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You’ll need to help patients to meet behavior criteria for the discontinuation of restraint or seclusion to comply with new guidelines from the Joint Commission on Accreditation of Healthcare Organizations, says Carrie McCoy, PhD, MSPH, RN, CEN, associate professor of nursing at Northern Kentucky University in Highland Heights.
"The intent of this standard is that patients be made aware of the rationale for restraint or seclusion, and the behavior criteria for its discontinuation," she explains. (For more information on the new restraint and seclusion requirements, which went into effect on Jan. 1, 2001, see ED Nursing, October 2000.)
Here are ways to comply:
• Assess a patient’s ability to agree that they will not engage in self-harm. In the case of a confused, intoxicated patient, assess whether the individual is oriented to the environment and able to follow directions, McCoy explains. If a patient has displayed violent behavior, the ability to agree not to engage in harmful acts might be judged by cessation of verbal threats, McCoy states.
• Consult with friends or family members. If an elderly patient is confused, or a patient has a mental health disorder, family members or individuals who are familiar with the patient should be consulted, McCoy recommends. "They may have suggestions for interventions that have been successful in the past with the patient."
• Administer medications for underlying disorders to help the patient meet behavioral guidelines. To discontinue restraint use, you may need to administer antipsychotic medications for a patient with a mental health disorder, says McCoy. Or you may need to treat an underlying metabolic disorder that results in confusion and inability to meet behavioral criteria.
• Don’t reapply restraints without a new order. Orders for restraints cannot be written as standing orders, warns McCoy. "You need to obtain a new order if restraints must be reapplied after the initial order has expired. [As needed] orders are not acceptable." When a restraint or seclusion is terminated before the time-limited order expires, that original order can be used to reapply the restraint or seclusion if the individual is at imminent risk of physically harming himself or herself or others and nonphysical interventions are not effective, McCoy explains. "However, if the original order has expired, a new order must be obtained."
• Remove restraints as soon as the patient meets behavior criteria for discontinuation. Discontinue restraint use when it becomes evident that the patient is no longer a danger to himself/herself or others, says Kathleen Catalano, RN, JD, director of administrative projects at Children’s Medical Center of Dallas. "Your assessment should note whether or not the patient is calmer, not thrashing around, not yelling, etc."
• Help patients to meet behavior criteria. You can help the process along when you check on the patient, says Catalano. "With behavioral restraint, the patient must be checked on every 15 minutes. During that time, talk with the patient to see how he/she is responding," she recommends.
• Try alternatives to restraint. After a 49-year-old patient was electrocuted, his mental capacity diminished to that of a 2-year-old, says Catalano. "The staff at the hospital couldn’t understand his behavior. They tried releasing him from restraints and found that he crawled around on the floor," she reports. The restraints were completely removed, and the floor was padded with mats, says Catalano. "They left balls and other soft objects on the mats," she explains. "The patient no longer needed to be restrained because the alternatives to restraints the staff had used worked."
For more information on removal of restraints, contact:
• Kathleen Catalano, RN, JD, 7307 Boxwood Court, Irving, TX 75063. Telephone: (972) 409-1251. Fax: (972) 409-1252. E-mail: email@example.com.
• Carrie McCoy, PhD, MSPH, RN, CEN, Associate Professor of Nursing, Department of Nursing, 346 AHC, Northern Kentucky University, Highland Heights, KY 41099. Telephone: (859) 572-6541. Fax: (859) 572-6098. E-mail: firstname.lastname@example.org.
The complete new restraint and seclusion standards are currently available on the Joint Commission's Web site (www.jcaho.org — Search for "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. Central Time on weekdays.