Restraints

elkpark · Jul 30, 2017

So true, it's a huge liability. Restraining a patient without an order puts your facility at risk from the state, TJC, CMS...any regulatory agency with hospital oversight.
What you can do is discontinue the restraints when the order expires.
If alternatives are tried and the patient still meets criteria for restraints, you can re-apply (counts as a separate episode), which buys you one hour to contact the provider for a new order.
This protects the patient's safety while meeting requirements.

Everywhere I've ever worked over the years, it has been the responsibility of the RN assigned to the restrained client to be aware of when the current restraint order expires and to contact the ordering physician (or some physician, if it's a matter of someone else being on call, or whatever) and get a renewal order for the restraints prior to the expiration of the current order. Even finding yourself in the position of needing to "buy time" to get the order renewed would be considered a significant error on the part of the RN.

It's pretty simple -- when someone is in restraints, it's the responsibility of the assigned RN to stay on top of and be proactive about the orders.

MunoRN, RN · Jul 30, 2017

There is a huge different between life-sustaining medical treatment and restraints.

In a way, yes of course there is a huge difference, but they are also two interventions that directly ensure the patient's safety, the paperwork that reflects those interventions is not. If you realize the renewal is late you have two choices; remove the restraints and directly expose your patients to harm, or get the order renewed, the choice seems pretty clear.

MunoRN, RN · Jul 30, 2017

The expectation, once the order has been written, is that the nurse and physician determine the continued need for restraints and ensure that the order has been renewed in a timely fashion. When the restraint order is written, it should include criteria for removal. If or when these criteria are met, the nurse should remove the restraints, and either discontinues the order per protocol, or if not allowed to do so, notify the physician that the order needs to be discontinued.
Regarding an expired order; if the nurse caring for the patient continues the restraints, as is likely to happen, he or she needs to be aware that the patient is no longer compliant with current restraint guidelines and should have the order renewed/rewritten as soon as possible as there is no grace period for compliance once the order has expired.

I completely agree that the nurse needs to get the order renewed as quickly as possible, but the solution is not to instead remove the restraints avoid needing the renewal.

Career Columnist / Author · Jul 30, 2017

I completely agree that the nurse needs to get the order renewed as quickly as possible, but the solution is not to instead remove the restraints avoid needing the renewal.

It's true nurses should not allow a restraint order to lapse. Neither should providers. But it happens.

CMS considers a remove/re-apply as a second, distinct episode (unless they are briefly removed for purposes of supervised ADLs or circulation/skin checks).

If I came to work and my patient was in restraints without an order (expired), and there was a delay in getting the provider to respond, the restraints could be discontinued/observe the patient/re-apply if neededed= second episode, rationale: restraints were applied for safety and the provider has one hour to call back.

Not ideal, but the patient is safe.

Esme12, ASN, BSN, RN · Jul 31, 2017

In cases like these I feel there is a systems failure. Where I have worked I have facilitated "RESTRAINTS RENEWAL" in the OE to flag to the MD that the order needs to be renewed.....BEFORE the order expires.

If I came in to an expired restraints order and I feel the patient is in need of them....I call the MD and get the renewal order.

Here.I.Stand, BSN, RN · Aug 8, 2017

There is a huge difference between life-sustaining medical treatment and restraints.

Not if the pt would be trying to self-extubate or rip out their lines while unrestrained. Not always the case, but for some pts it is a true safety issue. Personally I'd rather defend my use of the restraints than defend my failure to keep my now-dead or anoxic pt safe

PixieRN1 · Oct 4, 2017

Not if the pt would be trying to self-extubate or rip out their lines while unrestrained. Not always the case, but for some pts it is a true safety issue. Personally I'd rather defend my use of the restraints than defend my failure to keep my now-dead or anoxic pt safe

NurseBeth's excellent solution makes all this a moot point. D/C the restraints prior to expiration...closely observe your patient. If the patient is that unsafe that one would consider illegal restraints, we would know quickly. Keep the patient 1:1 in arms' reach until they show you they need restraints again. Then immediately reapply the restraints. This creates a new event and you now have a brand new hour to secure an order for this new restraint event. PIA? Maybe. Inconvenient? Sure. But I'd rather keep the patient safe AND be legal in my practice. You can be both in this scenario.

With NurseBeth's suggestion, the patient is now completely legally restrained, no one has broken the law or violated the patient's human rights...both of which are quite important when you want to keep your patient safe while not jeopardizing your nursing license. The BON cares a great deal about illegally restraining patients, even the critically ill ones who are trying to self-extubate.

The BON is not your friend; they do not care one iota that you kept your patient safe if you did so illegally and outside of the boundaries of the laws that serve patient protection. They will discipline that license.

Moral of the story: nobody needs to go down in flames over this one...no patients need to die from neglect and no nurse needs to face a Board hearing.

Nurses just need to be hyper-aware with their restraint orders. Period. Know when they expire and don't wait until the last hour to get them renewed. I couldn't reach the doctorâ€ won't hold up in court if you waited until an hour before it expired to try to reach the MD. I was busy and could not get to it in timeâ€ won't work either.

I've faced the BON and I will do everything in my power to never, ever visit them again. So when it comes to restraints, I do whatever I need to to keep things perfectly legal.

Best wishes.

Accolay · Oct 4, 2017

I think we need to be clear in how these restraints are being used. There are all manner of situations where I would continue restraints without an order (but getting one as soon as I can)

In the example put forth by Here.I.stand and Muno: I agree. It makes no sense to un-restrain a sedated, intubated patient or one in critical condition simply because the order expired.

Imagine going through that rationale with the BON:

"Sorry they died... but the order was expired" (RN shrugs shoulders)

An imperfect answer to an imperfect world: It's a bad grey area to be in, but we know this happens sometimes. Continue to check your orders and work with managers and teams to get a better fix. Use your best judgement and keep your patients safe.

PugRN · Mar 23, 2018

Restraints, contrary to popular opinion, don't do much in the way of preventing self-extubation. Interestingly enough, you are 3.5 to 5 times more likely to self-extubate in restraints than out of restraints - probably largely due to the huge spike in delirium these patients experience.

Triddin · Mar 24, 2018

Restraints, contrary to popular opinion, don't do much in the way of preventing self-extubation. Interestingly enough, you are 3.5 to 5 times more likely to self-extubate in restraints than out of restraints - probably largely due to the huge spike in delirium these patients experience.

I would love to see the literature regarding this

MunoRN, RN · Mar 24, 2018

Restraints, contrary to popular opinion, don't do much in the way of preventing self-extubation. Interestingly enough, you are 3.5 to 5 times more likely to self-extubate in restraints than out of restraints - probably largely due to the huge spike in delirium these patients experience.

There have been some articles that draw that conclusion from studies but if you look at the studies you'll see those conclusions are not supported and that the studies actually suggest the opposite.

The studies these articles refer to our case controlled and are not randomized. The factors that contribute to delirium are also the factors that indicate the need for restraints. This is where it's important to understand the difference between correlation and causation.

For instance if you look at stents and heart disease you'll find that people who've had stents are many, many times more likely to have heart disease, does that mean that stents cause heart disease?

What the studies these articles refer to actually show is that while we're pretty good at deciding which intubated patients should be restrained, we are incorrectly assessing a number of patients as not needing restraints.

MunoRN, RN · Mar 24, 2018

I would love to see the literature regarding this

This is the main study that articles misinterpreting the restraint/extubation/delirium cites:Influence of Physical Restraint on Unplanned Extubation of Adult Intensive Care Patients: A Case-Control Study

This is a chart review based study, meaning it did not compare evenly matched patients where one group was restrained and the other was not, to determine if there is a higher risk of unplanned extubation when a patient is restrained.

Instead, it found what you would expect; that patients deemed at higher risk for self extubation and therefore were restrained were more likely to self extubate, and that patients deemed a low risk and therefore not restrained, such as those with low GCS scores even without sedation, were less likely to self extubate. Delirium is associated with restraints and self extubation in that intubated patients with delirium are more likely to be restrained.