What to look for when updating your restraint and seclusion policies

by Brian Ward

Restraint and seclusion (R&S) violations are never to be taken lightly, due to the inherent risk of harm to patients or staff. Your facility should regularly review and update its policies to avoid an angry visit from CMS—or from a grieving family.

Kevin Ann Huckshorn, PhD, MSN, RN, CADC, ICRC, a national behavioral health consultant with years of experience in hospital settings and now the director of evidence-based practices and programs for Wellpath Recovery Solutions, spoke to Patient Safety Monitor Journal on how to keep your policy up to date.

Last resort

Your policy should explicitly state that R&S represents “emergency measures of last resort, to only be used in the face of imminent danger and to be halted as soon as possible, as soon as the person becomes calm,” Huckshorn says. R&S is dangerous, can be traumatizing for both patient and staff, and is not evidence-based practice, she adds.

“R&S should be avoided at all costs as part of the development of a trauma-informed system of care,” she says. “And there is a whole lot of practices that go into creating an environment of care that’s trauma informed and doesn’t use R&S. That’s why you want that statement ‘last resort‘ to be connected to R&S.”

Collect data

Every facility and health system should be collecting and recording information on every use of R&S, says Huckshorn. These should be used to generate weekly or monthly reports. Every case report should have the answers to these questions:

• Who ordered the restraint?
• What type of restraint or seclusion was used?
• How long was the patient left in restraint or seclusion?
• Were there any injuries to patients or staff? If so, what?
• Was medication used or involved?

And depending on your electronic health record (EHR), you can (and should) collect more useful information, she says, such as:

• How often is R&S being used?
• When is R&S most commonly being used—morning, noon, night? On a specific day of a week?
• When is R&S being used during patient stays—are restraints most often applied at the beginning, middle, or end of a stay? Does it happen in the first few days or after months?

“There’s just so many variables you can capture with an EHR that helps drill down on who’s getting restrained, why, when, and how,” she says. “Kind of like the questions a reporter would ask, you can capture [that info] if you’ve got a good database. For facilities that don’t have EHR, best practice says that you’re going to at least capture the number of events, the type of events, the duration of events, injuries to both staff and patients, and if medication was used before, during, or after the restraint.”

Clear training expectations

Next, you’ll want to ensure your policy clearly states the kind of training staff get on both R&S and de-escalation. use. This includes training upon hire and on an annual basis. Huckshorn says that your HR department should be involved in this part of your policy, and have someone monitoring it.

“You’ll also want to make certain that staff are supervised in the use of R&S by a senior staff member 100% of the time,” she says. “Because that’s what best practice says—midnight or noon, [there should be supervision]. The moment a code is called, you want a senior clinical person on site observing and monitoring so they can intervene if need be.”

Alternatives to R&S

The next things to look for in your policy are your alternatives to R&S. A good policy will explain how to develop behavior and safety plans for each patient upon admission. This will help avoid the kind of conflicts that can arise in an inpatient setting, particularly by identifying patients who have emotional control issues.

“Our ability to emotionally regulate ourselves was learned usually before the age of 3, so if that human being didn’t learn those skills when they’re very young, they tend to get angry quickly and violently,” says Huckshorn. “We need to train that person on how to emotionally regulate so they don’t get out of control. There’s a whole bunch of methods to do that.”

This kind of policy uses both peer support and advocacy to work with patients, she says, two things that all patients deserve. Used on a daily basis, these methods can protect patients and ensure they’re getting the services and treatment needed to avoid R&S.

“And if they are put on R&S, there [should be] an advocate who’s meeting with them afterwards to find out what happened from their perspective,” she says. “That way leadership can look at what really happen.”

Post-event debriefing

Every single R&S event that occurs your facility must result in a debriefing by your clinical team within 24–48 hours. That way, Huckshorn says, everybody figures out what happened, why it happened, and how to avoid it happening again.

“That often expects staff to be extremely honest about what happened, and it also expects leadership to be involved and not just leave it to the line staff to figure out what happened,” she says. “Leadership needs to come to these meetings and work with staff to drill down on how this occurred and how do we not have it occur again.”

Civil rights and power

The inpatient setting is the only place in healthcare, or in the country, where a person can be brought in and held involuntarily, says Huckshorn. This is why your R&S policies need to be extremely specific and clear, and why R&S should be used as infrequently as possible.

“Basically, if someone looks or acts like they have a mental illness or are acting in a manner dangerous to themselves or others, we’re allowed to strip them of their civil rights, lock them up in a facility, and basically give staff a ton of power over the patients we’re supposed to be serving,” she says. “So if you’ve got young staff, or staff that wasn’t trained very well, or are unsupervised, that can be a recipe for disaster—an abuse of power.”

Staff that work in inpatient settings need to be cognizant of the massive amount of power they hold over patients and be respectful and humble in how they use that power. Abusing or misusing power is only going to upset patients and make an R&S situation more likely.

“[For example,] I’m a patient in a facility and I get up at 10 at night and I go to the nurses’ station and I say, ‘Can I have a glass of orange juice?’ ” she says. “I can get three responses there. One is I’m ignored. The second is, ‘No one gets orange juice after 8 o’clock; go back to bed.’ The third is ‘Sure, I’ll be right back; I’ll go get you some orange juice.’ ”

The first two responses probably won’t escalate a patient to violence, but it certainly won’t make them happy. They might try to argue and could become less willing to cooperate with staff in future situations. The third response, meanwhile, will immediately defuse the situation—everybody is happy, and the patient goes back to bed.

“That’s the difference in what I call an abuse of power or staff convenience and customer service and trauma-informed care,” Huckshorn says. “Those kinds of situations happen a hundred times a day in inpatient facilities.”