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Documenting means more than checking a box
Restraint and seclusion has been a hot topic in emergency departments (EDs) at least since 1999, when the Centers for Medicare & Medicaid Services (CMS, then known as the Health Care Financing Administration) established a Condition of Participation that set new and stringent rules regarding the practice of restraining patients. The Joint Commission on Accreditation of Healthcare Organizations soon followed by revising its own restraint standards, and restraints remain a key focus of interest on the part of Joint Commission surveyors.
Indeed, because the practice of placing a patient in restraints or somehow isolating that patient is scrutinized so carefully — not just by CMS and the Joint Commission but by internal hospital committees and patients’ families as well — it’s vitally important for you to be able to document what you did, why you did it, and how often you followed up.
Objective criteria defined
The good news is that, after the initial uproar following CMS’ publication of the Condition of Participation on restraints, many EDs have become more consistent regarding their approach to restraint and seclusion. "I think there’s a little more clarity now," says Kathleen Emde, RN, MN, CCRN, CEN, trauma service coordinator at Overlake Hospital Medical Center in Bellevue, WA. "There’s been a lot of discussion of the issue at various levels, probably across the country. I know it has happened here. So I think people are just a little less anxious about it than they were because they’ve got a plan now."
One benefit of the increased focus on restraints has been the development of objective criteria for when patients should be restrained. "It added a little more complexity to the process, but it also added some accountability and clarity, so that we were all hopefully doing things the same way."
According to Emde, some of the things Joint Commission surveyors look for regarding restraints are whether you tried to use alternative interventions before restraining the patient, and what documentation you included regarding the reason for the restraint. Other questions surveyors might ask include:
Emde says the Joint Commission’s recent focus on restraints probably is related to its increased emphasis on patient safety, as well as the fact that historically restraints were misused at some facilities, either because people were restrained inappropriately, restrained for longer than necessary, or they weren’t observed closely enough when they were restrained. "I think this was a response to those sorts of situations and those dramatic problems that occurred," she says.
The first step in the process of documenting a restraint case has to do with the initial assessment, says Rochelle Caudill, RN, CEN, BSN, MBA, a staff nurse at St. John Medical Center in Tulsa, OK. The assessment essentially should take note of behavior that might result in harm either to the patient or to others. For example, for a medical/surgical restraint, is the patient at risk of pulling out catheters, tubes, or lines?
"The first thing you’re doing is trying to come up with alternatives to the restraints," Caudill says. "Because the last thing you want to do is restrain them. If they have family who can sit with them, that’s wonderful."
Emde notes that criteria differ between medical/surgical and behavioral restraints. (For examples of the different criteria, see sample restraint/seclusion flowsheet and orders.) Overlake has separate order sheets for each. Medical restraint orders usually concern patients with invasive catheters, mechanical ventilation, or other medical issues. If patients are restrained for behavioral reasons, "it’s a much higher standard in terms of what needs to be done," Emde says. "There are more frequent reassessments."
"Usually, when we do behavioral management, it’s because a patient is of harm to themselves or to others," Caudill says. "They have suicidal ideation and they want to leave. Then we are bound by law to keep them there, and sometimes that means we have to restrain them. Or we might have a violent-type patient."
Whatever the reason for the restraint was, it’s important to note that you must go beyond simply checking a box on a flowsheet, Emde stresses. "You have to carefully document what your indication was. In other words, what criteria did the patient meet? That needs to be not just checked off on the list; it also needs to be documented within the nursing documentation."
It’s also vital to document the ongoing monitoring and reassessment of the restrained or secluded patient. At St. John, the monitoring includes making sure the restraint is intact, that the patient has adequate circulation, and checks of color, temperature, and skin integrity. Range of motion also is checked regularly. In reality, of course, "you’re checking the patient all the time," Caudill says. "Certainly, patient safety and their comfort and those sorts of things are utmost in your mind."
Emde agrees: "Really, in the emergency department, if we have a patient who is restrained, they’re under continuous observation."
Other ongoing issues with restrained patients include offering them food, fluids, and toileting; assessing their level of consciousness; assessing whether they are experiencing pain; and reassessing whether the reason the patient was restrained in the first place is continuing or has been resolved. "All of those issues come into play," Emde says. "That’s where the documentation gets a little cumbersome. On the flowsheet, you can see all of the data points there that are addressed. It’s a lot of documentation."
Of course, even the best-designed flowsheet that reflects the state of the art in care is worthless if nurses either aren’t aware of it or don’t know how to use it properly. That’s where training comes in.
At Overlake, the initial instruction was conducted two years ago as part of the facility’s workplace violence training. "We did a massive training of all of the staff — not just in the emergency department but also in the hospital," Emde says. Not everyone received the same level of training, of course. Staff were assigned risk categories according to who most likely would be exposed to violent patients and/or family members. "For instance, if they work in the boiler room, they’re low risk. If they work in the emergency department . . . then those people got higher-level training."
The training didn’t just focus on the process of restraining patients. "We approached it as an entire program. What are the signs that a patient’s behavior is escalating? What techniques can you use to de-escalate their behavior? What if it doesn’t work and you have to defend yourself — how do you do that? What if you have to restrain the patient — how do you do that?"