EAST TEXAS EAST TEXAS MEDICAL CENTERMEDICAL CENTERManaging Behavioral Restraint or Managing Behavioral Restraint or

Seclusion in the HospitalSeclusion in the Hospital

Knowledge-Based Physician TrainingKnowledge-Based Physician Training

Revised 2-13Revised 2-13

Required TrainingRequired Training

CMS Rule: 482.13(e)(11)CMS Rule: 482.13(e)(11)

Physician and other LIP training requirements Physician and other LIP training requirements must be specified in must be specified in hospital policy. At a hospital policy. At a minimum, physicians and other LIPs authorized to minimum, physicians and other LIPs authorized to order restraint or seclusion by hospital policy in order restraint or seclusion by hospital policy in accordance with State law must have a working accordance with State law must have a working knowledge of hospital policy regarding the use of knowledge of hospital policy regarding the use of restraint or seclusion.restraint or seclusion.

Joint Commission: PC.03.03.03Joint Commission: PC.03.03.03

The hospital has written policies and The hospital has written policies and

procedures that guide the use of procedures that guide the use of restraint and seclusion for behavioralrestraint and seclusion for behavioral

health purposes which include staffhealth purposes which include staff

competence and trainingcompetence and training

Texas Administrative Code:Texas Administrative Code:

25 TAC 415.25725 TAC 415.257

Physicians authorized to give Physicians authorized to give

orders for restraint or seclusionorders for restraint or seclusion

must receive training and must receive training and demonstrate competencydemonstrate competency

DEFINITION OF RESTRAINTDEFINITION OF RESTRAINT

Any manual method, physical or Any manual method, physical or mechanical device, material, or mechanical device, material, or equipment that immobilizes or equipment that immobilizes or reduces the ability of a patient to reduces the ability of a patient to move his or her arms, legs, body, or move his or her arms, legs, body, or head freelyhead freely

THREE TYPES OF THREE TYPES OF RESTRAINTRESTRAINT

•MEDICAL OR NON-BEHAVIORALMEDICAL OR NON-BEHAVIORAL•BEHAVIORALBEHAVIORAL•FORENSICFORENSIC

MEDICAL RESTRAINTMEDICAL RESTRAINT

Definition:Definition:

Any method of Any method of holding or securing a holding or securing a patient for the patient for the purpose of conducting purpose of conducting tests, exams, or tests, exams, or procedures or to procedures or to protect the pt. from protect the pt. from falling out of bed or falling out of bed or to prevent injuring to prevent injuring themselves in some themselves in some type of activity type of activity

Examples:Examples:

Orthopedic devicesOrthopedic devices HelmetsHelmets Surgical dressingsSurgical dressings IV arm boardsIV arm boards Devices used to achieve Devices used to achieve

body alignmentbody alignment Soft foam wrist or ankle Soft foam wrist or ankle

straps or hand mittsstraps or hand mitts Side rails (2) or crib railsSide rails (2) or crib rails Safety beltsSafety belts Physical escorts from Physical escorts from

which the patient can which the patient can escapeescape

FORENSIC RESTRAINTFORENSIC RESTRAINT

DEFINITION: DEFINITION:

Application of handcuffs, ankle cuffs, Application of handcuffs, ankle cuffs, or belly chains by peace officers for or belly chains by peace officers for the purpose of security, detention, or the purpose of security, detention, or public safety; individuals in forensic public safety; individuals in forensic custody with these types of devices custody with these types of devices must be maintained and monitored must be maintained and monitored by peace officers.by peace officers.

BEHAVIORAL RESTRAINTBEHAVIORAL RESTRAINT

Any method (physical, mechanical, or Any method (physical, mechanical, or chemical) of restricting a patient’schemical) of restricting a patient’s

freedom of movement (incl. seclusion), freedom of movement (incl. seclusion),

physical activity, or normal access to his physical activity, or normal access to his or her body, and is not done as a part of a or her body, and is not done as a part of a medical-surgical condition or procedure.medical-surgical condition or procedure.

TYPES OF BEHAVIORAL TYPES OF BEHAVIORAL RESTRAINTSRESTRAINTS

Physical Hold (maximum of 15 min.)Physical Hold (maximum of 15 min.) MechanicalMechanical

• •Restraint ChairRestraint Chair

• •Restraint NetRestraint Net SeclusionSeclusion Chemical (not used )Chemical (not used )

PHYSICAL HOLD RESTRAINTPHYSICAL HOLD RESTRAINT

The application of body pressure by The application of body pressure by another person to the body of a another person to the body of a patient in such a way as to limit or patient in such a way as to limit or control movement of the whole or a control movement of the whole or a portion of a patient’s body. The portion of a patient’s body. The various techniques such as “physical various techniques such as “physical hold” or “take down” procedures are hold” or “take down” procedures are considered forms of physical considered forms of physical restraint.restraint.

Bear HugType of Physical

Hold

MECHANICAL RESTRAINTMECHANICAL RESTRAINT

This is any device used to restrict the This is any device used to restrict the movement of the whole or a portion movement of the whole or a portion of a patient’s body. It can be in the of a patient’s body. It can be in the form of ankle or wrist straps, a body form of ankle or wrist straps, a body net or a restraint chair. net or a restraint chair.

Caution: Geri Chairs and Side rails (4) can Caution: Geri Chairs and Side rails (4) can

be considered a mechanical restraint if be considered a mechanical restraint if the patient cannot control egressthe patient cannot control egress

Adult In the

Body Net Restraint

Example Of

MechanicalRestraint

RESTRAINTCHAIR

Type of Mechanical

Restraint

SECLUSIONSECLUSION

Seclusion is the confinement of the Seclusion is the confinement of the patient alone in a locked room or patient alone in a locked room or alone in an identified area from alone in an identified area from which egress is prevented. Patients which egress is prevented. Patients in seclusion must be monitored by a in seclusion must be monitored by a trained staff member at all times.trained staff member at all times.

Seclusion Room at

BHC

CHEMICAL RESTRAINTCHEMICAL RESTRAINT

Use of medication is considered a Use of medication is considered a chemical restraint when it is used as chemical restraint when it is used as a restriction to manage the patient’s a restriction to manage the patient’s behavior or restrict the patient’s behavior or restrict the patient’s freedom of movement and is freedom of movement and is notnot a a standard treatment or dosage for the standard treatment or dosage for the patient’s condition or diagnosis. patient’s condition or diagnosis. Chemical restraints are not used at Chemical restraints are not used at BHC.BHC.

CRITERIA FOR BEHAVIORAL RESTRAINT

• All less restrictive measures were attempted and failed

• No time to attempt less restrictive measures

• Must be evidence of eminent danger

Definition of a Definition of a “Least Restrictive Measure”“Least Restrictive Measure”

This is a term that is used extensively This is a term that is used extensively in mental health and in patient rights in mental health and in patient rights issues. It simply means “the least issues. It simply means “the least intrusive or restrictive service or intrusive or restrictive service or treatment that can effectively and treatment that can effectively and safely address the patient’s needs safely address the patient’s needs and stated preferences”. All less and stated preferences”. All less restrictive measures must be tried restrictive measures must be tried and documented before a behavioral and documented before a behavioral restraint or seclusion is ordered.restraint or seclusion is ordered.

EXAMPLES OF LESS EXAMPLES OF LESS RESTRICTIVE MEASURESRESTRICTIVE MEASURES

Making a contract for safe behaviorMaking a contract for safe behavior Helping the patient to identify the stressor Helping the patient to identify the stressor

causing the behaviorcausing the behavior Redirecting the patient’s attention by suggesting Redirecting the patient’s attention by suggesting

another activityanother activity Reducing the noise level and light intensityReducing the noise level and light intensity Allowing the patient to speak to a patient Allowing the patient to speak to a patient

advocate, minister, supervisor, or familyadvocate, minister, supervisor, or family Deep breathing exerciseDeep breathing exercise Negotiating a solution based on options availableNegotiating a solution based on options available Offering medications to assist in reducing Offering medications to assist in reducing

agitation/anxietyagitation/anxiety

EMINENT DANGEREMINENT DANGER

There must be evidence that there is There must be evidence that there is “eminent” danger to the patient or “eminent” danger to the patient or others in order to justify the need for others in order to justify the need for a behavioral restraint or seclusion. a behavioral restraint or seclusion. Threatening to do something is not Threatening to do something is not acceptable. Patients must be in the acceptable. Patients must be in the “act of” or “process of attempting” to “act of” or “process of attempting” to do something that could result in do something that could result in injury or damage.injury or damage.

TIME LIMITS FOR RESTRAINT TIME LIMITS FOR RESTRAINT AND SECLUSION BY AGEAND SECLUSION BY AGE

• Physical Hold: 15 minutes for all Physical Hold: 15 minutes for all ages (child-adult) ages (child-adult)

• 8 yrs. of age and younger: 1 hour8 yrs. of age and younger: 1 hour• 9-17 yrs. of age: 2 hours9-17 yrs. of age: 2 hours• 18 yrs. and older: 4 hours18 yrs. and older: 4 hours• Patient must be released as soon as Patient must be released as soon as

the risk of harm to self or others no the risk of harm to self or others no longer exists.longer exists.

MONITORING REQUIREMENTS EVERY MONITORING REQUIREMENTS EVERY 15 MINUTES WHILE IN RESTRAINT OR 15 MINUTES WHILE IN RESTRAINT OR

SECLUSIONSECLUSION

Circulation Circulation Respiration RateRespiration Rate Heart RateHeart Rate Blood PressureBlood Pressure Oxygen SaturationOxygen Saturation BehaviorsBehaviors Food/Fluid NeedsFood/Fluid Needs Elimination OfferedElimination Offered

ROM ProvidedROM Provided Hygiene Needs MetHygiene Needs Met Physical Comfort Physical Comfort

ProvidedProvided Psychological Psychological

Support OfferedSupport Offered Signs of InjurySigns of Injury Evaluated for Evaluated for

ReleaseRelease

PHYSICAN REQUIREMENTSPHYSICAN REQUIREMENTS

Face-to-Face Evaluation of Patient within Face-to-Face Evaluation of Patient within one hour of the onset of the R/Sone hour of the onset of the R/S

Completion the Physician Order Set for a Completion the Physician Order Set for a behavioral restraintbehavioral restraint

Completion of Physician Progress Note for Completion of Physician Progress Note for a behavioral restrainta behavioral restraint

Notification of attending physician if Notification of attending physician if physician ordering the R/S is not the physician ordering the R/S is not the attendingattending

PhysicianOrder Set For BehavioralRestraint

(located in red folder with all other physician orders)

Physician Progress

Note for a BehavioralRestraint or Seclusion.

CONGRATULATIONS!

You have completed the physicianTraining module for Restraint and Seclusion.

Please print the certificate below and signand date as indicated. Submit this document

to the medical staff office to be filed in your record.

Thank you.

Certificate of Training

RESTRAINT AND SECLUSION

Physician Name______________________ Date:________ Print

Physician Signature:_____________________________