Restraint and Seclusion - A Hot Topic for Hospitals

CMS and Joint Commission are taking the issue of patient restraint and seclusion seriously. Hospitals and individual care givers must do the same, Not just because of the regulatory agencies, but because patients deserve to feel safe, and to be treated with dignity.

That having been said, some patients need to be restrained, for their own safety and for the safety of staff. In my years working in an emergency department I saw more than a few abusive, dangerous, out-of-control patients. Interestingly, I also noted that every one of those patients seemed to share the same basic four-letter-word vocabulary; there is a cultural phenomenon in there somewhere.

There are also patients who may need to be restrained to prevent them from unintentionally harming themselves by pulling out tubes, IV's etc.

Hospitals are, however, seeking ways to reduce or eliminate the use of patient restraints, or to at least make their use safer when they are determined to be necessary.

On April 11, 2008 CMS issued updated Restraint and Seclusion Interpretive Guidelines for hospitals. Joint Commission standards have recently been updated to more closely align with CMS regulations.

Here are just a few points from the CMS Interpretive Guidelines. A link to the full text can be found at the bottom of this post. There are approximately 50 pages devoted to the topic of restraint and seclusion.

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From the April, 2008 CMS Interpretive Guidelines for Hospitals:

All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

Hospital leadership is responsible for creating a culture that supports a patient's right to be free from restraint or seclusion.

The use of restraints for the prevention of falls should not be considered a routine part of a falls prevention program.

Restraint use is separated in the guidelines into two primary categories:

Non-violent, non-self-destructive behavior
Violent, self-destructive behavior

CMS Surveyors are instructed to review medical record documentation to determine whether the number of patients who are placed in restraints increases on the weekends, on holidays, at night, or on certain shifts or units. If patterns are noted, surveyors are to obtain nursing staffing schedules to determine if staffing levels are adequate or if particular nurses are more prone to use restraints.

In addition to the more obvious types of restraints, the guidelines also identify:

Medications used to manage behavior or restrict freedom of movement that are not standard to the patient's treatment plan
Physically holding a patient to administer medications against their wishes, unless the medication is court-ordered.
Four side-rails up in order to prevent a patient from getting out of bed