Accreditation Readiness - The Use of Restraints

The Joint Commission Accreditation is required for a hospital to see federally-funded patients. Although The Joint Commission typically conducts surveys every three years, they can appear at any time. Our last survey was conducted more than a year ago.

The Joint Commission requires that each hospital have a medical staff executive committee that oversees the quality of patient care, treatment and services provided by practitioners privileged through the medical staff process. The management and coordination of each patient’s care, treatment and services is the responsibility of a practitioner with appropriate privileges.

Restraint
The surveyor will evaluate our compliance with standards as they relate to the care and services provided to our patients. One specific area that is an absolute for The Joint Commission is our adherence to the restraint policy. WellStar Health System uses restraint or seclusion when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, team members or others.

• The use of restraint for non-behavioral health purposes is restraint that is used for acute medical and surgical care that directly supports medical healing.
• Restraint or seclusion for behavioral health purposes is used primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder.

Documentation of Restraint
When ordering restraint for medical surgical/healing purposes, medical staff must document the need for restraints, time and date orders and reassess the patient and reorder restraints every 24 hours. Absent an order for restraints every 24 hours, patient restraints will be removed until an order is obtained. Restraint or seclusion should be discontinued at the earliest possible time, regardless of the scheduled expiration of the order.

Restraints ordered for violent/self-destructive behavior have more stringent time requirement for MD orders, initial evaluation and re-evaluation period. Please refer to the table that appears below under the Restraint Procedure headline.

Restraint Order Form
All use of restraint or seclusion requires the appropriate restraint order form: Medical Surgical, Violent or Self Destructive. The written order form should include the type of restraint and describe a specific situation or behavior necessitating the use of restraint. PRN or standing orders are not allowed.                                                                                                                          

Restraint Procedure
Physicians who order restraint/seclusion will complete pertinent training in conjunction with credentialing and re-credentialing and must demonstrate knowledge of the policy, WellStar SPP RI-40, which details the procedure:

1. Assess the immediate situation and the patient’s medical condition.

2. Implement the least restrictive intervention that protects the physical safety of the patient, staff or others.

3. Address medical issues that could be causing agitation/behavior.

4. Observe the patient’s reaction to intervention.

5. Consider restraint/seclusion if less restrictive alternatives are ineffective. It isn’t used as a means of coercion, discipline, convenience or staff retaliation.

Required Documentation	Medical/Surgical	Violent/Self-destructive behavior
Initial order signed, dated and timed	Within 12 hours	Immediately
Face-to-face evaluation	Within 24 hours of initial order	Within 1 hour to evaluate patient’s immediate situation, patient’s reaction to intervention, patient’s medical and behavioral condition, the need to continue or terminate the restraint or seclusion
Attending physician notification	Within 1 hour	Within 1 hour
Re-evaluation of patient and renewal orders (renewal orders are limited to 24 hours duration)	Signed, dated and timed daily following face-to-face evaluation	Adults – The initial order is good for 4 hours. The RN may receive a verbal order for additional 4 hour intervals up to a total of 24 hours.  Adolescent (9-17) – The initial order is good for 2 hours. The RN may receive a verbal order for additional 2 hour intervals up to a total of 24 hours. Child (<9 years) – The initial order is good for 1 hour. The RN may receive a verbal order for additional 1 hour intervals up to a total of 24 hours. All Age Groups - See and evaluate patient at a minimum of every 24 hours, providing a signed, dated and timed order.

For more information, review WellStar SPP RI-40: (1) Go to eSource > My Resources > Accreditation > Joint Commission E-dition Hospital. (2) On the left navigation menu, click “Accreditation Requirements.” (3) Scroll down to “Provision of Care, Treatment and Services (PC).” (4) Review PC.03.02.01 through PC.03.05.19.