairs. There is a policy for behavioral health, medical & long term care/geriatrics. Prior to utilizing restraints of any form in geri it must be documented in the treatment plan by the treatment team that all other less restrictive alternatives were utilized & failed. Once this has been documented then the order may be written for side rails, posey vest, geri chair, etc. The order is valid for 30 days- this is only in geri- the caregiver assigned to the patient must complete a flow sheet each shift for entire duration that restraints are used, it is Q15 minutes. The RN must write a detailed restraint note once every 4 hours for the entire duration of the restraint. We usually try to avoid side rails with alternative such as low beds, mats, alarms, etc. It really is a lot of work to have someone in any sort of restraint in geri, sometimes necessary but pia with the documentation. Myself I seldom use this form of restraint unless I am pulled from my area to geri. I usually use behavioral health guide lines & I use the quite frequently on locked admissions. Good luck, writing policy is so tedious I do not envy you the job;)
kadokin, ASN, RN
Here's my own little "off the cuff, in my opinion" guideline, which I may have got from another source, but have long since forgotten the reference: If it restricts a pt's freedom of movement, it is a restraint. If you are writing policy, it might be a good idea to offer suggestions (to techs as well as nurses) for appropriate alternatives to restraints such as: pain assessment, assisting pt to ambulate, 1:1 time w/pt, b&b q 2 hours. It never ceases to amaze me how, after yrs of a restraint "free" edict, my co-workers still want to restrain/medicate a pt who would be satisfied w/an assissted walk, toilet break, decrease in sedating medication. If EVERYONE is commited to reducing restraints, we can make our pt's lives better. I have seen it in action. And I myself was skeptical at first. Get creative, you can do it.
Thank you for all the info. In our ER we have stretchers with long siderails the length of the bed. When we medicate we need to put the side rails up for safety. Now that's a restraint. Any sugggestions?
If both side rails are up, you are restricting their freedom of movement. Thing is, people can, and often do, climb OVER the side rails, risking a fall from a greater height. This, and climbing out the end of the bed, also risks getting a limb caught in a rail. If their mentation is altered enough to risk a fall, they may not be thinking clearly enough to realize these risks. Lower the stretcher as far as it will go, make sure they are toileted and comfortable. If a sig other is present inform them of the fall risk w/meds. And make a call light available. That is the best advice I can give. Of course, you have to use your judgement and try to assess whether or not they are at greater risk if you leave a side rail down. It can be very difficult, I know.
Thunderwolf, MSN, RN
On our hospital beds with 2 top and 2 bottom rails, at least one has to be down to warrant not being called a restraint. However, despite bed alarms which we use often, we may need to have all 4 up IF we demonstrate/chart what has been done so far to prevent all 4 up. If it is truly a safety risk, all 4 are up and charted as such "for pt safety as evidenced by...". Also, we have had patients who have requested that all 4 be up in order to feel safe in bed and not roll out (the fear of that patient). As such, it is charted that "patient requests all 4 rails be up in order to reduce fear/anxiety as expressed by patient". But typically, at least one rail is down most of the time. Usually we have the over bed table on that side of the bed (that has the rail down) which the patient can easily push away, but has all personal items within easy reach.
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