Behavioral Emergency/Seclusion
Violent
Patients have the right to be free from
restraints and/or seclusion of any form
imposed as a means of coercion,
discipline, convenience or retaliation.
› “Generally used in the med-surg patient
population and applies when the primary reason for use directly supports medical healing” (i.e. a patient pulling out lines or tubes)
› “Limited to emergencies and implemented for
the management of violent or self destructive behavior that jeopardizes the immediate safety of the patient, a staff member or others”
The type of restraint (violent vs.
nonviolent) is based on the behavior
demonstrated by the patient, not the
diagnosis.
Requires a physician’s, resident’s, fellow’s or APP’s order › If a resident, fellow or app orders, must be
approved by staff physician and documented on order sheet
› Before initiation OR
› As soon as possible (defined as “within a few minutes”) in an emergent situation
› Med Surg/ICU: Wrench in and document on the Non-Violent Restraint Flowsheet in Doc Flowsheets
Must specify
Restraint Type
and Reason
Type of Restraint or Seclusion Who May Accept
Signed, Dated, and Timed by Ordering Provider
Non-Violent/Non-Self-Destructive Behavior (Restraint only)
Licensed Nurse
Within 48 hours of issue
Behavioral Emergency (Restraint or Seclusion)
RN Within 24 hours of issue
A PRN order or Trial Release is not permitted. Note: A temporary release for the purpose of caring
for the patient’s needs (e.g., toileting, range of
motion exercises) is not considered a discontinuation or trial release as long as the patient remains under
direct staff supervision.
PRN orders
Wrench in Restraints non violent tab in flowsheet tab and document the following:
Alternatives tried (A minimum of one) › Bed Alarm, Repositioning, disguise equipment, etc…
Clinical Justification
Q2 Monitoring
Restraint Type › Wrist, Side Rails X4, etc…
Education: › Behaviors or criteria required to discontinue restraints/pt
response › Why the patient is being restrained
› Who was educated
The standard CMST checks - RN › Visual Check
› Circulation
› Range of Motion
Interventions – RN, LVN, CNA › Restraints released
› Food & fluids offered
› Toileting needs met
Comments
› Add any additional information
1) Click on
“Add
Template”
2) Type in
“restraint” in
search box
3) Choose type of
restraint then click
accept.
4) Check the problem,
goals, and interventions
appropriate for the
patient
5) Click
Accept
3) Check the problem
and mark both goals as
completed
4) Click
Accept
1) Highlight
the Problem
2) Check
Resolve
Problem
Medical non-violent restraints must be renewed each calendar day
“PRN” or “standing” orders are not allowed
If the restraints have been discontinued, then a new order is needed, not a renewal order
Only a Physician, Resident, APP or RN
may discontinue restraints
Add a column for the
time you discontinued
them and mark the
restraint type as
discontinued
Behavioral Emergency/seclusion:
Behavioral Emergency is defined as:
A situation in which it is immediately
necessary for Restraint or Seclusion of
an individual to prevent
Imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit
suicide or serious bodily harm; or
Imminent physical harm to others because of acts the individual is committing.
The definition of seclusion is involuntary confinement of a patient, alone in a room or area, from which the patient is prevented from leaving
Note: Seclusion includes when staff is physically intervening to prevent the patient from leaving
the room as well as giving the patient the perception that threatens the patient with
physical intervention if the patient attempts to leave the room, regardless of whether the door is
actually locked.
Behavioral Emergency (Restraint or Seclusion)
can be ordered by:
› Physician, resident, or fellow only
Before initiation OR
› As soon as possible (defined as “within a few
minutes”) in an emergent situation
Wrench in and document on the Violent or Self-Destructive Restraints flowsheet for hourly assessment
Safety documentation every by the person providing direct (1:1) observation
Requires a physician’s renewal (1 time only)order › Adult: Every 4 hours
› Children aged 9-17: Every 2 hours
› Children under 9: Every hour
Patient must be continually monitored in-person
LVNs can not obtain telephone order for behavioral emergency restraints/seclusion, initiate, or discontinue restraints
Elements of assessment & care more detailed
If a patient falls asleep, restraint must be removed
More required documentation
Time of initiation of restraint or seclusion
Patient’s current physical, emotional and
behavioral status
Any medications administered
Type of care needed
Staff member must:
› Assist re-entry of patient into care setting
› Observe patient for 15 minutes and
document patient behavior
Debriefing:
› Must occur and be documented after
discontinuation
› See policy for details