New restraint standards will change your practice
New restraint standards will change your practice
ED staff are at high risk for placing patients in unnecessary restraints, according to Robert Wise, MD, vice president of standards for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL.
"If things are very busy, ED staff might be tempted to use restraints to resolve an issue quickly. If patients are restrained because there is low staffing, it would be seen as abuse," he warns.
New restraint standards require you to use restraints or seclusion only for emergency situations when there is imminent risk that patients will harm themselves or others, according to Wise. "Even then, restraints are only to be used as a last resort," he says. (See key changes in the standards, p. 95.)
You’ll need to demonstrate that a patient is in restraints for specific reasons, stresses Wise.
"You will then have to document the severity of the presenting problem to show it reaches the level of imminent danger. You need to show that it’s not just being done for staffing reasons or convenience."
The standards will be scored for compliance in January 2001, Wise reports. Type 1 recommendations are usually built on information gathered across the facility, notes Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a health care professional consulting firm in Marblehead, MA, specializing in regulatory compliance. "However, with restraints, just one order could do it," she says. "Follow policy and procedure to the letter."
The two basic issues are patient safety and respecting patients’ rights. Because of safety issues and the known deaths associated with restraint use, the general feeling is that the new standards will not be capped for scoring, which means there won’t be a sliding scale scoring system that’s typically used for several months after standards are introduced, he says. "You’ll need to check your policies for holes and see if anything needs to be changed." (See how the standards differ from those of the Health Care Financing Administration, below left.)
Here are ways to ensure compliance with JCAHO’s new restraint and seclusion standards:
o Provide staff with training. Staff need ongoing training in restraint use, says Wise. The training should address the following, he advises:
— understanding how underlying causes such as medical conditions and staff interventions can cause aggressive behavior;
— de-escalating patients’ agitation;
— recognizing readiness for discontinuation of restraint or seclusion;
— recognizing signs of physical distress.
o Continuously monitor patients. Continuous monitoring is accomplished through continuous in-person observation by an assigned staff member, says Wise. "We left it pretty open so an ED can figure out how to do this," he adds. "It requires some creative thinking about how somebody in restraints would be continuously monitored." It could be a drain on staffing, Wise notes. "However, that would be an impetus to facilitate the appropriate transfer or remove the individual from restraints as quickly as possible," he says. "In a busy ED, it’s possible that someone in restraints could be left alone for significant periods of time, which would be viewed as a serious issue."
o Know when to use medical/surgical or behavioral health standards. You don’t have to use the more stringent behavioral health standards until you have ruled out a medical condition, says Wise. "If a patient in your ED is acting strangely or bizarrely, and it’s not clear whether it’s for a psychiatric or medical reason, the triage nurse will have leeway if you need to restrain the person for a medical exam," he explains.
At that point, you might reasonably think that a medical problem might be present, says Wise. "So you could use the medical/surgical standards, until it becomes clear that it is a behavioral health problem," he notes. At that point, the behavioral health standards would apply. "It’s up to the careful judgment of the triage person to determine initially what standards are being used and to use the appropriate standard as the work-up progresses."
o Realize that a diagnosis is no longer adequate to justify restraints. Many hospitals use diagnoses such as "altered consciousness," "psychiatric hold," "demented," or "overdose" as criteria for restraint use, but those criteria are insufficient, says Stuart Shikora, MD, FACEP, a JCAHO surveyor and an ED physician at Mount Diablo Medical Center in Concord, CA.
"Just because a patient is demented, that doesn’t immediately justify use of restraints," he stresses. "That is not satisfactory."
The need for restraint has to be described by behavior, not diagnosis, says Shikora. "For example, you can have a patient coming out of anesthesia who is combative but is not demented," he says. In that case, document that "restraints are needed to prevent dislodging of tubes," he suggests.
Formulate specific criteria to justify restraint use, he says. "Look at behaviors which are dangerous to the patient or staff and write those down as a reason to use restraint, not the diagnosis. That implies the need for restraint but doesn’t clearly state it."
o Consider alternative measures for restraint. Document that alternative measures were considered before restraints were used, says Shikora. For example, the nurse might check off "family at bedside, unable to calm patient," he suggests. "Document that we tried this, but it didn’t work,’ or resources weren’t available,’ or an out-of-control patient might be calmed by a family member, but none were available.’"
If the patient wants someone there, the effort to contact that person must be made and documented, Catalano says. "If several options are given, call several people until you find one of them at home. Document all attempts."
[The new restraint and seclusion standards are available on the Joint Commission’s Web site: www.jcaho. org. Double-click on "For Health Care Organizations and Professionals." On the next page, click on "Standards" in the top bar. That will take you to the standards page, which includes a link to the restraint and seclusion standards. The manuals including the standards can be purchased by calling the Joint Commission at (630) 792-5800, 8 a.m. to 5 p.m. Central time on weekdays.]
• Kathleen Catalano, RN, JD, The Greeley Co., 200 Hoods Lane, Marblehead, MA 01945. Telephone: (781) 639- 8030. Fax: (781) 639-0085. E-mail: [email protected].
• Stuart Shikora, MD, FACEP, Mount Diablo Medical Center, Emergency Department, 2540 East St., Concord, CA 94520. Telephone: (925) 258-0013. Fax: (925) 258-0014. E-mail: [email protected].
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