Lessons Learned

Lessons learned from the CHPSO database

Restraints are sometimes necessary for the protection of the patient or others. As Centers for Medicare and Medicaid Services (CMS) states, “The use of restraint or seclusion must be selected only when less restrictive measures have been judged to be ineffective to protect the patient or others from harm. It is not always appropriate for less restrictive alternatives to be attempted prior to the use of restraint or seclusion… While staff should be mindful of using the least intrusive intervention, it is critical that the intervention selected be effective in protecting the patient or others from harm.”

There are two main categories of restraints: physical and chemical. Per the CMS definition in the state operations manual for hospital surveys, a restraint is “Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.” This means that the answer to the question “Is it a restraint?” may be “It depends.”

Some devices, such as Posey vests and wrist restraints, either two-point or four-point, hard or soft, are clearly restraints; however, with other devices and drugs it may not be as clear. In those cases one must consider the intent of the medication or device. A common intervention is the use of side rails which, depending the patient’s condition, may or may not be considered a restraint. If the motivation behind having the side rails up is to prevent a patient from inadvertently falling out of the bed – when a patient is having a seizure, sedated, or recovering from anesthesia – it would not be considered a restraint. If all four rails are up to prevent the patient from intentionally getting out bed, then the side rails would be considered a restraint.

Because of the complexity of the definitions and rules, CHPSO recommends that organizations review the applicable CMS state operations manual (hospital, long term care facility, critical access hospital, etc.), applicable state laws, and any applicable accrediting agency (e.g., The Joint Commission) rules and guidance to ensure that both policies and practices are in compliance, and that good practical guidance and education is provided to front-line caregivers. Note that CMS rules have changed over time and differ for different care settings. California Hospital Association members can obtain CHA’s Mental Health Law Manual, which includes a section on restraint rules as they apply to California hospitals.

CHPSO database analysis

CHPSO recently completed an analysis of over 5,300 safety events related to the use of restraints submitted to the database between January 1, 2018 and August 30, 2018. The purpose of this analysis was twofold: to determine what themes or issues were present and to identify potential opportunities for improvement that might be gleaned from these data. An analysis of these data revealed the following themes and issues:

  • Behavior/ Workplace violence/ Danger to Self or others
  • Communication/ orders/ documentation
  • Elopement/ patient left Against Medical Advice (AMA)
  • Falls/ fall prevention
  • Lines/ tubes/ drains
  • Security/ law enforcement involved
  • Skin or other injury
  • Events submitted for tracking/ trending purposes

From these data there arose several categories of potential opportunities for improvement. These included cases involving incorrectly applied physical restraints which resulted in injury when the patient subsequently fell and/or removed a necessary line tube or drain (e.g. self extubation and/or pulling out peripheral IVs, PICC lines, foley catheters, NG/OG tubes). In some cases, restraints were applied correctly, but were later removed by family members.

Another area for potential concern was related to the use of restraints to ensure cooperation with a medical procedure. This was a rare occurrence; however, these cases warrant close examination to see whether the use violated the patient’s right to refuse medical treatment or was appropriate, either because the patient wanted the procedure but could not cooperate, or because the patient was incompetent and the procedure was authorized by the patient’s legal representative.

Another category of events found in these data was related to missing documentation, missing or expired orders and poor communication between the team members. In some cases the safety event was related to confusion regarding who was managing the patient and the restraint orders. In one such case the RN was caring for a patient in a large, tertiary care center and the restraint order was about to expire. The RN contacted Dr. A, who was listed as the first call for the patient. Dr. A told the RN he was not responsible for the patient. The RN then called Dr. B and then Dr. C and was told the same thing. The RN attempted to contact Dr. D (the first call for general medicine listed in the chart for another patient) and received no response. As a last resort, the RN called the hospital operator to obtain the phone number of Dr. E (attending physician listed in the record). That number provided a recorded message instructing the RN to call the provider’s cell phone number. The RN called the cell phone number and left a message as there was no answer, and the RN received no call back at end of shift.

An additional area to consider in assessing restraints related opportunities for improvement was the need for specific monitoring and assessment to prevent skin injuries resulting from the use of restraints. In rare cases, severe injuries occurred, including wrist fractures resulting from severely agitated patients struggling against the restraints for an extended period of time.

Another issue related to restraints, which has also been noted in previous analyses of CHPSO data related to workplace violence, was that of staffing issues, particularly a lack of sitters. In some cases, having an available sitter may have allowed for restraint removal, less aggressive forms of restraints, and a decreased number of falls and/or patients removing an essential medical device. The CMS state operations manual for hospital surveys states “a restraint must not serve as a substitute for the adequate staffing needed to monitor patients.”

Wrist restraints, either two-point or four-point were the most commonly mentioned among the physical restraints. Posey vests and other vest restraints were mentioned less frequently (n = 148) with nearly half of the Posey/vest restraint related cases associated with a mention of a fall or high risk for falls. 

Another issue that arose from these data was the use of restraints among patients on BiPAP. Many institutions have policies against restraint use with BiPAP, as patients may be unable to clear excessive secretions or have episodes of emesis while restrained and on BiPAP. Confused hypoxic patients starting on BiPAP present significant management challenges, and an organization should ensure that, if both BiPAP and restraints are considered, there is an appropriate review process to weigh the risks and benefits to the individual patient of this course of action.

The analysis of these data can provide organizations with insight into areas for consideration regarding the use of restraints for the protection of staff, to prevent patients from harming themselves due to violent behaviors, or from interference with essential medical devices