JCAHO clamps down on restraint use

Quality professionals take steps to retrain staff

The use of restraints is probably a rare occurrence in your hospital — a patient care issue most quality professionals rarely think about. But public pressure and horror stories such as nonviolent suicidal patients being strapped down in emergency departments have driven the Joint Commission on Accreditation of Healthcare Organizations to clamp down on restraint use.

Admitting that restraint use is low, the Joint Commission is nonetheless reacting to the public pressure by forcing hospitals to re-examine the use of restraints and devise policies to use nonphysical or less restrictive methods whenever possible. And many hospital quality professionals working to meet the new standards find that staff know little about the alternatives to restraints. While your facility grapples with the new standards, you should also be aware the Joint Commission has warned that the standards it released in July are only the beginning. In other words, you need to show no restraint in attacking your hospital’s policy on restraints.

"I expect that the standards are going to get tougher in the years to come," says Michelle Pelling, MBA, RN, president of The Propell Group, a health care management consulting firm in Portland, OR. She says she wouldn’t be surprised to see the new standards calling for a maximum of 24 hours between evaluations of restrained patients to be ratcheted down to 12 hours or less.

Some facilities view the standards as an opportunity to improve their use of restraint devices; others see it as a bother. Bother or not, most believe the Joint Commission will not take their focus off this issue any time soon.

Cynthia Caudle, BSN, nursing quality coordinator at Methodist Hospitals of Memphis, TN, would fall into the opportunity category. She reports nothing but good has come out of her organization’s evaluation of its restraint use, which resulted from changes in the standards.

What’s the frequency?

As discussions progressed at Methodist about its restraint policy revisions, Caudle realized nobody had a good idea of how frequently restraints were used. The number of patients in restraints is key, not only to have a base number for comparison, but also to determine how many data elements could feasibly be collected in a quality improvement project. Data on use of restraints are generated through manual chart reviews at Methodist.

Some believe the restraint rate was quite high; Caudle remained neutral and executed two simple polls of the 60 nursing units at four of Methodist’s five facilities.

She asked five questions:

• What was your census as of noon on a particular day?

• Of those patients, how many patients are in medical protective devices to prevent falls, wandering, or removal of medical equipment at the moment?

• How many patients are in restraint devices for assaultive, aggressive behavior due to medical or surgical reasons?

• How many patients are in restraint devices for assaultive, aggressive behavior due to behavioral health reasons?

• How many patients are in restraint devices because they are intubated?

To see if the restraint rate varied at night, the survey was repeated for patients in the hospital at 10 p.m.

Caudle found the rates of restraint ranged from 0% to 5%. With the numbers so low, a detailed look at how the restraint devices are used is possible. The new restraint policy took effect Oct. 14, and a quality management survey is scheduled for January 1997. The final details of the survey content have yet to be hammered out. It may have as many as 23 data elements.

"Even with the low numbers, there is room for improvement," Caudle says. "We want to find out the length of time the restraint episodes last. We want to pay special attention to patients with multiple restraint episodes." Understanding why less-restrictive restraint measures failed will lead to improved patient management techniques, Caudle says.

Improvement at a cost

The Children’s Mercy Hospital in Kansas City, MO, got a jump start on the updated restraint standards. An intensive review of the hospital’s restraint policies precipitated definitions of restraints, descriptions of when restraints are appropriate, and for which patients. Lengths of time were also addressed with the overriding emphasis that patients should only be restrained after minimal measures have failed, and restraints are removed as soon as an episode is over.

"Our hospital’s work prior to our February ‘96 [Joint Commission] survey has positioned us well with only minor revisions to our restraint policy and procedure necessary for compliance with the [new] standards," says Sharon Mellor, RN, CPHQ, director of Quality Resources at Children’s Mercy.

While pleased with the policy changes, Mellor and others have questioned the new emphasis the Joint Commission has put on restraint matters. "There has been, perhaps, too much time spent on restraint issues," she says. "I really think there are other issues related to improving the quality of care that more time could have been spent on. Sometimes, we get caught up in something that won’t produce great changes in care. I don’t think they needed to get down to the detail they have."

"There was significant pressure from patient’s rights groups and patient advocacy groups to deal with the issue of restraints," says Ann E. J. Kobs, MS, RN, associate director of Joint Commission Department of Standards. "The research literature pointed to moving in the direction of less-restrictive methodology and even moving to a restraint-free environment. Two years of field input was gathered and used in development [of the revised standards]. This was placed in the framework of performance improvement, charging organizational leadership with making the use of restraints a high priority with an eye toward reducing utilization."

Organizations like Children’s Hospital may be on top of their restraint policies, but others are not, Pelling argues. "A lot of organizations looked at restraints before the new standards came into play," she says. "They may be saying, ‘Gee, our restraint use is so far down, how are we going to meet this new standard for improvement.’" She advises hospitals in that position to demonstrate the changes made — regardless of when they were implemented — and document the improvements that have resulted.

"From the Joint Commission’s perspective, the majority of organizations need to carefully consider their use of restraint and their policies regarding restraint," she says. "As I visit organizations, the majority of them are in this category. There’s a lot of stuff that is going on that could be a lot better." She noted one organization restrained suicidal patients in the emergency department. Unless they are violent and pose imminent danger to themselves or others, these patients need counseling, not leather straps on their arms, she says.

"It was a very big effort," says Cheri Hunt, RN, MHA, director of nursing practices at The Children’s Mercy Hospital, referring to her organization’s evaluation of its restraint practices. "I personally think that what we did was worth it, however. It helped clarify what a restraint is by definition. At the same time, we developed tools that will help us document."

For example, Hunt helped create a flow sheet to make documentation and administration of restraint episodes easier and more complete. (See example of flow sheet, p. 161.)

Physician’s order sheets for use of restraint were revised. The new order sheet lists less-restrictive measures — removing environmental stimuli and sitting quietly with the patient — that can be checked off before more confining measures are taken. (See example of order sheet, p. 162.)

The Children’s Hospital’s new policy also calls for a chart review of every restrained patient. In conjunction with that, a quality improvement tool was developed for the review. (See example of chart review tool, p. 163.) Hunt estimates there are five to six restraint episodes per quarter.

Before you restrain someone

Once restraint policies had been crafted, both The Children’s Hospital and Methodist put staff through intensive inservice training. The seminars clarified when restraint is appropriate, but they also showed the staff that less-restrictive measures are available, such as counseling for suicidal patients.

"There was a lot of ‘ah-ha’ experiences," Caudle says of the mandatory education sessions for nurses at Methodist. "The inservice showed them that restraints are not always necessary to prevent patients from falling." Those attending the seminars found that simple techniques can prevent falls, the dislodging of medical devices, and wandering. (See story on using alternatives to restraints, right.)

"We have never said to the nurses before that we expect them to try other things before you try restraint," Caudle says. "But, we are saying that now. We are changing the culture. We are changing our expectations, and we are communicating that to the staff."

Caudle cannot definitively say Methodist’s low restraint rate is getting any lower. She suspects, however, that the raised consciousness of the staff and the emphasis to try less-restrictive devices first has already led to fewer calls for restraint devices.