restraint/seclusion order question

[sassyann85]

Hi everyone,

So on our physician order form for restraint and seclusion (which we often get the order as a verbal from the Dr.) there are check boxes for "type of restraint/seclusion" and the little boxes to select for: seclusion, manual restraint, physical extremity restraints, etc. My question is, what if you initially start the patient out in locked seclusion (less restrictive measure than restraints in most cases) and then they escalate and end up needing physical restraint (extremities) as well? When you first put them in seclusion, you may very well not know that they are going to end up requiring extremity restraints as well. So, on the order, if you get a verbal for seclusion and then they end up needing extremity restraints, do you need a whole new order and have to call the Dr again? Once our psychiatrists leave, we use the hospitalist to call for restraint orders. How do you handle this in terms of your orders? I have often seen locked seclusion patients requiring physical restraints when the seclusion does not manage them.

thanks so much for any input!

[elkpark]

According to CMS, Joint Commission, and, probably, your state mental health agency, seclusion and restraint are two entirely separate and different procedures. If someone starts out in locked seclusion and then has to be restrained, that does require a whole new order and the process starts all over again.

[Loo17]

I would agree with the above poster. Any time the restraint or seclusion is changed we also need a new order. Our orders in the ED are only valid for 4 hours and need to be renewed after that.

[sassyann85]

thanks for the reply! so if both restraint and seclusion are going on simultaneously, in terms of the 4 hour renewel for the orders, you would have two different timelines going on (on for renewing the seclusion order and one for the restraint?) thanks!

[elkpark]

You always have the option of getting an order renewal sooner than necessary, which can be helpful for coordinating/scheduling reasons. Also, they would not necessarily count as two separate orders. Going from "just" locked seclusion to four pt. restraints is definitely a change that requires a new order, but, if your policy is that someone in four pt. restraints is placed in seclusion as part of being in restraints, you no longer need a separate order for seclusion once the restraints have been ordered. You would only need to worry about the restraint order.

If your policy doesn't call for seclusion along with the physical restraints (which is hard for me to imagine, but ...), and you are choosing to have the individual in seclusion in additional to the physical restraints, you can always reorder one or the other (seclusion or the restraints) early in order to get them "synched up," so that both orders come due for renewal at the same time (e.g., if seclusion was ordered at 5 PM and the person needed restraints at 6:30 PM, you can get a renewal order for the restraints early, at 9 PM, so they are both due for renewal at the same time going forward). You don't have to wait the full four hours to renew either order; you just can't go longer than four hours.

[sassyann85]

thanks so much this was very very helpful! One last question, if you don't mind. I just want to make sure I am doing everything right. If a RN initiates the restraint/seclusion, let's say at 6:30 pm, and then by the time they call the Dr. to get a verbal order for this it is 6:45pm, then does the 4 hour order renewal have to occur at 10:30 pm or 10:45 pm? ie-is it 4 hours from when the pt actually went into restraint or 4 hours from the order for restraint? thanks again!!

[MrChicagoRN, RN]

the order starts at the time the patient was actually placed in seclusion / restraint. So if the patient is at 6:30 p.m. The order would expire at 10:30 p.m., regardless of when you actually got the order from the LIP

[sassyann85]

thanks! when elkpark mentioned "if your policy doesn't call for seclusion along with the physical restraints (which is hard for me to imagine, but ...)"....I am just wondering: if a patient is in, say, 4 pt restraints, what would be the purpose of seclusion at the same time as this? I can see a patient going into seclusion then if that doesn't help them calm down, next needing to be restrained, but if they are restrained, wouldn't seclusion at that point not be necessary?

[MDMBSNRN]

Our restraint room was also the seclusion room. This was convenient for us, as restrained patients could be segregated from the general population, and other patients did not have to witness that. Generally, restraints don't go over well, and patients scream, yell, attempt to thrash, and try to fight for a while. I can see how this would escalate other patients on the unit, feed into paranoia, and cause chaos in general (which definitely isn't what you want with this type of patient population). Also, restraining someone in a seclusion room provides a low stimuli environment that you are more in control of. You can close the door, possibly dim the lights, and eliminate noise and traffic. This also eliminates an audience, so patients have no reason to display acting out behaviors for attention, as only one or two staff members will be witnessing it, as opposed to stirring the entire unit into a frenzy.

[sassyann85]

this is our set-up too. so if the seclusion door remained open with the patient in restraints, it would just be considered "restraint" and not "restraint and seclusion," right?

[psychnursie]

yes, it is an entirely new order.

[MDMBSNRN]

That's how it is done at my hospital. If the patient is in restraints, I have always been told that the door must remain open. For some reason, seclusion generally isn't ordered at my facility. It tends to be that the patient begins escalating, staff attempts to calm them, medications are offered, and the patient escalates to the point of having to be restrained. I have only seen seclusion used one time. In the crisis ED, we have no seclusion room, and restraints are done inside the patient room, as there is no designated space for restrained patients.