Prevention, Intervention and Postvention: Restraints and Seclusion

1. Prevention, Intervention and Postvention: Restraints and Seclusion • Battle Creek Health System • Behavioral Health Units

2. Restraint or Seclusion • BCHS • Behavioral Health • Guidelines • Centers for Medicaid and Medicare • Joint Commission on Accreditation of Hospitals • Michigan Mental Health Code • The following course addresses meeting the requirements of CMS, the Joint Commission and the State of Michigan Mental Health Code related to the implementation of restraint or seclusion.

3. Course Objectives • Define Physical Restraint, Drug or Chemical Restraint, Legal/Administrative/Forensic Restraint and Seclusion • Define patient rights regarding the use of restraint or seclusion • Identify dangers associated with placing a patient in restraint in prone position • Identify required documentation for initiating, monitoring and discontinuing restraint or seclusion • Identify least restrictive interventions • Identify the requirements for reporting a death related to restraint or seclusion

4. Physical Restraint • A physical restraint is 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.

5. Drug or Chemical Restraint • A drug or medication, or a combination, when it is used as a restriction to manage the patient’s behavior, restrict the patient’s freedom of movement, or to impair the patient’s ability to appropriately interact with their surroundings and is not standard treatment or dosage for the patient’s condition.

6. Legal/Administrative/Forensic Restraint • Corrective restraints used for security reasons and administered by forensic personnel. • (Use of handcuffs, manacles, shackles, other chain-type devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are considered law enforcement restraint devices to patients at BCHS.)

7. Seclusion • Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. • Timeout is not considered seclusion – patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving.

8. New Terminology for Behaviors • CMS defines two types of behavior that could warrant the use of restraint or seclusion • Non-violent, Non-self-destructive Behavior • Violent, Self-destructive Behavior

9. Staff Behavioral Triggers • Staff may exhibit behaviors that trigger patient behaviors requiring restraint or seclusion • Attitude: hurried, inattentive, preoccupied, non-supportive, non-open • Routines: becoming so involved in following the routines that the patient’s needs become secondary • Rules: being too rigid with rules and not individualizing the care because it would break a rule • Personal triggers: not being in touch with own triggers or preconceptions related to patients and their care

10. Environmental Triggers • Noise • Confusion • Increased census • Overall milieu • Admissions and discharge processes • Activities happening on the unit

11. Restraint or Seclusion Interventions • “Seclusion and restraint when used properly, can be life-saving and injury-sparing interventions. These emergency measures aim to protect patients in danger or harming themselves or others and to enable patients to continue in treatment successfully and effectively” (Success Stories and Ideas for Reducing Restraint/Seclusion, p.3)

12. Patient Rights • All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.(CMS 4821.13(e))

13. Patient Rights • Least restrictive interventions must be implemented or at least considered prior to initiation of restraint or seclusion • Restraint or seclusion use can not be based solely on the patient’s diagnosis or history of dangerous behavior • The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. • Asking the patient who is demonstrating the behavior “what would help you right now at this moment?”

14. Use may result in strong negative physical effects such as: Discomfort Increased risk of pressure ulcers Increased risk of pneumonia Increased cardiac load Increased risk of de-conditioning Increased risk of injury or death Use may result in strong negative psychological effects such as: Increased disorganized behavior Social isolation Demoralization Humiliation Sense of being punished Interferes with therapeutic relationship Risks Associated with Restraint or Seclusion

15. Awareness of Escalating Behaviors • CPI training for each Behavioral Health staff member • Majority of restraint or seclusion events occur within the first 24 hours of admission in BCHS Behavioral Health • Escalating signs may include: • Pacing, hand wringing, clenching fists • Red faced, perspiring heavily, rapid breathing • Loud, pressured or rapid speech • Lack of eye contact

16. Least Restrictive Interventions • Re-direction • Counseling • 1:1 Intervention • Decreased environmental stimuli • Increase rounding frequency • Move patient closer to nurse station • Approach patient in calm, unhurried manner • Limit setting • Quiet atmosphere • Visual suprvision • Diversional Activities • Television, radio • Games

17. Least Restrictive Interventions • Refocusing attention • Reality orientation • Pain relief/comfort measures • PRN medication • All interventions attempted must be documented • Any interventions that were considered but not attempted should be documented and the reason not implemented

18. Is it Time for Restraint or Seclusion? • Behavior that precipitates a decision to restrain or seclude a patient should first trigger investigation and treatment aimed at understanding and eliminating the cause of the behavior. • Underlying causes of threatening behavior may include: • Fear • History of physical or sexual abuse, past restraints • Misinformation • Symptomatic behavior related to diagnosis, i.e. paranoia

19. Initiation of Restraint or Seclusion • Assessment of patient’s needs • Addressing medical problems may eliminate or minimize the need for restraint or seclusion. • Medical problems may include: • Substance abuse, drug interaction or drug side effect • Elevated temperature and infection • Pain • Organic Brain Syndrome or delerium • Hypoxia • Hypoglycemia • Electrolyte imbalance

20. Positional Asphyxia and Restraint or Seclusion • The prone position (face down) should not be used for restraint as it may lead to positional asphyxia • “Positional asphyxia is insufficient intake of oxygen as a result of body position that interferes with one’s ability to breathe”(Mohr & Mohr, 2000, p.289;National Institute of Justice Program [NIJP], 1995, p.1) • As a consequence of the restraint application respiration is compromised causing insufficient oxygen in the blood to meet the body’s oxygen needs or demands (hypoxia) which then results in a disturbed heart rhythm (cardiac arrhythmia)(Patterson,et.al., 1998, p.62).

21. Prone Restraint Complications • Compression or restriction of movement of the ribs (intercostal muscles) limits the ability to expand the chest cavity and breathe • Abdominal organs may be pushed up, restricting movement of the diaphragm and further limiting the available space for the lungs to expand • Further restriction of the chest cavity may come from a staff person pressing a hand or knee into the patient’s back or leaning body weight into or against the back or chest • Agitation or aggressive struggle further increases the body’s oxygen demands and increases the heart rate • Increased heart rate and insufficient oxygen may cause a fatal cardiac arrhythmia

22. Agitated Delerium and Sudden Death Involving Restraints • Condition of extreme mental and motor excitement characterized by aggressive activity with confused and unconnected thoughts, hallucinations, paranoid delusions and incoherent or meaningless speech. • Display extraordinary strength and endurance when struggling • Hyperthermia is often present • Described in patients with psychosis, chronic schizophrenia, mania, and high blood concentrations of cocaine, methamphetamines or other stimulants

23. Obtaining an Initiation Order • Order may be initiated prior to receiving order, if imminent danger to patient or others • Nurse initiated order is for 30 minutes. If physician was not notified prior to restraint or seclusion, within a few minutes contact the psychiatrist or physician to obtain an order for up to 4 hours. • In Powerchart – click Add an order – and then choose Restraint/Seclusion Behavioral Problem • If order was not received from the attending or the physician covering for the attending, notify the attending as soon as possible • Behavioral Health Administrator on Call must be notified of every restraint or seclusion event

24. Restraint or Seclusion Order • Must Never Be Written as PRN • Choose Restraint or Seclusion • Include Duration (hours or minutes) • Include Duration Unit (number of hours or minutes) • Include least restrictive interventions attempted or considered/not attempted and why not attempted • Include clinical justification for use • Include type of restraint • Include behavioral criteria that must be demonstrated for discontinuation and this information is also shared with the family when authorized by the patient

25. Physician Face to Face Assessment • Must be performed within one hour of the initiation of the restraint or seclusion • RN documents on the restraint form the time the physician performs assessment • Physician documents the assessment findings in Powerchart

26. Monitoring of Restraint or Seclusion • Staff will be assigned to monitor the patient one to one • In seclusion, the staff member will remain outside the locked door to observe the patient • In restraint, the staff member will remain in the room with the patient • Documentation must be done every 15 minutes on the assessment section of the restraint form • A simultaneous combination of restraint and seclusion (restrained alone in a room that the patient would not be able to leave if he/she were not restrained) is not practiced at BCHS Behavioral Health

27. Restraint or Seclusion Assessments • Document every 15 minutes • Vitals • Based on the patient’s condition • Circulation and range of motion • Checking skin color and temperature • Complaints of numbness, tingling • Asking how extremities feel • Repositioning and release of restraints • Which restraints have been released • Patient was repositioned

28. Restraint or Seclusion Assessments • Offer and document every 2 hours • Hygiene and elimination • With assistance, loosen restraints and assist patient to commode for elimination needs and or hygiene needs • Nutrition and hydration • Increased calories being used related to behaviors • Increased risk for dehydration and or electrolyte imbalance related to increased perspiration

29. Psychological Status and Comfort • Continue to offer support to the patient, focusing on what they need and how we can help them • Continue to rebuild therapeutic rapport • Continue to listen for their concerns or complaints • Continue to learn from the patient what led to the behaviors that required restraint or seclusion

30. Vulnerable Patient Populations at Risk While in Restraint or Seclusion • Pregnant • Respiratory conditions such as asthma or COPD • Cardiac disease • Seizure disorder • Fractures, arthritis • Head or spinal injury • Victim of sexual, physical or emotional abuse • Victim of rape • Cognitive limitations, language limitations

31. Assessment of Patient Distress Related to Restraint or Seclusion • Shortness of breath, coughing, choking, gasping, saying he/she can’t breathe • Changes in vital signs, changes in mental status or speech • Skin cool or cold to touch, perspiring heavily and hot to touch • Pain symptoms - guarding an area, grimacing, saying he/she is in pain, pointing to a painful area • Nausea and vomiting • Any physical changes must be reported to RN for further action up to and including calling 911 for transport to the Emergency Department • Initiation of CPR for absent pulse or respirations

32. Helping the Patient Meet the Criteria for Discontinuation • Criteria has been identified in the initial order and communicated with the patient and/or family • Offer to contact the family if that would help • Ask how we can help the patient meet his/her needs • Continue to dialogue with the patient

33. Recognition of Patient Readiness to Discontinue Restraint or Seclusion • Behavioral criteria identified at initiation of order has been met • Changes in physical activity and verbalizations • Must be discontinued at the earliest possible time, regardless of the length of time identified in the order • Once discontinued, a new order must be obtained if restraint or seclusion needed again (releasing for hygiene or elimination needs is not discontinuation) • A final assessment documentation must be performed 15 minutes after discontinuation • The restraint or seclusion event must be entered on the restraint/seclusion log on the unit

34. Care Plan Modification • The use of restraint or seclusion must be in accordance with a written modification to the patient’s plan of care. • Use of restraint or seclusion constitutes a change in a patient’s plan of care. • The change in the plan of care should be based on assessment and evaluation of the patient.

35. Debriefing after Restraint or Seclusion • As soon as possible, but no longer than 24 hours, after the event hours • Includes all staff present during the event and the patient and/or family as applicable • Documentation in the EMR should indicate any injuries the patient sustained and how the patient perceived the restraint or seclusion. Document if the patient identifies something else that could have been done to help he/she regain control and avoid restraint or seclusion. • Postvention form needs to be completed after each restraint or seclusion event and should be submitted to the Nurse Manager or the Educator for use in staff training and for Performance Improvement

36. Death Reporting Requirements • You must report any death that occurs in relationship to restraint or seclusion to Risk Management • Death that occurs while a patient is in restraint (physical or drug/medication) or seclusion • Death that occurs within 24 hours after the patient has been removed from restraint or seclusion • Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the patient’s death • A PEERS must also be completed

37. Contact Required for Reporting a Death • Must be reported to Risk Management • Call operator and ask Risk Management be paged to your number • Sending an email or leaving a phone message is not acceptable • You must speak to someone from Risk Management

38. Staff Training Requirements • CPI certification on initial hire and annual recertification for all staff • Staff are not allowed to participate in restraint application or seclusion procedures until CPI training has been completed • Review of this Behavioral Management training module

39. Patient Safety and Quality Performance Indicators • Every restraint or seclusion event in Behavioral Health will be audited through concurrent chart reviews at the unit level and reviewed at staff meetings • Report of restraint or seclusion events to Behavioral Health Quality Improvement Team monthly • Report of restraint or seclusion events to Patient Safety and Quality monthly

40. References • BCHS Restraint & Seclusion Policy # TX-70 • CMS Manual System. (2008). Pub. 100-07 State Operations Provider Certification. 482.13(e) • Standard: Restraint or Seclusion, 482.13 (f) • Standard: Restraint or Seclusion: Staff Training Requirements, 482.13 (g) Standard: Death Reporting Requirements • Crisis Prevention Institute, Inc. 2002. Instructor manual: Nonviolent crisis training program. Brookfield, WI: Compassion Publishing, Ltd. • Michigan Association of CMH Boards. (2001). Michigan’s Mental Health Code. Lansing, MI.

41. References • American Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems. 2003. Success stories and ideas for reducing restraint/seclusion in behavioral health. • DeLacy,L.C.(2001). Seclusion and Restraint Standards: A platform for creating safety for patients and staff. Journal of the American Psychiatric Nurses Association, 7 (4) 99-102. • Mohr & Mohr, 2000, p.289;National Institute of Justice Program [NIJP], 1995, p.1. • Myers, R.E., Williams, J.E. (2001). Relationship of less restrictive interventions with seclusion/restraints usage, average years of psychiatric experience, and staff mix, 7 (5) 139-144.