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Focus is on education for restraint and seclusion
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Emergency nurses must receive more rigorous training in the use of restraint and seclusion to control violent or self-destructive behavior to comply with new standards from the Centers for Medicare & Medicaid Services (CMS).
"The training for managing aggressive behavior is done for the protection of the staff as well as the safety of the patient," notes Patti Muller-Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant working with hospitals on performance improvement and regulatory compliance.
Examine your ED's existing policies, your current education and when it was last presented, and documentation requirements for when a patient is put in restraints, recommends Muller-Smith. This documentation should include description of the patient's behavior, other methods used and the patient's response, and why restraint was needed, she says.
At Methodist Hospital in Indianapolis, nurses use a computer-based training module on restraint and seclusion, which includes documentation, interventions, and policies and procedures, says Sandra Pavey, RN, clinical educator in the emergency medicine and trauma center.
The computer based training was created internally based on Clarian policy and The Joint Commission requirements.
"We have a systemwide restraint committee that reviews all changes to restraint standards, changes policy as needed, and develops the educational plan," says Pavey. "We currently have not implemented anything in respect to the latest changes but will be as soon as the committee finalizes the plan."
ED nurses will now be required to demonstrate the proper application of restraints, says Pavey. "The current online module that we use for education will be updated and will be a mandatory requirement for staff," she adds.
New ED nurses are given a specific lecture on psychological emergencies, which covers appropriate use of restraint and seclusion, says Ron Kraus, RN, BSN, CEN, the ED's clinical orientation coordinator at Methodist.
At Rogue Valley Medical Center in Medford, OR, restraint education was added into a mandatory four-hour class on management of aggressive behavior class given by two ED nurses, developed by the hospital's behavioral health clinical nurse specialist, says Heather Freiheit, RN, BSN, EMT-P, clinical manager of emergency services. "Oregon statues require that any staff member who may care for these patients, including monitoring the patient via a camera or window, have training in restraints," she says.
The class covers stress reactions, how to apply restraints, how to enter rooms safely, signs that a patient or family member is beginning to escalate, nonverbal cues, how to diffuse a situation, and when to call for assistance, says Freiheit.
At St. Joseph's/Candler Hospital in Savannah, GA, ED nurses are required to attend a nonviolent physical crisis intervention class within one year of hire, says Karen Hust, RN-CEN, MSN, BSN, ADN, advanced clinical educator for the ED. The classes are given by the Brookfield, WI-based Crisis Prevention Institute.
"We have been requiring this for years, and the staff is 100% compliant," she says.
The training covers:
The new CMS requirements have a strong focus on verbal de-escalation before resorting to physical or chemical restraints, says Muller-Smith.
"The general rule of thumb is to go from least restrictive to more restrictive as the patient's behavior escalates," she says.
Documentation of what occurred before restraints were used probably will come under more scrutiny because of the new regulations, says Muller-Smith.
Training at St. Josephs/Candler emphasizes that the intervention be based on an individualized assessment of the patient's medical or behavioral status or condition, says Hust. "Seclusion is utilized using the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm," she says. The ED's focus always has been on limiting use of restraints and seclusion, adds Hust. "Alternative methods are considered first, and efficacy is documented in the patient's medical record," she says.
ED nurses created an "alternative therapies" kit with items such as playing cards and puzzles that can help to distract an agitated patient, adds Hust. (See list of kit's contents.) The items are stored in a large plastic box.
Some of the items are disposable, and other items may be laundered or cleaned with a wipe, says Hust. Many of the items were bought at the local dollar store. "This can sometimes negate the escalation of patient behavior that would otherwise have required restraints," she says.
For more information on education on restraint use in the ED, contact:
The Nonviolent Crisis Intervention training program teaches emergency department staff to respond effectively to the warning signs that an individual is beginning to lose control. A one-day seminar costs $399, a two-day workshop costs $749, and a four-day instructor certification program is $1,199. For more information, contact: