Warning! Surveyors won’t hold back in evaluating new restraint standards
Warning! Surveyors won’t hold back in evaluating new restraint standards
Restraint, seclusion is No. 1 cause of Type 1s, margin for error is slim’
Are you often too busy to make an effort to contact family members of patients in restraints? Do you document the need for restraint by describing the patient’s diagnosis? Is chronic short staffing ever a factor in the decision to place a patient in restraint?
If the answer to any of these questions is "yes," you aren’t in compliance with new standards for restraint and seclusion from the Joint Commission on Accreditation of Healthcare Organizations. The standards become effective Jan. 1, 2001. (See key changes in new standards, p. 154.)
Restraints are the No. 1 area for Type 1 recommendations, notes Ann Kobs, president and CEO of Type 1 Solutions, a Fort Myers, FL-based compliance consulting firm specializing in preparation for Joint Commission surveys.
"Restraint is a very hot public issue," she says. "Therefore, the surveyors will be forced to focus on it."
A hospital receives a score of 1 (total compliance) only if 99% of the restraint orders are time-limited, says Kobs. "The margin for error is slim," she warns.
The standards will be scored for compliance in January 2001, and are not going to be capped, reports Robert Wise, MD, vice president of standards at the Joint Commission. "This is because of patient safety issues and the known deaths associated with restraint use," he explains.
Although new standards are generally "capped" for compliance to give facilities time to prepare, the restraint standards will be scored immediately, notes Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a health care professional consulting firm in Marblehead, MA, specializing in regulatory compliance.
Usually, Type 1 recommendations build on information gathered across the organization, Catalano says. "However, with restraints, just one PRN’ order could do it," she adds.
During surveys, ED staff will almost definitely be asked about restraint, says Catalano. "And this topic will be more under fire than usual because of the changes in the standards by both HCFA [Health Care Financing Administration] and Joint Commission," she warns. (See story on differences between the HCFA and Joint Commission standards, p. 152; and controversy over the one-hour rule, p. 153.)
ED staff are at higher risk
ED staff are at high risk for noncompliance because there is a tendency to place patients in restraints when it’s not truly necessary, warns Wise. "If restraints are used because the ED is crowded or short-staffed, surveyors will take that very seriously," he stresses. (See story on use of medical/surgical or behavioral health standards in the ED, p. 153.)
Here are ways to ensure compliance with the Joint Commission’s new restraint and seclusion standards:
• Only use restraint when there is a clear risk of harm to the patient or others. Use restraints or seclusion only under one circumstance: when there is imminent risk that patients will physically harm themselves or others, according to the new standards. "Even in that case, you should only use restraints as an absolute last resort," says Wise.
Use restraint or seclusion only when nonphysical methods are ineffective or not viable, stresses Carrie McCoy, PhD, MSPH, RN, CEN, associate professor of nursing at Northern Kentucky University in Highland Heights, KY. "Do not base use of restraints solely on previous history of dangerous behavior."
The way you document needs to address those criteria directly, stresses Wise. "You need to demonstrate the specific reasons that a patient is in restraint, and show that the risk of harm to self or others reaches the level of imminent danger," he says. "The key is to show that you are not using restraints for convenience or because you are short on staff."
• Provide staff with training. Staff should have ongoing education regarding restraint use, says Wise. The training should address the following:
— aggressive behavior stemming from under-lying causes such as medical conditions and staff interventions;
— ways to de-escalate patients;
— ways to recognize when a patient is ready for discontinuation of restraint or seclusion;
— signs of physical distress.
There are four training requirements for staff under the Joint Commission standards, says Catalano. "What staff are allowed to do will be dependent on which training requirements they have mastered," she adds. Here are the four levels:
1. A = training requirements for all direct care staff;
2. B = training requirements for staff who are authorized to physically apply restraint or seclusion;
3. C = training requirements for staff who are authorized to perform the 15-minute assessments;
4. D = training requirements for staff who are authorized to initiate restraint or seclusion and/or perform evaluations and re-evaluations.
• Monitor patients closely.
You need to assess patients at the initiation of restraint, and every 15 minutes thereafter, says McCoy. Your assessment should include the following, she recommends:
— injury associated with the restraint;
— nutrition/hydration;
— circulation and range of motion to the extremities;
— vital signs;
— hygiene and elimination;
— physical and psychological status and comfort;
— readiness for discontinuation of restraint or seclusion.
Someone should watch the patient for distress at all times, says McCoy. Continuous monitoring is required, in addition to checks every 15 minutes, she stresses.
Wise acknowledges that it’s not easy to keep a constant eye on a restrained patient in a busy ED. "But that is a strong incentive to remove the individual from restraints as quickly as possible," he adds. "If a patient in restraints is left alone for a significant length of time, that would be viewed as a serious issue."
Document the monitoring of circulation, color, toileting, and nutrition, says Kobs. "If you perform checks every 15 minutes, then there needs to be documentation that it was done every time," she stresses. "If it isn’t documented, it isn’t done." (See items that you need to document, at right.)
• Describe the patient’s behavior. Instead of writing a diagnosis such as "overdose" or "altered consciousness" on a patient’s chart, describe the behavior instead, advises Wise. Justify restraint use based on those criteria, he stresses. An example would be "restraints are needed to prevent the patient from dislodging tubes," says Wise.
• Follow protocols to the letter. Be ready to answer surveyor’s questions about your restraint policy and procedure, Catalano advises. "You must be able to regurgitate word for word. You must know what training you’ve had and if you have been involved in any performance improvement activities for monitoring restraint or seclusion," she says.
Organize your policy and procedure with the following four sections, recommends Catalano:
— philosophy;
— alternatives to restraint/seclusion use;
— clinical justification for restraint/seclusion;
— restraint/seclusion specifics.
All restraint policies should contain the following, according to Catalano:
— a statement that says, "The goal of ______ hospital is to have a restraint-free facility"
— a list of alternatives to restraint use;
— what constitutes clinical justification;
— specific procedures for restraint.
For more information on the Joint Commission’s new restraint and seclusion standards, contact:
• Kathleen Catalano, RN, JD, The Greeley Co., 1328 Stonecrest Drive, Coppell, TX 75019. Telephone: (972) 393-3336. Fax: (972) 462-7079. E-mail: [email protected].
• Ann Kobs, President/CEO, Type 1 Solutions, 166 S.E. 18th Terrace, Suite A, Cape Coral, FL 33990. Telephone: (941) 574-8318. Fax: (941) 574-8814. E-mail: [email protected].
• Carrie McCoy, PhD, MSPH, RN, CEN, Associate Professor of Nursing, Department of Nursing, 346 AHC, Northern Kentucky University, Highland Heights, KY 41009. Telephone: (859) 572-6541. Fax: (859) 572-6098. E-mail: [email protected].
The complete restraint and seclusion standards are available on the Web site for the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org). Double click on "For Health Care Organizations and Professionals." Under "Future Standards," click on link to the restraint and seclusion standards. The manuals that include the standards can be purchased by calling the Joint Commission’s Customer Service Center at (630) 792-5800, between 8 a.m. and 5 p.m. CST weekdays.
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