Restraint and Seclusion Solutions Team

1. Restraint and Seclusion Solutions Team Leads: Carol Markus, RN, Tony Weiss, MD Facilitators: Mallory Davis, Claire Seguin, RN (MGH Compliance Office) Content Experts: Associate Director, Acute Psychiatry ServiceAssociate Director, Acute Psychiatry Service

2. Restraint Overview Restraint is any method used to immobilize or limit a patient�s movement Goal: Use alternatives to restraint; if not possible, use least restrictive method Two reasons for restraint: Non-behavioral medical and behavioral Most common types: limb restraint, roll belt, mitts, siderails Most common sites: ICU�s, neuro, medicine, ED Regulatory standards are rigorous re: MD orders, documentation of assessments and alternatives

3. CMS Findings* Restraints applied without an MD order Restraints used on a �prn� basis; included multiple types ordered at one time Restraints discontinued without an MD order Mitts not treated as a restraint The following not evidenced in documentation: Daily clinical assessment by provider Behavior requiring intervention Alternative measures tried Type and location of restraint Patient response to restraint Updated care plan Restraint and seclusion is a hot spot with both CMS and the Joint Commission and a common area where hospitals are cited for being out of compliance. Restraint and seclusion is a hot spot with both CMS and the Joint Commission and a common area where hospitals are cited for being out of compliance.

4. Operating Principles Success is best achieved via an interdisciplinary, collaborative approach For sustainable improvements re documentation Provide triggers Reduce steps Build on earlier successes Utilize what technology has to offer

5. Policy Changes: Non-Behavioral Restraints: Restraint Orders

6. Policy Changes: Non-Behavioral Restraints: Discontinue Orders

7. Policy Change:Mitts and Side rails

8. Documentation Enhancements: Providers POE order screen includes triggers for initial clinical assessment data Each subsequent day, A pop-up in POE reminds the ordering provider to complete the daily assessment Pop-up contains a link to daily assessment form which contains triggers re: specific documentation requirements The ordering provider prints, completes, and places the form in the patient record

10. Documentation Enhancements: Nursing Restraint Flowsheet eliminated Required shift documentation embedded into the nursing progress note Sticker implemented which contains triggers re: specific documentation requirements Sticker vs template. No centralized location for the template; would need to be housed on individual sites; as updates occur, would be difficult to ensure that each template would be used.Sticker vs template. No centralized location for the template; would need to be housed on individual sites; as updates occur, would be difficult to ensure that each template would be used.

11. Clinician Education: Providers and Nurses Utilization of restraints Changes in requirements for doctors orders Documentation of assessments System enhancements

12. Interdisciplinary Program Evaluation Indicators: Active MD order present Restraint utilization matches order Daily MD/NP/PA assessment documented RN assessment and interventions documented each shift Restraint nursing problem list is current

13. Actions Consider further policy changes e.g. RN can change to less restrictive restraint then obtain order Consider trial of a �restraint checklist� during MD/nursing patient rounds; Goal: Trigger a patient-by-patient review during rounds; examples include: active order present that matches restraint on patient, need for discontinue order; daily assessment documented Focused reeducation Discussion at QOC re additional strategies to improve physician compliance