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Infection Prevention

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Infection Prevention Contact Info

Janie Lane, RN MSN Infection Prevention / Employee Health / Education


773-975-3294
jlane@thorek.org

Sorinel Branzan Interim Director Quality Assurance/Performance


Improvement
773-975-1177
sbranzan@thorek.org

2
Infection Control Program
What is it and why have one?

Surveillance
Identify healthcare associated infections and report
as required by law
Prevention and control of infections and
infection risks
Provide interventions
Assess effectiveness and modify as needed
Educate staff about infection prevention
Result
A safer hospital
3 Improved patient care
Infection Control Manual

Infection Control Policies


Guidelines for isolation patients
Exposure control and follow-up plans for staff
Work restriction policies for staff
Dust mitigation measures for construction
Basis for Infection Control Policies
CDC Recommendations
OSHA (federal/state) & State Laws
HFAP Requirements
CMS Conditions of Participation
Other Professional Organization Recommendations
(APIC, WHO)
4
Hand Hygiene

Most common mode of


transmission of pathogens in
healthcare settings
According the the CDC, the
single most important thing
we can do to prevent
hospital acquired infections
is HAND WASHING
CDC estimates each year 2
million patients in the United
States get an infection in
hospitals, and about 90,000
of these patients die as a
5 result of their infection.
Hand Hygiene and Nail Care

Nails must be short-less than inch


Nails must be kept clean
Polish may be worn if unchipped
Artificial Nails or artificial nail products may
NOT be worn by employees who provide
direct patient care, clean and process
equipment, or prepare medication or food.

6
Indications for Hand Hygiene
All personnel involved in direct patient care shall wash hands with
soap and water or use hand sanitizer:
At the beginning of work
Before and after patient contact, including dry skin contact
Before gloving
After removing gloves
Before performing invasive procedures
Before and after contact with wounds
After contact with patients body substances
After handling equipment, supplies, or linen contaminated with body
substances
Before handling sterile or clean supplies
After using the restroom
After touching or blowing your nose
7 Before leaving the unit
8
Which product should I use?

USE SOAP AND WATER:


When hands are visibly soiled
Before preparing or eating food
After using the restroom
After caring for a patient who
has C. difficile
Scrub for at least 15 seconds
9
Which product should I use?

Hand Sanitizer
For non visibly
soiled hands
Use after removing
gloves
Use after dry skin
contact
Dispense gel or
foam and rub all
surfaces of hands
10 until dry
Isolation Precautions

Protects patients,
healthcare workers and
visitors from the spread
of communicable
diseases

Prevents spread of
infection by the
standard, airborne,
droplet and contact
routes
11
Standard Precautions
Standard Precautions is
the foundation of
Infection Prevention
Used for every patient,
every encounter
Intended for the
protection of the patients
and the health care
workers
Patients are AT RISK
for infection
Patients can be THE
SOURCE of infection

12
Standard Precautions

Three Major
Components
Hand Hygiene
Proper Use of
Personal Protective
Equipment
Surface Cleaning
and Disinfection

13
Respiratory Etiquette

In waiting areas:
Provide tissues and no
touch receptacles for
disposal
Provide hand sanitizer;
make sure that appropriate
supplies are always
available in hand washing
areas
Offer masks to coughing
patients; place immediately
in exam rooms if possible
Perform hand hygiene after
contact with respiratory
14 secretions and
Transmission-based Precautions

Transmission based
precautions are used in
addition to Standard
Precautions for patients with
documented or suspected
infection or colonization with
certain epidemiologically
significant organisms.
A sign should be posted
outside the door indicating
the type of precautions

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Transmission-based Precautions

Contact Precautions
Draining wounds
Multi-Drug Resistant Organisms
Diarrhea of unknown origin
C. difficle (soap and water hand
hygiene required)
Rotavirus
Other organisms at the
discretion of the Infection
Control Department
Gown and gloves required
upon entrance to room AND
Other PPE as required by
Standard Precautions
16
Transmission-based Precautions

Droplet Precautions
Coughing, sneezing
RSV
Influenza
Meningococcal
meningitis
Mask required when
within arms reach of
patient AND
Other PPE as required
by Standard
Precautions
17
Transmission-based Precautions

Airborne Precautions
Chickenpox
Disseminated Varicella
(Herpes) zoster
M. tuberculosis (TB),
suspected or confirmed
Negative pressure room
required, door closed
Fit tested N-95 respirator
AND
Other PPE as required by
18 Standard Precautions
Personal Protective Equipment
(PPE)

PPE is used to protect healthcare workers from


exposure to microorganisms that affect our patients
Whether the patient is on isolation precautions or not,
PPE use is based on the behavior of the patient and
the task to be performed
Gown and/or gloves for wound examination or
dressing changes
Mask and eye protection when in close proximity
to a coughing patient
Gown, glove and mask use all appropriate when
performing a task that may generate aerosols
(e.g. intubation, suctioning) or may result in
contact with blood or body fluid
Glove use is based on the task and the extent of
anticipated contact with the patient or patients
environment
Dispose of PPE prior to leaving patient care area

19
Blood-borne Pathogens

Hepatitis is an infection of the liver- many


types, in the hospital B and C are of most
concern
B and C can become chronic increasing risk of
cirrhosis and liver cancer.
No cure for chronic infection but viral
treatments can reduce presence of the virus
Hepatitis B vaccination recommended and
provided without cost in EHS

20
Blood-borne Pathogens

HIV is a viral infection that attacks the bodys


immune system
There is no cure and if untreated may
progress to AIDS
Transmitted by unprotected sexual
contact, contact with blood or body fluids,
and from mother to baby.
No vaccine for HIV

21
Blood-borne Pathogens
Approximate risk of transmission following exposure
Hepatitis B 6 to 30% depending on the hepatitis Be antigen status
of the source individual
Hepatitis C 1.8% following needlestick or cut exposure
HIV 0.3% (percutaneous) 0.09% (mucous membrane)
Following an exposure you should
Wash the area immediately with soap and water
Report the injury to Employee Health/Needlestick Hotline (3278)
Inform your supervisor
Needlestick Hotline (3278)
Report all needlesticks, lacerations and splashes
Confidential assessment/triage, counseling, testing, treatment and
information
Prophylaxis and/or treatment available following work related
22 exposures to blood-borne pathogens
Tuberculosis

Transmission by inhalation
Must have active pulmonary disease
to transmit
Classic symptoms
Prolonged productive cough
lasting >3 weeks
Coughing up blood
Weakness
Weight loss
Night sweats
TST skin test annually (for everyone)
TST is a test for EXPOSURE
(latent TB)
90% of TST positive persons do

23 NOT develop active TB


Surface Cleaning and
Disinfection
All patient care items and
surfaces used for multiple
patient contacts must be
adequately cleaned and
disinfected between uses
Visible soiling must be removed
A hospital-approved detergent
disinfectant must be applied
and allowed to air dry before
the next patient contact
Follow label directions for
surface contact/air dry time
Items you carry with you and/or
use frequently are also targets
24 for surface disinfection
Other Miscellaneous

In patient care areas where specimens may be


present
No food or drink is allowed
Do not apply cosmetics
Do not insert or handle contact lenses
No items under sinks
Waste management
Learn how to properly dispose of waste
Keep biohazard containers covered and
stored securely
Safe syringe technology
Know what is in use in your area and how to
use it properly
Do not re-cap needles. If absolutely

25 necessary to re-cap, use the scoop method.


Performance Improvement and
Quality Assurance

26
What is Quality Assurance?

A program for the systematic monitoring and


evaluation of the various aspects of a project,
service, or facility to ensure that standards of
quality are being met

27
What is Performance
Improvement?
Performance refers to the way people do their jobs and the
results of their work.
Performance Improvement uses a systematic methodology
used to find the root causes of a performance problem and
then implement an intervention that applies to that specific
performance deficit.
PI helps to ensure that selected interventions are supported
and sustained by involving a stakeholder group from the
outset and ensuring that an organizations staff participates
actively in every step of the process.

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Avoidable Harm
Prevent harm from high-alert medications, including
anticoagulants, sedatives, narcotics and insulin.
Prevent injurious falls by implementing evidence-based practices.
Reduce surgical complications by implementing all of the changes
recommended by the Surgical Care Improvement Project (SCIP)
Prevent pressure ulcers by using science-based guidelines for
their prevention.
Reduce methicillin-resistant staphylococcus aureus (MRSA)
infection by reliably implementing scientifically proven infection
control practices.
Deliver reliable, evidence-based care for congestive heart failure
to avoid readmissions.

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Avoidable Harm
Deploy Rapid Response Teams at the first sign of patient decline
Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction to
prevent deaths from heart attack
Prevent Central Line Infections by implementing a series of
interdependent, scientifically grounded steps called the "Central Line
Bundle"
Prevent Catheter-associated Urinary Tract Infections through compliance
with CAUTI bundle
Prevent Ventilator-Associated Pneumonia by implementing a series of
interdependent, scientifically grounded steps including the "Ventilator
Bundle"

30
Occurrence Reporting

31
Life Safety

32
Life Safety Code

Sets standards for:


Building design
Building construction
Building operation
Building maintenance

These standards are meant to protect building


occupants during a fire.
33
Healthcare occupancies and
Defend-in-place
Healthcare occupancy: building with beds for people who cannot
save themselves from danger (ie bedridden, debilitated, wired to
electrical equipment, recovering from surgery, etc)

Defend-in-place means defending against a fire, while remaining


in place.
Healthcare occupancies must be built with features that make it possible to
survive a fire from inside the building, ie:
Compartmentation
Fire alarm systems
Portable fire extinguishers
Exit strategies
Special furnishings and interior finishes

34
CODE RED: Fire

RACE (overall strategy in case of fire)


Rescue person from smoke and/or fire
Alarm (pull fire alarm, call 5100 for public safety)
Contain smoke and/or fire by closing doors
Extinguish fire

PASS (operation of fire extinguisher)


Pull, Aim, Squeeze, Sweep

35
Equipment Safety

36
Hospital Beds
Over 900 incidents involving harm or death
Avoid use of electric beds in psych unit due to cord and suicidal
precautions
Prevent fires involving electric beds
Make sure power cord is not damaged
Plug power cord directly into wall outlet
Make sure plug and outlet fit together safely and securely
Reduce risk of bed rail entrapment
- Use bed rail protector pads
- Test beds for gaps that pose a risk of entrapment

37
Infusion Pumps

Risks:
Infiltration
Time-to-alarm
Occlusion release bolus
Air emboli
Air-in-line detection
Device failure

38
Infusion Pumps (cont.)

Use only after receiving training on operation of


pumps
Ensure pump is in good working order, up to
date on maintenance and service, and has no
signs of damage or dropping prior to use.

39
Other equipment

Lasers and electrosurgical units are common in


the healthcare environment.

Ensure thorough training prior to use


Take steps for safety

40
Single-Use Devices

SUDs also known as disposable devices.


Convenient

Risks:
Initial use (defects)
Use of reprocessed SUDs
- Risk for infection and device failure

**Inspect all SUDs before use**

41
Hazardous Waste &
Materials Management

42
Hazardous Materials

Chemicals can have physical &/or health


hazards.
Routes of exposures to hazardous chemicals
include the eyes, skin, inhalation, ingestion,
and injection.
Toxic chemicals can have local or systemic
health effects.
Hazardous materials may be solids, liquids or
gases.
43
Safety Data Sheets

Responsibilities:
Manufacturer: Must record all hazard info in a
Safety Data Sheet (SDS) & provide to
purchaser
Employer: Must have list of all hazardous
chemicals used in facility, and a SDS for each.
Employee: Should know what hazardous
materials are used in work area, where to find
SDS, and how to read SDS
44
Safety Data Sheets at Thorek

Can be found on the


THINTRANET

45
Labeling of Hazardous Chemicals

Manufacturer must label all containers in


English
Label must include product identifier, signal
word, hazard statement, pictogram,
precautionary statement, and contact info for
the manufacturer.
8 mandatory and 1 optional pictogram used to
identify the class of the hazard.

46
Personal Protective Equipment (PPE)

Purpose: Shield workers from physical and


health workplace hazards

Employer responsibilities:
Select types of PPE appropriate for all hazards
& train all workers required to use PPE
Employee responsibilities:
Follow facility procedures for PPE

47
Types of PPE

Types of PPE may include:


Protective clothing (ie gloves, gowns, coveralls,
hoods, boots)
Respiratory equipment
Eye protection (ie goggles, face shields)

48
Information Management

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Commitment to Information Management

Ensure privacy and security of protected health


information (PHI)

Policies and procedures exist to safeguard this


information

50
Overview of policies

Workstations and internet not for personal use.


Access levels determined by job descriptions
and/or context-based access controls.
Workforce members and other users shall use
careful consideration to access and obtain only
the type and amount of PHI necessary to carry
out the specified purpose.

51
Overview of policies (cont.)

Workstation users must:


Maintain password confidentiality
Log off prior to leaving the terminal
Comply with all applicable password policies
and procedures, including storing any written
passwords in secure locations only
Close files not in use

52
Other safeguards

IS assigns a unique user ID, password and


security level for each employee
Thorek continually assesses potential risks and
vulnerabilities to individual health data,
including electronic PHI in its possession
Automated lockouts and reporting after 3 failed
log-in attempts
Limited physical access to workstation
terminals
53
Any person who compromises their security code
or that of another employee will be subject to
disciplinary action that may include dismissal

54
Patient Rights

Prepared by
Janie Lane, RN, MSN

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Why important?

CMS requires participating hospitals to protect and


promote the rights of patients.
Joint Commission and HFAP also expect accredited
hospitals to protect the rights of patients.
Hospitals should provide care that respects a patients:
Dignity
Ability to make choices
Involvement in care
Civil Rights

56
Overview of Patient Rights

6 general areas covered by Patient Rights:


1) Information disclosure
2) Participation in treatment decisions
3) Respect, safety, and nondiscrimination
4) Confidentiality of health information
5) Complaint resolution
6) Access to emergency services

57
Information Disclosures

Patients have the right to know about:


The facility
Examples how to file a complaint, accreditation status,
quality and consumer satisfaction ratings etc
Their healthcare team
Examples provider names, professional status, education,
years of practice etc
Their rights as patients

Patient rights must be presented so that the patient can understand it. Some
patients may need special help to overcome language barriers, hearing
deficits, or other mental/physical barriers to understanding.
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Participation in Treatment Decisions

Patients have the right to make decisions about their care, and set
the course of treatment.
Patients have the right to know about their diagnosis, prognosis,
and treatment options.
Patients have a right to effective pain management.
Patient must give informed consent before the start of any
procedure or treatment.
Patients have the right to refuse or discontinue treatment.
Healthcare professionals play a critical role in protecting patient
rights.

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Respect, Safety, and Non-discrimination

Patients have the right to considerate, respectful, compassionate


care.
Help ensure a safe environment of care for your patients by
reporting any suspected victims of abuse.
Restrain patients only when medically necessary and ordered.
During necessary restraint, protect the patients safety, comfort
and dignity.
Share PHI only with people who are directly involved in the
patients case.
Patients have the right to see their medical records.
Patients have the right to have visitors of their choice.

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Complaints and Grievances

Patients have the right to complain.


Review, investigate and resolve complaints
promptly.
Patients have the right to file complaints with
external agencies, and should be given contact
info for the correct state agency.
A patient has the right to examine his/her bill.
S/he also has the right to a detailed
explanation of each item.
61
Access to Emergency Services

The need for emergency services is based on


whether the patient has signs or symptoms that
a prudent layperson would consider an
emergency.
Under EMTALA, hospitals must provide ED
patients with emergency medical screening
and stabilizing medical care.
Medically unstable patients may not be
transferred for economic reasons.
62
Restraints & Seclusion

Prepared by
Janie Lane, RN, MSN
Learning Objectives

Training content will ensure that staff have education, training and
demonstrated knowledge based on the specific needs of the patient
population, and shall include:
1) Techniques to identify staff/patient behaviors that may trigger
circumstances that require use of a restraint/seclusion
2) Use of non-physical intervention skills
3) Choice of least restrictive intervention
4) Safe application and use of all types of restraints/seclusion
5) Recognition/response to physical or psychological distress
6) Clinical identification of specific behavioral changes that indicate
restraint/seclusion are no longer necessary
7) Monitoring the physical/psychological well-being
8) Use of first aid techniques
Training Program Overview

Training interval:
a) Initial orientation
b) Annually

Appropriate staff: (all staff that apply restraint/seclusion, monitor,


assess, remove or otherwise provide care for patients in
restraints/seclusion)
Physicians and LIP (Nurse Practitioner)
Registered Nurses
Mental Health Specialists
CNAs (under direction and supervision of RN)
Public safety officers (under direction and supervision of RN)
Definitions of restraints

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.

a) Physical (soft restraint) Ie soft wrist restraint, soft posey vest,


mittens tied to bed, 4 side rails raised
b) Seclusion- Involuntary confinement; only to be used for the
management of self-destructive behavior that jeopardizes
immediate physical safety of patient, staff, and other.
c) Behavioral- Restraint locked onto patient and only removable by
key. To be used for behavioral issues of managing violent,
aggressive behaviors that place patient and others in immediate
danger.
Definitions (cont.)

d) Chemical When a drug/medication is used as a restriction to


manage a patients behavior or restrict patients freedom of
movement, and is not a standard treatment or dosage for the
patients condition.
e) Forensic Use of handcuffs or other restrictive devices applied
by law enforcement. Not involved in provision of healthcare.
f) Voluntary mechanical support Used to achieve proper body
position, balance, or alignment.
g) Medical immobilization Positioning or securing device used to
maintain the position, limit mobility or temporarily immobilize
during medical, dental, diagnostic, or surgical procedures. Usual
and customary requirements for a medical procedure.
Myths about restraints

Decrease risk of falls


Increases sense of security
Decreases lawsuits
Lowers staff costs
Improves quality of life
No other alternatives
Restraints can be USEFUL

Allow needed treatment (Med/surg or ICU)


A combative or confused patient may need to be
restrained in order to . . .
Perform an exam
Intubation
Administer an IV
Give other needed medical treatment
Keep patient and others safe (Behavioral)
- A violent patient may need to be restrained
temporarily, if no other calming efforts work
But can also cause serious HARM

Injuries from improperly positioned restraints


May get tangled in straps and asphyxiate (#1)
May struggle to get free, resulting in broken bones, cuts,
concussions, etc
Medical complications as a result of non-mobility
Poor circulation Pressure sores
Constipation Weak muscles/bones
Mental and emotional problems
Humiliation Depressed
Agitation Withdrawal
Assess the patient

Goal: To find the safest, least restrictive way to care for the patient.

Discover cause of problem.


Monitor labs for abnormalities
If patient is wandering, what is he/she seeking?
If patient is unsteady, look for underlying problems (ie deconditioning, poor
shoes, side effects of meds, or bad eyesight?)
Learn about patients interests/preferences
Give patient a say in treatment
Involve family members
Identification &
Management of Triggers
Triggers: Warning signs of potential
Uncomfortable physical aggressive behavior:
environment (noise, Restlessness
temperature, crowds, light) Hand wringing
Long waits Pacing
Staff attitude Finger drumming
Fear Facial and/or body tension
Loss of personal control Audible sighing
Pain Darting eyes
Displaced anger Rapid
Identification and Management of triggers:
TeamSTEPPS

STEP situation monitoring strategy


1) Assess Status of patient
- Ie patient history, vital signs, medications, physical exam,
plan of care, psychosocial
2) Assess level of Team members
- Fatigue, workload, skill, stress, personal triggers
3) Assess Environment
- Triage acuity, human resources, other patients
4) Assess Progress towards goal
- Status of patient, task/action or team, plan still appropriate?
Identification & Management of Triggers:
Crisis Prevention training
Purpose of CPI: To provide training in safe, respectful, non-
invasive methods for managing disruptive or assaultive behavior
in a way that is compatible with staffs duty to provide the best
possible care (CPI, 2014)

Mandatory for ED/Psych clinical staff

Encouraged & offered to all other clinical staff


Alternatives to restraints:
Non-physical interventions

Active listening Patient care attendant


Diversional activities Public safety assistant
Effective communication Room change
Environmental control Reorientation
Family supervision Supportive devices and
Medication interventions
administration Treatment review
Verbal instruction
Least Restrictive Intervention

The least restrictive intervention should be chosen based on an


individualized assessment of the patients condition, needs,
strengths, weaknesses, and preferences.

Least to most restrictive

4 side rails up
Posey Vest
Soft limb restraints
Case Study

Mrs. Jones is confused and combative at times in 619-1, but


especially at night. She was admitted for ARF, and is currently
receiving hemodialysis and strict I&Os via foley catheter. She
continues to pull at both the permacath and foley catheter.

What can be done?


Are restraints appropriate?
If so, what type?
Physical (soft) restraints:
Order
Used for non-violent & non self-destructive behavior
In case of emergency, a RN may apply restraint or seclusion
without an order. In these emergent cases, an order must be
obtained immediately (within a few minutes) of application by an
MD/LIP.
MD examination (face-to-face) MUST occur within ONE hour of
application, and every 24 hours thereafter.
Written order for physical restraints shall not exceed 24 hours.
Attending physician must be notified STAT (within 30 minutes).
Family must be notified as soon as possible.
If patient was recently released from restraint/seclusion, and
exhibits new behavior that can only be managed through
reapplication, a new order is required.
Physical restraints:
Safe application

Consistent with TMH policy so that restraints are applied in safe


and effective manner that preserves patient dignity and safety.
Quick release tie must be used at all times
Only applied after consideration and/or implementation of
alternative methods have failed.
When restraints are applied, the least restrictive yet effective
restraint device will be utilized.
Appropriate competency-trained staff can initiate emergency
application prior to obtaining an order from a physician or other
LIP, and include MD/LIP, RN, MHS, CNAs, Public Safety Officers
Direct patient caregivers are to complete competency training.
Physical restraints:
Safe application (cont.)

Mittens:
Place hands in each mitt and secure strap ABOVE wrist bone.
Secure with quick release tie to bed frame, if needed.

Limb restraint:
Wrap the limb with the soft limb restraint and secure the
plastic clip.
Tighten the restraint so that the patient is unable to pass
his/her wrist through the restraint, being careful not to restrict
blood flow to extremity.
Physical restraints:
Safe application (cont.)

Posey Vest
Choose appropriate size
Put vest on with the V neck in front only. Crisscross strap,
making sure to thread the left strap though the slot. Secure to
bed frame with quick release tie. The tie should be done so
that it does not slide in any direction.
Ensure that you are able to slide your open hand (flat)
between device and patient.
Patient should be able to breathe comfortably.
Physical restraints:
Patient monitoring & assessment

Assessment & Monitoring:


(Vital signs q 4 hours, Assessment q 2 hours)
Position
Mental status
Behavior
Respiratory status with O2 saturation
Neurological status
ROM
Skin integrity
Alternatives attempted prior to restraint/seclusion
Response to attempted alternatives
Need to continue or discontinue restraint/seclusion
Injury sustained related to use of restraint/seclusion
Physical restraints:
Provision of care

To be performed every 2 hours

Nutritional needs
ROM exercises
- By appropriate trained staff
- One limb at a time must be released to perform ROM
Hydration needs
Elimination needs
Personal hygiene needs
Special considerations:
Hand mitts & Siderails
Mitts not typically restraint unless. . .
Pinning or otherwise attaching those same mitts to bedding or using a
wrist restraint in conjunction with hand mitts.
Applied so tightly that the patients hand or fingers are immobilized.
Mitts are so bulky that the patients ability to use their hands is
significantly reduced.

Siderails **
Seizure precautions with all side rails padded and raised
Immobile patients
Patient on stretcher, recovering from anesthesia, sedated, experiencing
involuntary movement etc
** Considered restraint if all four side rails raised in order to immobilize or
reduce ability of patient to move his/her arms, legs, body or head freely
Physical holding for forced medications

Application of force to physically hold a patient, in


order to administer a medication against the
patients wishes, is considered a restraint.

A patient has a right to refuse medications


(unless a court has ordered medication
treatment)
Physical restraints:
Discontinuation
Must be discontinued at earliest possible time, regardless of
length of time identified in order.
Can be discontinued by appropriate staff once unsafe situation
ends
Decision to discontinue should be based on determination that the
need for restraint/seclusion is no longer present, or that patients
need can be addressed using less restrictive methods.
For example:
- Improved cognition
- Able to follow verbal direction
- Ceases behavior that caused restraint/seclusion
- Contracting for safety to self, staff and others
Behavioral health (hard) restraint/seclusion
for psychiatric and/or violent behavior

Use of locked restraint and/or seclusion with patients in the


Behavioral Health Department

Use of locked restraint and/or seclusion for patients who are


receiving behavioral health care services in another area of the
hospital and whose behavior is believed to arise from a psychiatric
disorder.
Behavioral restraints/seclusion:
Utilization
To be used only as a therapeutic measure to prevent a patient from
causing physical harm to self or others & only after alternatives/less
restrictive interventions have been attempted and proved
unsuccessful.

Restraints are never used:


To punish or discipline a patient
As convenience for staff
As mechanism to provide regression
As retaliation
As coercion
As a routine part of the falls prevention program
Behavioral restraints/seclusion:
Orders
RN initiates use of restraints in an emergency situation.
Attending physician/LIP must be notified immediately and order
received
Order for restraint/seclusion must have all components.
May only be renewed in accordance with the following limits for up
to a total of 24 hours:
4 hours for adults 18 years of age and older
2 hours for children and adolescents age 9-17
1 hour for children under age 9
Use of restraint or seclusion should be limited to the duration of
the emergency safety.
Behavioral restraints/seclusion:
Patient monitoring and assessment

To be assessed by appropriate trained staff and documented upon initiation


and q 15 minutes thereafter:
- Behavior - Breathing
- Staff intervention - Skin/circulation
- Patient response
To be assessed by a RN and documented q hour after initiation:
- Pain/musculoskeletal discomfort - Signs of injury
- Cardiac/respiratory complaints - Comfort needs
- Restraint/seclusion release readiness
To be assessed by appropriate trained staff and documented q 1 hour after
initiation:
- Vital signs - Nutrition/hydration -Hygiene/elimination
ROM to be performed q 2 hours, whereby one limb at a time must be
released.
Behavioral health restraints:
Continuation of restraints

Process for continuing behavioral restraints:


Patient is reassessed for need by attending physician, LIP, or RN.
Attending physician will give a written/verbal order for continuation
based on reassessment by physician or RN with supervisory
responsibilities according to time frames.
Patient must be re-evaluated face-to-face by the physician/LIP:
Every 8 hours for patients 18 years of ago or older
Every 4 hours for patients 17 years of age or younger
If the patient is no longer in restraints or seclusion when the verbal
continuation order expires, the physician must conduct an in-person evaluation
within 24 hours of the initiation of restraint/seclusion.
Behavioral health restraints:
One hour face to face

Patient must be seen face to face within 1 hour after the initiation of
the intervention by a physician or LIP, or trained nurse to evaluate:

Patients immediate situation


Patients reaction to the intervention
Patients medical and behavioral condition
Need to continue or terminate restraint/seclusion

Also applies when chemical restraint is used to manage violent or


self-destructive behavior.
Simultaneous use of restraint & seclusion

Only permitted if the patient is continuously monitored face to face


by an assigned staff member.

Must be adequate documentation that justifies decision for


simultaneous

* An individual who is physically restrained alone in his/her room in


not necessarily simultaneously secluded.
Behavioral health restraints:
Less restrictive measures

Restraints may be applied only after less restrictive measures


have failed.

Staff shall assess an escalation in agitation and attempt to use


less restrictive measures, including but not limited to:
Verbal intervention
Time out
Diversion activities
Reduce milieu stimuli
Redirection
PRN medication
Behavioral health restraints:
Practical application

Code White may be called if physical assistance is needed to


restrain.
Staff members participating in care of a restrained/secluded patient
will have keys with them at all times.
Additional guidelines:
Patients to be restrained face-up and procedure should not cause undue
physical discomfort
Initial application utilizes 4-point of extremities for behavioral only. 5-point
restraint may be employed if necessary with a physician or other LIP order.
Arms restrained at wrist to bedside in hands-down position, with the arm
positioned to lie down alongside the patient
Legs are restrained at ankle, with legs together.
At time of initiation of restraint and/or seclusion, an explanation is given to
patient and criteria for release are explained.
Behavioral health restraints:
Discontinuation

Discontinued immediately once patient meets criteria for release.


Removed at discretion of the nurse supervising application of
restraints/seclusion, when it is determined that:
Patient is no longer a danger to himself/herself or others
Alternative methods are appropriate to maintain safety

Guidelines for releasing patients from restraint/seclusion in non-


behavioral health setting:
Progressive method (alternate left-right, alternate wrist- ankle) or
all limbs based on patient assessment
Patient debriefing with first 24 hours of release
If patient requires reapplication of restraints/seclusion,
physician/LIP called to obtain a new order
Recognition & Response to distress
(physical and psychological)

Recognize: Respond:
Compromised breathing Immediately release restraint
Circulation changes Complete nursing
Change in level of assessment
consciousness Intervene as necessary, ie
first aid or CPR

Increased agitation
Withdrawal

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