Use of Restraints on Intubated patients - ER and ICU

Altra, BSN, RN · Jun 9, 2012

You do need an order. When our ER docs are leaving the room following an intubation, I make sure I remind them to enter the orders for restraints and whatever we're giving for sedation.

elkpark · Jun 9, 2012

The Federal CMS regs require an order. Your hospital policy/procedure manual should spell out all the details of required observation, documentation, renewal of orders, etc.

I used to work as a surveyor for my state and CMS. The requirements for different situations (medical vs. behavioral restraints) differ, but there is no situation in which it is legal to restrain someone without a physician's (or other licensed independent provider's) order.

Mini-Murse · Jun 9, 2012

I'm incredulous. You work in an ICU and you don't know the laws and your hospital policy on restraints? Needing an order for ANY restraint is the first thing they teach you in your Ethics section of Nursing Fundamentals I.

I really hope none of my family members are ever patients of yours - I don't want their nurse to be making up his or her own rules about restraints, treatment, etc.

I honestly recommend going back and taking some CE on ethics, ICU, and restraints ASAP.

Ok, so I'm definitely unsure of the state/federal laws on using restraints for intubated patients that are used solely to prevent a patient from pulling out their ET tube. I regularly place soft wrist restraints on my intubated patients. Often we have to adjust their sedation and I once had a patient pull out her tube, so I'm very cautious.
There's an educator where I work whose specialty is geriatric psych, so I'm not sure she knows how the law/rules apply for our specific population/environment, since this type of restraint is different. She states we need an order.
I haven't been able to find the specific laws on this topic. I have been looking for resources to be able to check my own nursing practice. I'm sure I'll be called out again for this by this educator, so I just want to be sure that what I'm doing is not just "how we've done it," or is there validity to what I have been doing.
I also do not regularly see orders for an ICU patient that has "soft wrist restraints" as an order to protect ET tube.
Ideas? Thoughts? Resources?
Thanks!

One1, BSN, RN · Jun 9, 2012

You probably need an order for non-behavioral restraints. We cannot place somebody in any kind of restraints (soft, hard, medical, behavioral or non-behavioral) without an MD order.

MassED, BSN, RN · Jun 9, 2012

I'm incredulous. You work in an ICU and you don't know the laws and your hospital policy on restraints? Needing an order for ANY restraint is the first thing they teach you in your Ethics section of Nursing Fundamentals I.
I really hope none of my family members are ever patients of yours - I don't want their nurse to be making up his or her own rules about restraints, treatment, etc.
I honestly recommend going back and taking some CE on ethics, ICU, and restraints ASAP.

No, I don't work ICU. I work ER. I don't know how long you've been a nurse, but laws/rules, as well as individual hospital regulations differ. Certainly over the years. This isn't about being "incredulous" or posting anything negative, it's about finding out the specific resources for restraints, federal/state. I'm specifically referencing the use of restraints for an intubated patient to prevent pulling of the ET tube. I'm not discussing all other aspects of restraint use/documentation/and orders.

Also, a few other nurses that I work with, who have been in the ER for 20 + years were also scratching their heads, unsure as well. We have always used them, just as we have used the side rails to be up on a comatose, confused, or intubated patient. When I worked med/surg, restraints up all the way around were considered restraints, but that doesn't apply to the ER, so I'm sure you can see where I'm coming from now.

I'm sure ICU does have their standing orders, but since I don't work there, I can't speak to that.

ckh23, BSN, RN · Jun 9, 2012

I'm incredulous. You work in an ICU and you don't know the laws and your hospital policy on restraints? Needing an order for ANY restraint is the first thing they teach you in your Ethics section of Nursing Fundamentals I.
I really hope none of my family members are ever patients of yours - I don't want their nurse to be making up his or her own rules about restraints, treatment, etc.
I honestly recommend going back and taking some CE on ethics, ICU, and restraints ASAP.

Lets not be so dramatic. This is obviously a teaching moment here and not a reason to bash the OP. This does not make the OP a bad nurse and I'm sure you would be singing a different tune if your loved one had self extubated, developed edema from the traumatic extubation and needed an emergent cric because they were not restrained.

OP-As others have pointed out you do need an order. There is nothing wrong with putting on the restraints and getting the MD to put the order in, regardless of if you are in the ER or ICU. Restraint policies differ from facility to facility, but I'm surprised it was not covered in orientation. Every facility I have ever worked had a part of orientation designated just for restraints including orders, documentation, proper application, etc. One facility I worked at allowed a verbal order for restraints, but the patient has to have a face to face evaluation by the MD to continue the order. I would recommend looking up your restraint policy at your facility and go from there.

MassED, BSN, RN · Jun 9, 2012

The Federal CMS regs require an order. Your hospital policy/procedure manual should spell out all the details of required observation, documentation, renewal of orders, etc.
I used to work as a surveyor for my state and CMS. The requirements for different situations (medical vs. behavioral restraints) differ, but there is no situation in which it is legal to restrain someone without a physician's (or other licensed independent provider's) order.

Thanks, that's great info. I will research Federal CMS guidelines. Our hospital has a very tricky intranet and they are always updating and making changes. Very difficult to access. So this question lent the other questions about federal/state guidelines. I tend not to just follow, but prefer resources to back up the changes/new information. For instance, new AHA guidelines (since I'm recerting ACLS) are to check for responsiveness, watch rise/fall of chest, check carotid, if no pulse start chest compressions. What a big change from airway!! Makes sense and I love new and improved information.

MassED, BSN, RN · Jun 9, 2012

Lets not be so dramatic. This is obviously a teaching moment here and not a reason to bash the OP. This does not make the OP a bad nurse and I'm sure you would be singing a different tune if your loved one had self extubated, developed edema from the traumatic extubation and needed an emergent cric because they were not restrained.
OP-As others have pointed out you do need an order. There is nothing wrong with putting on the restraints and getting the MD to put the order in, regardless of if you are in the ER or ICU. Restraint policies differ from facility to facility, but I'm surprised it was not covered in orientation. Every facility I have ever worked had a part of orientation designated just for restraints including orders, documentation, proper application, etc. One facility I worked at allowed a verbal order for restraints, but the patient has to have a face to face evaluation by the MD to continue the order. I would recommend looking up your restraint policy at your facility and go from there.

Thanks.

I do think that we usually throw on those wrist restraints as we're taking our patient to ICU/SCU/CTICU, and likely don't think about an order because we're in transit and try to get the patient there quickly. If anyone has dealt with a patient who has self-extubated, you would understand the caution to protect the ET tube.

We often have limited orders from our ER docs and usually move them up even before the SCU team has written orders. We have an 8 page documentation on restraints, which is the impetus for this question.

Thanks!

PS - just a quick scan of CMS regulations of restraints really focuses on nursing homes. Will try to find more and see how the regulations change for psych, hospital, etc.

MassED, BSN, RN · Jun 9, 2012

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/PatientsRights.pdf

JCAHO explained that during the

treatment of certain specific conditions

(for example, post-traumatic brain

injury) or certain specific clinical

procedures (for example, intubation),

restraints might often be necessary to

prevent significant harm to the patient.

For those conditions or procedures,

protocols for the use of restraint may be

established based upon the frequent

presentation of patient behavior that

seriously endangers the patient or

compromises the effectiveness of the

procedures.

So that answers my question. In the ER, we don't have these protocols, but I'm sure ICU's must.

morte, LPN, LVN · Jun 9, 2012

If you don't have it in your P+P, perhaps it could be added. Or included in the "order set" for intubation? and remember the paramedic saying "it is easier to defend a live one, than a dead one."

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/PatientsRights.pdf
JCAHO explained that during the
treatment of certain specific conditions
(for example, post-traumatic brain
injury) or certain specific clinical
procedures (for example, intubation),
restraints might often be necessary to
prevent significant harm to the patient.
For those conditions or procedures,
protocols for the use of restraint may be
established based upon the frequent
presentation of patient behavior that
seriously endangers the patient or
compromises the effectiveness of the
procedures.
So that answers my question. In the ER, we don't have these protocols, but I'm sure ICU's must.

edmia, BSN, RN · Jun 9, 2012

Listen, in the ED restraints are used all the time without an order, we all know that. In p&p you bet an order is "needed". Just make sure you get the order or remove them before you transfer them out.

In all other units you must get an order no matter what the reason for application is and is renewable every 12 or 24 hrs depending on policy.