Adult ED Staff Meeting

1. Adult ED Staff Meeting January 12, 2010

2. Thanks to all of our Guest Presenters • Health Promotion/Disease Management • MHTAV Care Coordinators • Patient Boarding • Carol Wilson • EVS • Mike Jolley • Mike Daly • Restraints

3. Mike Daly Restraints

4. Objectives • What we have done? • Restraints data • Audit Tool • Stumpers

5. What have we done? • Updated policy • Approved policy • Clinical practice • MCMB • Education

6. Restraint Trend Restraint orders • Average of 1445 restraint orders per month • 1438 restraint orders per month for VUH • 7 restraint orders per month for Children’s Hospital • Average of 48 restraint orders per day Restraint Data from HED per month • X = Y/19*(30) • 1528 Restraint Days, 416 Restrained Patients • Average of 3.6 restraint days per patient Restraint orders for violent patients (all have been in VUH) • Estimate of 58 restraint orders for violent patients per month

7. AuditforViolent Patients

9. Welcome to Stumpers!

10. Restraint Today we’ll be playing Stumpers Case Studies The Violent Patient Definitions Orders The Non-Violent Patient

11. Restraint Stumpers Case Studies Orders The Violent Patient Definitions The Non-Violent Patient 200 400 600 800 1000 200 400 600 800 1000 200 400 600 800 1000 200 400 600 800 1000 200 400 600 800 1000

12. A 1 200 • 15 yo with known head injury from Motor vehicle collision. He is combative to staff. What should you do first? Give examples.

13. Q 1 200 • What is consider alternatives to restraints: bring parents in the room, reassure patient, treat his pain, and/or provide distractions, etc.?

14. A 1 400 • For a violent category 17 y/o in restraints, how often does the order need to be renewed?

15. Q 1 400 • What is every 2 hours?

16. A 1 600 • 45 y/o male s/p liver transplant that has been weaned from the vent and is beginning to wake up. He is currently in the SICU and continues to try and pull off his EKG leads and pull out his IVs. • The patient gets an order for “nonviolent” restraints. Why is the order for “nonviolent” restraints instead of “violent.”

17. Q 1 600 • What is - the patients behavior is interfering with our ability to provide medical care and is not severely aggressive or violent.

18. A 1 800 • 35 y/o male has just been admitted to a trauma s/p self-inflicted GSW. He has a known history of paranoid schizophrenia. The patient begins pulling off his leads yelling that they are uncomfortable. He also starts pulling out his IV’s and tells his nurse that the IV is hurting. • Does this patient fit the violent or non-violent category?

19. Q 1 800 • What is non-violent? The patient’s behavior is interfering with your ability to provide medical care. It is not severely aggressive or violent. The behavior is related to the discomfort and pain she is experiencing from the EKG leads and IV.

20. A 1 1000 • A 67 y/o woman has just been admitted to a telemetry unit for observation from the ED (where she has been for 18 hrs) because of syncopal episode related to atrial flutter. She has a known history of paranoid schizophrenia. The patient begins pulling off her leads yelling that the they are feeding information from her soul to the government. She also starts pulling out her IV’s and tells her nurse that she believes the IV is our method of implanting a computer chip in her so that the government can monitor everything she does. She tries to choke herself and her nurse with the iv tubing before this occurs.  • Does this patient fit the violent or non-violent category?

21. Q 1 1000 • What is violent category? The patient’s behavior can be considered severely aggressive or violent and seems to be due to the patient’s mental health condition, not a medical condition.

22. A 2 200 • For a violent category 11 y/o in restraints, how often does the face-to-face have to be done by the provider?

23. Q 2 200 • What is every 4 hours?

24. A 2 400 • For a violent patient in restraints, nursing documentation needs to be done how often?

25. Q 2 400 • What is every 15 minutes?

26. A 2 600 • For the Non-violent patient in restraints, nursing documentation needs to be done how often?

27. Q 2 600 • What is every 2 hours?

28. A 2 800 • The initial restraint order must be placed within what time frame in Wiz/HEO for both non-violent and violent patients?

29. Q 2 800 • What is within 1 hour?

30. A 2 1000 • What is the difference for Violent patients between order renewal every 1, 2, or 4 hours versus a new order every 24 hours?

31. Q 2 1000 • Requires discussion

32. A 3 200 • What must be completed within 1 hour of initiation of restraint by a trained staff member for all violent patients placed in restraints?

33. Q 3 200 • What are a face-to-face evaluation and a restraint order?

34. A 3 400 • In the rare event a violent patient requires restraints >24 hours, notification must be made to the _______.

35. Q 3 400 • Who is the medical director?

36. A 3 600 • Name at least 3 things that must be included in the Q 15 minute nursing documentation for the violent patient in restraints?

37. Q 3 600 • What are : Nutrition, hydration, circulation, skin condition, patient response, ROM, pain, elimination, hygiene, and discontinuation goal?

38. A 3 800 • How soon should restraints be removed from the Violent patient?

39. Q 3 800 • When is as soon as possible?

40. A 3 1000 • How often does the face-to-face need to be repeated for the violent 65y/o patient in restraints?

41. Q 3 1000 • When is every 8 hours?

42. A 4 200 • Any manual method, physical or mechanical device, material, or equipment, that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

43. Q 4 200 • What is a physical restraint?

44. A 4 400 • Require restraint to support patient safety and/or provide optimum medical care. These are patients who present with behavioral changes that are primarily related to their medical/surgical condition (e.g., delirium due to high fever/sepsis, alcohol/drug withdrawal, dementia, or pulling IVs, endotracheal tube, or feeding tube).

45. Q 4 400 • What is a non-violent patient?

46. A 4 600 • Patients suffering from severely aggressive or violent behavior that poses an imminent danger to self or others. These are patients who present with mental or emotional health symptoms for which a medical etiology is ruled out, and who are identified as primarily requiring mental health services (e.g., psychotic episodes, manic, attempted suicide, physical assault, or violent/aggressive behavior).

47. Q 4 600 • What is a violent patient?

48. A 4 800 • Involuntary confinement of a patient in a room alone or areas from which the patient is physically prevented from leaving. This is only used for the management of violent or self-destructive behavior.

49. Q 4 800 • What is seclusion?

50. A 4 1000 • A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition, is not a drug that is used within the patient’s normal dosage to help patient interact more appropriately with their environment.