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Greeley Reflections

Accreditation Connection, July 6, 2009

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Time to start working on restraint

Part 3 of 4

Last week we continued our discussion on restraints policies. We recommend measuring compliance with your policy. Here are some additional areas to focus on the “direct impact” requirements (summarized below):

PC.03.05.05, EP5 only applies to restraint used for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours.

Suggestion: It is a rare episode of “behavioral” restraint that will last more than 24 hours. If, however, this happens at your hospital, make sure the provider is visiting the patient often. Do not wait until the 23rd hour to call for a physician’s visit. Consider following the former Joint Commission rule (no longer in effect for “deemed status” hospitals) and have the physician perform a face-to-face evaluation every eight hours (i.e., at every other “renewal”).

PC.03.05.05, EP6 requires renewal of “medical” restraint according to hospital policy. A single instance of a missing order could generate a direct impact requirement for improvement.

Suggestion: Consider the use of protocol orders with very specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day.

PC.03.05.07, EP1 requires that trained staff members monitor patients in restraint or seclusion.

Suggestion: Ensure that competency in restraint use is measured and documented at the time of orientation. Don’t forget about security guards or other non-licensed personnel you rely on them to observe patients in locations like the emergency department.

PC.03.05.09, EP2 requires that physicians and other licensed independent practitioners who order restraint have a “working knowledge” of the restraint policy.

Suggestion: Consider including a very brief half-page flyer signed by physicians during the credentialing and privileging process. This will supplement, not replace, physician education efforts. Also, “hard wire” the policy into preprinted order forms or templates that force documentation related to appropriateness, assessment and indications for discontinuation.

With the number of standards and EPs involved, we have decided to expand the discussion one more week. Please join us next week when we will conclude our discussion on restraints.

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