Restrain patients safely: Reduce Risks

Restraint problems can be reduced by enlisting help of ancillary staff, adhering to protocols, and ensuring that needs of patients are met.

Restraining patients who are violent, acting out physically, or disoriented presents a multitude of risks to nurses. "The ED environment results in a larger nurse to patient ratio than anywhere in the inpatient setting," notes Carol Buschur, RN, CEN, clinical coordinator for the ED at University Hospital in Cincinnati. "Inpatient restrained patients have a higher acuity level and require more nursing time devoted to their care than in the ED setting."

This presents risks to both patients and nurses, notes Ruth Shaull, RN, MSN, CS, psychiatric liaison clinical nurse specialist at University Hospital. "Those risks can be reduced with careful adherence to written protocols and ongoing education," she says.

To reduce risks of restraint, follow these guidelines:

Ensure that needs of restrained patients are met. "The greatest challenge is providing the patient with the needed ROM, toileting, and ADL needs that a person without restraints would be afforded," says Mary Anderson, RN, BSN, nurse manager of emergency services at Medical University of South Carolina. "The busier your department gets, the greater a challenge this becomes."

The ED's restraint assessment form (see restraint observation flow sheet, page 149) has reminders for toileting and food and drink. "That makes it easier because everything you need to remember is all right on the form," says Anderson.

Monitor restrained patients carefully. University Hospital uses a one-page Observation Flow Sheet to document type and location of the restraint used, proper placement and body alignment, circulation, food/fluid offered, toileting needs, skin integrity, ROM, and environmental safety. "All the criteria we need to check for when we observe a patient in restraint is on that one sheet," says Buschur.

Tracking boards can be used to remind nurses that a restrained patient needs to be checked frequently, suggests Anderson. "Use a color-coded magnet, colored dot, or other visual mechanism to indicate that a patient is in restraint and needs closer attention," she says.

Enlist help of ancillary staff. Documentation can be overlooked even though tasks are performed. "A solution to this problem is to have a secretarial staff that is anticipatory in their work ethic," says Anderson. The ED's secretaries pull the documentation form as soon as restraint is mentioned, stamp it, and place it on the patient's chart, she explains.

Provide inservicing. Thorough documentation requires continual reminders and inservicing. "Once staff get past the learning curve, documentation is done on a routine basis," Anderson explains. "Periodically, I remind nurses about documentation in staff meetings and ask if there are any problems with using the restraint forms, so I can get feedback that way." Restraint is part of the yearly competencies for all employees, she notes.

Training of ED staff in crisis intervention is key. "This makes us more aware of how to de-escalate situations, how to be aware when a patient is beginning to escalate, and how not to become a precipitating factor to escalate the situation even more," says Buschur.

The entire ED staff should go through training, urges Anderson. "Inservicing in crisis intervention isn't just for nursing staff and security. It should also be part of the yearly competency for the radiology staff, secretaries, and registration clerks," she says. The whole ED staff goes through eight hours of crisis intervention training, with a four-hour refresher course the following year.

Ensure that patients are not carrying lighters or cutting instruments. "Some patients are Houdinis who can magically get out of their restraints in the blink of an eye," says Anderson. "Patients may hide sharp items or lighters in strange places like under their breast or in their groin area and are not detected by a search."

Often, nursing and security are not comfortable searching patients. "This causes problems when the patient either cuts their way or burns their way out of restraints," says Anderson. "I had a patient who had a lighter in his pocket and was not adequately searched and burnt his restraint off. Another had a small switch blade in his pocket and was not searched properly and cut his restraints off."

If patients aren't adequately searched, it puts nurses at risk, says Anderson. "Searching the patients became such a big problem that we purchased paper scrubs and changed all patients into them as soon as possible," she explains.

Document thoroughly. University Hospital's ED developed a grid form to make documentation easier (see CEC Restraint/Assessment form, page 148). "We created an easy, short form that includes the time frame to obtain the order, how often RN assessment needs to be documented, and criteria for reduction and termination," says Buschur.

The form is a single page, but contains all the necessary information. "We try to reduce the number of papers that we need to use," says Buschur. "On that form, we have all the information we need to put a patient on restraints or take them off."

The form includes a section on behavior warranting restraints. "In the past, we didn't document that as well as we should have, so we put it in a prominent place on the form, to make it as easy as we possibly could," notes Buschur.

Having forms readily available makes documentation easier to remember. "Your forms need to be easily accessible so nurses will remember to use them and won't have to go digging through drawers to find what they need," says Anderson.

At University Hospital, a "restraint packet" was created, which is kept with the ED's restraints. "It contains the assessment sheet, observation sheet, statement of belief that needs to be signed by either the police officer, fireman, or doctor, and our CEC restraint "cheat sheet" (see chart, page 151), all in one manila envelope. That way, all the paperwork nurses need is in one place," says Buschur.

Comply with JCAHO standards. In 1997, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) formed a Restraint Standards Task Force to address concerns. "JCAHO is proposing new standards for restraint of non-psychiatric patients," says Sue Dill Calloway, RN, MSN, JD, director of risk management for the Ohio Hospital Association in Columbus. JCAHO's restraint standards have resulted in more Type 1 recommendations against hospitals than any other standard, she reports.

JCAHO investigators often check for adequate documentation in patient charts. "They will pull individual charts to make sure there was a physician order for the restraint, that it was time limited, which type of restraint is required, and the physician's signature," says Anderson.

Investigators also look for documentation of why restraints were used. "Be sure to document the behavior of the patient who made restraints necessary, such as not responding to verbal commands," says Anderson.

JCAHO wants to see a restraint and seclusion policy that is used throughout a facility. "They are looking at continuity of care now. The benefits of a hospital-wide restraint form is the consistency provided to the physician and nursing staff," says Anderson. "This ensures that the same quality of care will be rendered no matter where in the hospital the patient may be."

Always consider alternatives to restraint. At University Hospital, a checklist of possible alternatives is included on the ED's restraint assessment form. The list includes stimulation reduction, moving the patient to a private room, medication, and verbal de-escalation techniques. "This serves as a written reminder to nurses to consider alternatives," says Buschur.

Alternatives to restraining difficult patients

Finding alternatives to restraint can be difficult in the ED, but it's necessary. "In the ED, you don't know who is going to be walking in the door next, and if patients are violent or acting out, restraint may be the only intervention possible," says Shaull.

Alternatives that require closer observation are difficult in the ED. "In an ED setting, you don't have a true nurse to patient ratio, because we take all who come in. Sometimes, we have patients in the hallway or every nook and cranny, and closer observation is not always an option if you don't have extra staff to provide that," says Anderson. "The time investment in many alternatives comes under a crunch when you're busy."

Still, nurses should rise to the challenge and consider alternatives, says Buschur. "Joint Commission is emphasizing alternatives to restraint, so it's important to look for them," she notes. "In the ED, you just have to be more creative in finding alternatives. To reduce stimuli or find a quiet place is more difficult, but it can be done."

Try the following restraint alternatives:

Eliminate communication barriers. "If a patient comes in after a car collision and is acting out, we might not realize they are upset because they are hearing-impaired and can't hear us, or there is a language barrier," says Buschur. "As soon as you can get an interpreter there, that will eliminate the need for restraints."

It's important to assess patients for communication barriers, says Buschur. "In the ED, you need to be acutely aware of this possibility," she explains. "We don't know the people walking through our doors, whereas nurses on the floors will get a report on the patient beforehand."

Decrease stimulation. Providing a quiet environment for patients who are acting out physically is difficult in the ED. "If you don't have a room designated for agitated patients, that can be a roadblock," says Anderson. "And even if you have seclusion rooms with cameras for observation, being secluded can escalate the patient if they don't like being locked up in that manner."

Still, it's usually possible to reduce lights and noise to some extent. "Even if the patient is not in a private room with a door, we can still pull the curtain around the area and block the lights," says Shaull. If patients are already restrained, doing this can speed up the removal process, she notes.

Determine the reason that the patient is acting out. "A parent may be in a rush to pick up a sick child from school. If we don't take the time to listen and respond to that, we are just causing them to act out more," says Buschur. "If we call in social service and make arrangements to take care of the child, the parent will calm down immediately."

Respect personal space of patients. "Any time we take care of a patient, we are invading their personal space," says Buschur. "If you have a patient who is escalating, stay a distance of 3 ft. away. That arm's length means a patient would have to take a step forward to hit you. That would give you an amount of time to step back."

Consider how you speak to the patient. "Most communication is nonverbal. It's not what we say, it's how we say it," says Buschur. "People don't hear the words as much as they hear the tone, cadence, and volume of your voice." At University of Cincinnati, the ED staff is inserviced on non-violent crisis intervention techniques, including body language and tone of voice.

Involve family members. In some cases, friends or relatives can calm patients who are acting out. "Often, they can be very helpful in reducing the need for restraint, although sometimes that backfires and they can escalate the patient," notes Shaull.

Ancillary staff such as chaplains, technicians, or security can also help. "In our facility, security have training in de-escalation so they can help to some extent, although they might not be there from the onset like the nurses are," says Anderson. "If a nurse is in a bind and doesn't have time to consider alternatives, the nursing supervisor may have some other resources in the hospital to send you."

Medication. "Often, chemical restraint is a viable option, but you may have to start out with physical restraint before medication takes effect," says Anderson.

Medication is most effective when used in conjunction with other alternatives, says Shaull. "Most often, it's the combination that works the best," she explains. "Whenever we restrain, the physician assesses the patient before if possible, while, or afterward, and can order medication if necessary to calm the patient so restraints can be removed."

Enlist the help of a different nurse. If one nurse is angering a patient, another may be able to calm him or her. "We are able to work as a team when we see another nurse unable to de-escalate a situation. Another nurse will step in and say, 'why don't you let me try,'" says Shaull.

A particular nurse may remind the patient or a family member of somebody they've had problems with in the past, because of their appearance, how they talk, or their mannerisms. "To have a different person say the same thing may have a completely different result," says Shaull.

Use treatment to avoid restraints. "In many cases, if you impact a patient's condition, you may not need the use of restraints," says Shaull. "For example, if you can prevent people from going into alcohol delirium, you won't need restraints."

Treatment of patients who come in with alcohol withdrawal is inconsistent, says Shaull. "It's typically based on the approach of individual physicians," she says.

The hospital has piloted an algorithm that uses a scored severity scale, which will be tested in the ED. "The higher the score, the more severe the alcohol withdrawal," says Shaull. "You can be more aggressive with treatment because you have concrete parameters to guide your dosing." That might eliminate the need for restraint, she notes.

Consider staffing. Close observation of patients can reduce the need for restraint. "If staff are spread out too much, that means you can't concentrate them where they can do work and observe a patient simultaneously," notes Buschur. "You need to consider where you put the restrained patient, in relation to where staff are."