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SHC's policy on appropriate use of restraints:
what physicians need to know

The issue of patient restraint continues to be a topic of concern and scrutiny by the federal government and the Joint Commission on Accreditation of Healthcare Organizations. Both entities have extensive, complex regulations and standards devoted to the topic. A recent revision of Stanford's restraint policy reflects newer interpretations of these requirements.

For health-care personnel, the guiding principle is that restraints are to be used only when absolutely necessary to prevent injury to the patient or others, or to limit mobility when movement could seriously interfere with the patient's treatment. Restraints are to be employed only when other, less-restrictive methods have proven ineffective or when the situation is serious enough to require immediate restraint.

There are two categories of restraint: medical-surgical and behavioral management. Each is defined based on the clinical justification for using the restraint and has its own set of requirements related to physician orders, monitoring and documentation.

Definitions:
The medical/surgical restraint designation applies when the clinical justification for applying restraints is to support medical healing. For example, the patient may be trying to pull out lines or tubes or has a fracture requiring restricted mobility and less-restrictive methods haven't worked.

The behavioral management restraint designation applies when the patient is exhibiting violent, destructive or aggressive behavior that presents an immediate, serious danger to the patient or others, and the patient has no lines or tubes that could be pulled out nor any other health problem requiring restricted mobility.

Physician orders:
Medical/surgical restraints may be initiated by an RN with appropriate training in the use of restraints, but a physician's verbal or written order must be obtained within 12 hours. The physician order must be renewed every calendar day, after the physician has seen the patient face-to-face and determined that restraints are still necessary.

Behavioral management restraints may be initiated by an RN with appropriate training, but the physician must be notified immediately and must evaluate the patient and write the order within one hour of initiation. This order must be renewed every four hours. A verbal order is acceptable at the end of the first four hours, but the physician must evaluate the patient at least once every eight hours. If the patient is age 17 or younger, the written order must be renewed following face-to-face evaluation every two hours. A verbal order may be obtained at the end of the two hours, but the physician must evaluate the patient face-to-face at least once every four hours.

Monitoring and documentation:
For medical/surgical restraints, the following must be completed and documented by the nurse every two hours: a physical assessment; safety checks; attention to the patient's personal hygiene and nutritional needs; and determination of the ongoing need for restraints.

For behavioral management restraints, the same assessments, care and documentation must be completed every 15 minutes.

Final notes on the use of restraints:

Restraint orders cannot be written as "PRN."
Restraint orders must include the date and time of the order.
If a death occurs while a patient is in restraints, Risk Management must be notified immediately. The case may need to be reported to regulatory agencies.

Note on the use of seclusion:
Patients who are violent, aggressive and/or present a danger to themselves or others may be placed in seclusion, meaning the door to the patient's room is locked. This practice is used rarely and generally occurs on the locked psychiatric unit or, less commonly, in the emergency department. Patients may be placed in seclusion with or without restraints. Patients who are in restraints and in seclusion must have a staff member with them at all times. The procedures listed above for the use of restraints also apply to the use of seclusion.

Questions about the use of restraints can be directed to
Pam Simmons, quality management coordinator, at (650) 723-5311 or Pamela.Simmons@medcenter.stanford.edu.