Q.What restraint standards apply to an organization that is surveyed under the Behavioral Health Care (BHC) accreditation manual?
A. Programs surveyed under the Comprehensive Accreditation Manual for Behavioral Health Care will continue to use the current restraint/seclusion standards in the BHC manual. The standards have not changed.The restraint and seclusion standards are PC 12.10 through PC 12.190.
Q. There seems to be some confusion regarding where the Acute Medical and Surgical (Nonpsychiatric) Care restraint standards, and the Behavioral Health Care Restraint and Seclusion Standards apply in a hospital. What determines which set of standards would apply?
A. The decision to use restraints for medical/surgical reasons or for behavioral health care reasons is not based on the treatment setting but on the situation the restraint is being used to address. The Behavioral Health Care Restraint and Seclusion Standards apply to all behavioral health settings in which restraint and seclusion is used for behavioral reasons, such as free-standing psychiatric hospitals, psychiatric units in general hospitals, and residential treatment centers that are owned by the hospital. Further, these standards also apply to restraint or seclusion that is applied for behavioral health reasons, regardless of where these patients are in the organization, ED, medical/surgical units, etc.
In the latter cases only select Behavioral Health Care Restraint and Seclusion Standards would apply if behavioral restraint was applied anywhere in a hospital, other than a psychiatric unit. The select standards are PC.03.03.11, PC.03.03.13, PC.03.03.15, PC.03.03.17, PC.03.03.19, PC.03.03.23, PC.03.03.25.
The acute medical and surgical care restraint standards would apply to medical care, post-surgical care, and in situations in which behavior changes are caused by medical conditions or symptoms, for example, for confusion or agitation. In such cases protective interventions may be necessary.
Q. If the Behavioral Health Care Restraint and Seclusion Standards, (or select standards if the patient is not on a psychiatric unit in a hospital), apply only when restraint or seclusion is for behavioral health reasons. How is behavioral health reason defined?
A. The simplest way to determine what is a behavioral health reason is first to determine what it is not. When restraints must be applied to directly support medical healing - this is not a behavioral health reason. While the patient may be exhibiting behavior that could be classified as irrational or uncooperative, such as attempting to seriously interfere with a physical treatment or device, such as an IV line, other indwelling lines, respirator, or a dressing, and less restrictive approaches don't work to prevent this interference, then restraint could be applied.
However, regardless of where the patient is receiving this type of treatment in the hospital, (even if on a psychiatric or geriatric psychiatric unit), the Acute Medical and Surgical (Nonpsychiatric) Care restraint standards, PC.03.02.01 through PC.03.02.11 apply. Any other clinical justification to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive would then be behavioral health care reasons for restraint.
Q. Is a bed enclosure or side rail a restraint or is it seclusion?
A. The specific nature of a device does not in itself determine either, which set of restraint standards, or even if any of these standards would apply. It is the device's intended use, (such as physical restriction), its involuntary application, and/or the identified patient need that determines whether the devices used triggers the application of restraint standards. Technically, a bed enclosure or side rails are neither purely a restraint nor a form of seclusion, based on the definitions that accompany the Joint Commission standards. However, a bed enclosure ( e.g., net bed) and likewise a side rail could potentially restrict a patient's freedom to leave the bed and as such, would be restraint. If for example a bed rail is used to facilitate mobility in and out of bed, it is not a restraint. If the patient/client can release or remove the device, it would not be a restraint. You would still need to make a determination between applying the Behavioral Health Care Restraint and Seclusion Standards or the Acute Medical and Surgical (Nonpsychiatric) Care restraint standards based on the intended use, involuntary application and identified patient/resident/client need, (clinical justification).
Q. For Behavioral Health Care Restraint and Seclusion, when must an LIP, (licensed independent practitioner) perform a face-to-face assessment of the patient?
A. When a patient/resident/client is placed in restraint or seclusion it is done in a crisis situation and usually in the absence of an LIP to protect a patient/resident/client from injury to self or to others. The organization determines who is competent to make this decision in the absence of an LIP. However, if the hospital uses accreditation for deemed status purposes a physician or other LIP must evaluate the patient within one hour of the initiation of the restraint or seclusion, as required by CMS's Interim rule for Patient Rights (effective August 1, 1999).
Time Frames for Reevaluation/Reordering of Restraint or Seclusion for an Adult
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Adult placed in restraint/seclusion. |
Order obtained from LIP within 1 hour of initiation of restraints/seclusion. |
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Adult evaluated in person by LIP. |
1. If hospital uses accreditation for Medicare deemed status purposes, LIP in-person evaluation to be completed within 1 hour of initiation of restraint/seclusion.
2. If not for deemed status, LIP in-person evaluation to be completed within 4 hours of initiation of restraint/seclusion.
3. If adult is released prior to expiration of original order, LIP in-person evaluation conducted within 24 hours of initiation of restraints. |
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LIP reorders restraint. Evaluation by qualified staff. |
Occurs every 4 hours until adult released from restraint/seclusion. |
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In-person evaluation by LIP. |
Occurs every 8 hours until adult is released from restraint/seclusion. |
Time Frames for Reevaluation/Reordering of Restraint or Seclusion for an Children and Youth
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Child or youth placed in restraint/seclusion. |
Order obtained from LIP within 1 hour of initiation of restraints/seclusion. |
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Child or youth evaluated in person by LIP. |
1. Within the first 2 hours for youth 9-17 or for children under 9, LIP conducts an in-person evaluation of the youth or child.
2. If youth or child is released prior to expiration of original order (2 hour or 1 hour), LIP in-person evaluation conducted within 24 hours of initiation of restraints. |
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LIP reorders restraint. Evaluation by qualified staff. |
Every 2 hours for youth (9-17) until youth is released. Every 1 hour for children (under 9) until child is released. |
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In-person evaluation by LIP. |
Every 4 hours for children and youth (17 or younger) until child or youth is released. |
Q. PC.03.03.23 seems to require that every 15 minutes a patient/resident/client in behavioral restraint or seclusion is assessed and assisted with:
- Signs of injury associated with the application of restraint or seclusion;
- Nutrition/hydration;
- Circulation and range of motion in the extremities;
- Vital signs;
- Hygiene and elimination;
- Physical and psychological status and comfort; and,
- Readiness for discontinuation of restraint or seclusion.
Does this mean that we need to address each of the items noted in the intent of the standard every 15 minutes? Are we then expected to also waken a patient to perform these tasks?
A. No, it is not expected that all of the bulleted items in the intent statement of PC.03.03.23, be assessed every 15 minutes. The intent is that some physical assessment of the patient/resident/client be performed immediately after the patient/resident/client is placed in restraints, and as appropriate to the patient/resident/client's condition, needs, and the type of seclusion or restraint employed some or all of these activities occur. After all, immediately after a patient/resident/client is placed in restraint or seclusion or even after the first fifteen minutes approaching the patient or attempting some of these activities could be dangerous and may increase the patient/resident/client's agitation. Use clinical judgment and knowledge of the patient/resident/client and their individual needs to set a schedule of when and what items need to be evaluated. Also, waking a patient/resident/client in restraint or seclusion can be dangerous for both the staff member and patient/resident/client . Finally, there are visual checks that can be done when and if the patient/resident/client is too agitated to approach.
Q. What is the meaning of continuously monitoring in PC.03.03.25?
A. Monitoring a patient/resident/client in restraint or seclusion is done to ensure that the patient/resident/client is physically safe in restraints or in the seclusion room. Continuous means uninterrupted observation of that patient/resident/client . For a patient/resident/client in restraint this observation must be done in-person as long as the individual is in restraint. For the patient/resident/client in seclusion, the in-person observation can progress to audio and visual monitoring after the first hour in seclusion.
In-person means that the observer must have direct eye contact with the patient/resident/client. However, this can occur through a window or through a doorway, since staff presence in the room in which the patient/resident/client is restrained or secluded could be dangerous or add to the agitation of a patient/resident/client .
Q. How does the Joint Commission define the term "episode", as used in the phrase, 'all restraint and seclusion episodes…" in standard PC.03.03.31?
A. The Joint Commission does not specifically define the term "episode" in the restraint and seclusion standards. An organization would be free to define this data element to meet their needs when collecting data on restraint and seclusion.
For example, an organization may wish to collect data each time an order for behavioral restraint orders are written. In this case the definition for episode might be; each time a behavioral restraint is ordered whether for the same patient/resident/client or for different patients/residents/clients.
An organization with a large behavioral population or multiple behavioral health care settings or psychiatric units might wish to collect data at a more general level. The definition in this organization might be, each time an LIP conducts a face-to-face reassessment and writes an order for restraint or seclusion.
In both cases the organization defined this data element to fit within the scope of their data collection needs. This is not prohibited by the restraint and seclusion standards. As long as an organization collects, aggregates, and uses data to improve a process they are free to define data elements that work for their measurement strategies.