CMS 2018 Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes

  Transcript

patient died and some states have actually banned this in their specific state that you can't do a prone position.

And then this is just to show you kind of an article that just actually appeared about 11 months ago to show you kind of how the process works.  But this was a hospital down south and there was a patient that actually had been shot in the arm and he was actually strapped to the gurney again face down or in that prone position and he died of traumatic asphyxiation.

And so, what would he even double trouble was that the coroner ruled the death was a homicide, so if the death is a homicide than who, the two security guards were the ones that secured him face down so are they guilty of homicide?

And the CNS was going to take away the hospitals Medicaid/Medicare reimbursement, but then again, they did come into compliance and then that was listed in this is just an article there were quite a few of these articles that were out there if you want to go and read more about that.  And then this is an article that came out a few years ago that had some significant points.  They found that 27,000 patients are restrained every day in hospitals in America.  That’s about five per hospital.  And the prevalence is 50 per 1,000 bad days.  Days now, I want you to know that there's citing an older study in 2007.  So that was 11 years ago.  

If you look at the more current data, if you go in and look at benchmarking data, you will find that we have done a lot better than this.  And when I first got out of nursing school.  We used to restrain everybody and their brother.  And if a patient fell then I automatically would have work clerk or nursing assistant come back and bring two soft wrist restraints and they would get restraint if you automatically do that, that is a violation of the CNS standards actually tag 154, which I'm going to talk about.  Restraints to increase delirium by four-fold.  This is still true, and I used to teach as an adjunct professor.  And I would always teach the class on restraint and seclusion.

We had nursing students in the labs and they had to because we would do education and then competency, competency where you hand them the restraint and they actually have to put them on.

And we would actually I would actually require that the nursing student had to remain in restraint and seclusion for 15 minutes because we wanted them to know how it felt and it's amazing how agitated and irritable that they got, and I'm like well how do you think our patients feel?

And it was a very good course to have you know to get them to understand why CNS is now a last resort not a first resort and this is still true that fresh that restraints can increase the risk of pressure ulcers.  Respiratory complications and strangulation those are primarily from vest restraints and most hospitals do not use that restraint anymore.  And then they mentioned the study, which we're going to talk about with Health and Human Services and CNS is under Health and Human Services and this is why they made a change.  In 2006, they found that 40% of hospitals failed to report deaths to CNS.

So that's going to kind of lead us into what we're going to talk about here in just a little bit about when you have to report patients that die in restraints and there was a change made a few years ago and we're going to talk about what that is.

So, this is the article if you would like to go out and read it.  And then this is an important article.  There's actually this is the finding of this particular article was the finding of many other evidence based literature.

The bottom line is that if you don't have enough trained RN that your use of restraints would go up.  They also found that the use of restraint has declined remember, we're getting better we’re being more creative.

Again, restraints aren't the first response and now I can put the patient in the emergency department in a low bed and now I have a 2-inch padded matt, I have a garage door opener that I can close so that if they’re agitated I don't have to worry about anything else and we've created the safe room.  And again, the bottom line is that putting on restraints can cause agitation, especially agitation people get really irritated when you restrain them, and it can cause confusion.  It can cause adverse psychological and health effects.  So, what they found is that some hospitals that had a shortage of RNs were supplementing with nursing assistants or other staff.  

And again, the study found that this does increase the use of restraints and the quality suffers.  And if you go onto AHRQ.gov the agency for healthcare research and quality, they have a website and they have a landmark case of the shortage of RNs and how it can cause readmissions and increase codes and increase pressure ulcers and increase medication.  All that research has been out there.

But this is the article if you would like to read it.  Again, more nurses could reduce the need for hospital restraints and they looked at almost a million patients and 869 hospitals.   And they looked at also the data in the national nursing quality indicators from 2006 and 2010 and found out that 1.6 percent of patients were restrained and 51 were restrained to prevent falling so we're going to talk about that, because there are a lot of things.

In the fall, I teach an all-day falls course.  A lot of tools that I have other than restraining patients that really not one of the primary things in my tool kit.

And then member I said that we're getting much better, so during the four years the study of the use of restraints, it dropped by 50%, so again, we're getting better at being more creative and I can remember one time working in an emergency department before we had you know the low beds and the padded matts that you know, I took a mattress off the cart pulled the cart out, but I'm on a couple of blankets and then we steam cleaned it for infection control reasons at the end.

And again, whatever it takes.  I'm trying to be more creative and the guy was agitated in the last thing I wanted to do was restrain him.  So, I said, sir, I don't want to put these restraints on what if we do that.

And we wouldn’t have to do that, and he's like yeah, let's go for it.  So, I just let the doctor know what was going on.  So again, the more RNs the lower use of restraints and in fact, if you don't have enough RNs, your odds of using restraints are 11 to 18 percent higher.  And then using them to prevent a fall, which again we're going to talk about tag 154 again is 9 to 16 percent higher.  Again, finding that RNs were trained to find alternatives to restraint and seclusion.

So, one time I was working with the hospital and it was a medical surgical unit and they did a lot of especially elderly patients with broken hips and stuff, and they had they were restraining them, they were putting on two soft wrist restraints because they were pulling their IVs out.

So, there's a company that makes these they're really nice, I actually wore one for a day and it was so comfortable and we had this little dome that had adhesive, we would put over the IV and then we would put these sleeves on.

And they had them to match the skin color with the patients are kind of out of sight out of mind and they weren't even restraints because patients could move around and reduce restraints on that unit by 54% and some of the patients like them, so much especially the elderly.  My friend used to say the little old ladies want to know if they could have one for the other arm.  Because they kept their arms warm.  So again, trying to be creative to do that.

So, again, this article shows that it’s not the number of people you have that’s present, but rather having an adequate number of RNs again, because they were more likely to be trained.

Now we're going to go through the 50 pages of standards, 50 pages.  If you consider that that's about 10% of the manual because it's 528 pages and they have section numbers or tag numbers and restraint and seclusion goes from tag number 154 to 214.

And as I'm walking you through the slides, you will be able to see the tag number and I'm going to show you how to get a copy at no expense of the CNS manual so if you want to read more about tag 161, you're going to be able to do that, and then also you can also send questions to, and this is so wonderful, this is fairly new and I've done this about 35 times.  And I realized while I was doing this program the other day and the first four questions I got asked, I’m like oh my gosh, these are all things that I emailed CNS and got an answer in writing, so how cool is that, that we can hear directly from the horse's mouth, so hospitals, CG@CMS.HHS.gov.  

How wonderful is that in fact, just before this conference, I was on a conference call with CNS because I had emailed them in a question and they were kind enough to set up a phone thing, so that we could go over and talk about that, so how they end up into this 528 page manual is that first they are published in the Federal Register, and then they come along and they add interpretive guidelines, so that we, as hospitals and surveyors will know what it means.  And then some of them have a survey procedure go do this go do that.

So, on slide 16, here’s that email again and at least once out of every webinar that I do, I get a call, and someone will say?  Can you tell me what that email address is to ask questions so again I've given it to you twice?

And then I'll have at least one person that will call and say now how do I get a copy of the manual so again on slide 16 here it is again and all you do is today we're talking about hospitals.  So, you would just click and hold your browser over the letter A and then the manual will appear.  It is a no cost.  You can download it, you can print it, you can just save it as a favorite and go out and periodically look at it.  Again, this is the website, hold your browser over A and manual will pop up.  This is the most current one, I always take you to the most current one.  This is the one that in fact, Dr. Bottle and I were just talking of Dr. Bottleraft who was my contact person from audio educators.  And they are going to put on the ligature risk one.

But this had the 13 pages of those new standards on how to and by the way that ligature risk.  It's not only if your behavior health hospital.  It's not only if your behavior Health Department of the hospital it’s anywhere where patients who are suicidal go so you could in the emergency Department we see them all the time.  In fact, I worked at a hospital at one time and I created a safe room on the Med storage unit.  We had, and one in postpartum can sometimes you get postpartum patients that are having postpartum depression.

And it affects anywhere where patients go, but anyway this is why the manual was updated and now they also issued the texting memo and it amended critical access hospitals, but it didn't amend the language because there was already language in the medical records section, basically, you can never text an order in for an IV or for consult or whatever.  All orders have to be entered in the medical records so computerized provider order entry is the preferred sometimes we take verbal orders for that now.

Other things can be texted if you have a secure platform, but not physician and provider orders and of course, here again the website where you get a copy of the manual.

And then I'm going to show you a survey memo that was issued on restraint and I'm going to talk about in just a few minutes and this is a good way to keep up in the future is maybe have one or two people who go out and see if the manual has been updated.  Have them go out and see if there's any new policies, so again, we talked about the texting one and ligature risk one and the one before that was Legionnaire’s disease, there’s been a 286% increase and in 15% of those cases are hospitals.  So, this is where all of those memos, including the one on restraint and seclusion that I'm going to talk about in a few minutes.

And then all you would do is just click on one, so if you wanted to see the ligature risk policy or the texting policy again.  You just click on that and up it will pop, and you can see it and then this is what the survey memos look like I'm going to talk about this one in a few minutes they pretty much all look alike.

They always tell you what they apply to.  So, this one applies to hospitals and when it talks about critical access hospitals.  They're allowed to have up to ten bed behavioral health unit or rehab unit and if they do those distinct units are governed by appendix A, which I’m going to talk about here in just a second.

And then whenever the issue is a survey memo, they reserve the right to tinker with it and when they get it done they put it into a transmittal, and that very same day they put it into a manual.  And I'm going to talk about the proposed changes, so that if you wanted to see what those were when they got passed that's how you would do it.

So, the first thing that you can do also to keep up in the future so in just a second, I'm going to tell you about the proposed change to the restraint standard.  When its final it will be published in the Federal Register then CNS will probably do a survey memo and then add it to the manual, so you can pick it up at you know several different ways, but again this is free now so have one or two people who sign up and then it comes to your computer every day.

And I scroll down, and I look under CNS and I look under OSHA and few other agencies.  Obviously, you're looking for CNS, so you would just go there.  It takes two seconds.  And if there's nothing there you just delete it, if there's something there, you click on it to see if it's relevant to your hospital.

And then this is.  And I did update this, so I will send this to Dr. Bottlerath, and have him forward it on to those of you in attendance today, but Dr. Girardi and Dr. Kelly and I wrote this and it’s kind of nice because it's a word document and it follows very nicely the PowerPoint so it's a good reference that you can use and then I wrote this.  And I just got permission from Dr. Boudreaux.  To share this so I will also send this to Dr. Bottlerath and have him send it on to those of you that signed up today and this is nice because again just like the other one there.  It kind of just goes through and summarizes the restraint standards and I had Dr. Boudreaux, we wrote this for emergency department physicians because they insure emergency departments.  

And we had a lot of requests from our ED physicians and because they were kind of getting into trouble because they weren't familiar and when CNS was coming in.  We were finding a lot of the EDs were being assessed for not being a compliance.  Now in 2013 with the first time that's CNS told us by the way from here on out on a quarterly basis, we're going to be providing you information on why hospitals are cited.  How fabulous is that?  So, when this comes out and they pretty much kept their word, I spent like a whole day and all I did was read why hospitals got into trouble.

For those of us that teach this, this is like a treasure trove of information and so that's how I know that there are 2,300 hospitals that have been cited on this.  And so that's the highest number in patient rights is the number one patient right there were over 7,000 deficiencies and 2,300 of them was on restraint and seclusion.

So, in the most current report is October the fourth of 2017 just to show you how this number is gone way up.  The first report that was issued again in March of 2013, there were 363, okay?  And you should be aware it does name hospital names and addresses and zip codes.  So, it's public data, anyone can go out there and look at it and on the bottom of slide 28, this is the website.  If you want to go look at it.  Now I do in cumulative of how long that report has come out since 2013.

This is an Excel spreadsheet.  So, if you want to just see ones in your state, or if you just want to see one from 2017.  You can slice and dice the data any way that you want so it's really an excellent report and again, I spend a long time reading these and so what I did is I took each of the tag numbers and I actually told you how many areas which were the number of deficiencies so you can see that tag 154 had 164 deficiencies and look at tag 168 it had 422.  And we're actually going to walk you through every one of these tag numbers.  Over on this page is tag 175 it had 180 deficiencies and that brings us to a total of 2,300.  That is more than half of the Appendix A hospitals that are governed by these standards have been cited or that number of deficiencies.

Now let's talk about terminology.  Joint Commission that the patient is either a behavioral health patient or a non-behavioral health patient.  CNS uses a little different terminology.  The patient is either a violent and are self-destructive or nonviolent nonstop destructive and the decision to use it is not direct drive from the diagnosis or the department the patient is in, it’s from the assessment so.  

A patient could be throwing chairs and swinging at people in the emergency department just as well as they could in the behavioral health unit.  Now, Joint Commission, which accredits about 80% of the hospitals has actually been around since long before CNS.  In fact, since 1951 and they actually had it in the federal law that they had these status meetings that if you use the Joint Commission, you automatically got reimbursed for taking care of Medicare and Medicaid patients.  

And in 2008 they agreed to apply for dean status just like the other three accreditation organizations.  DND house care, CIH’s Q, and the AAHC healthcare facility accreditation program.  So that is why the Joint Commission went back and changed their standards.  So, their crosswalk there at 10 standards in the provision of care so when I used to do all day programs.  I would have to do a day in the morning and do the Joint Commission standards and then do a day in the afternoon on CNS because they were different.  Now we don't have to do that, they're pretty much crosswalk.  And again, these are the four accreditation organizations that are out there and for example, if you look at for example, CIH’s Q and DND, they are the 2 newest kids on the block their standards are just basically shortened version of what's in CNS, so we have you know we have you covered?

And you if your DMV or CHQ, you can actually go to the website.  You have to sign in but it's free you can download a copy of their manual.  Unfortunately for the Joint Commission, we still have to pay to get that and I get the e-addition, but you know that still costs.  And then CNS has a complaint manual.  It was actually they did a memo on this actually updated again in 2016, but basically this is what the surveyors, when they are investigating complaints in seclusion.  It tells them what to do this is a this is a public document anyone can read it.  

So, we always suggested that you have a restraint guru or King or Queen in your hospital.  And they're the ones that would keep up, make sure the teaching was done, and things we’re going to talk about and also, you'd want to take a look at this because they could give you some insight on what they're going to ask you if they come and investigate.  

And it’s been, I actually had a hospital that called me and wanted me to work with them on the restraint and seclusion policy and it was the first time I've ever had a call.  I always get calls when people are in trouble never that they're doing on a proactive basis.  And we'll talk a little bit about doing a gap analysis, but it's something that you can do now, and you will find it to be very helpful and in a gap analysis, by this is by the way that complaint manual, this is a memo that came out again, they updated it, the manual, but again in in in also in this CNS said that if you are accredited by somebody and they find a problem they're going to notify your accreditation organization.

So anyway, so I mentioned that on June the 16th of 2016 and the hospital proposed improvement rule, that’s just a short name for it, they proposed to change the terminology from a license independent practitioner to licensed practitioner.  And that would make it clear that a physician assistant would be allowed to order restraint.

And CNS doesn't tell you, who is a LIP and who is not.  Your state does.  So for example, our state Medical Board license PA's and they say in our state that they're not an independent practitioner, they're a dependent practitioner, so CNS was just enforcing whatever your state, said, but it's kind of silly because, you know, nobody opposed it, so if they just change the terminology then we wouldn’t have to get into that and then our PA’s that are licensed would then be able to order restraint and then all these other things were going to talk about today and this is the full name.  

Medicare and Medicaid Programs Often on Critical Access Hospital Changes to Promote Innovation Flexibility and Improvement in Patient Care of a Proposed Rule.  Now as I mentioned, the restraint standards have tag numbers, and they go from tag 154 to 196 and remember, we were talking about it that if it’s a critical access hospital has attended distinct unit.  They have to follow this.  But the critical and if you don't know what it critical Access Hospital is it's usually 25 beds or less.

They're usually 35 miles away from mount restrain and the 35 miles away.  Unless there is not in restrained and however, we have seen some of the hospitals not being cited and not having a policy, if you read the Critical Access Hospital Manual.  It’s 281 pages, the only time they reference restraints is actually in the section on swing bed, but again hospitals have to adopt something and we’re finally a Critical Access Hospital are insistent, so pretty much we adopt the same rules with the exception maybe of the reporting to the regional offices.  So again, this is the website where you can get to the manual.  We're going to be walking you through now and I'm going to be showing you the tag numbers.

Now, if you do send and remember I said, now you can email directly to the horse's mouth and you can get it straight, and so you would want to make sure you tell them what one you have a question on.

So, you might say oh, I have a question on tag A 154.  You do want to include the A so they know what manual you don't have to say dash oh, but you do need to say A 154.

And then the nice thing is that if you not noticed this before that every section in the CNS manual will tell you in that section has last been amended so whenever I write a lot of pot and I've written a lot of policies working for hospitals and in hospitals for 35 years and I would say this policy is written to comply with you know, CNS tag number 154 and so, if I'm gone and next year the, and next year somebody else is reviewing the policy, they can say oh, this one hasn’t been changed for ten years.  So that is probably current.  And then here’s the section that appears in the Federal Register, here’s a section that appears, again CNS comes along and adds interpretive guidelines and again, some of them have a survey procedure.

Uh so again we've talked about Critical Access Hospitals.  Now, if this is this is how the rule used to be in and I'm going to show you the last minor change.

If the patient died in a restraint even if the restraint didn’t cause the death and if the patient died within 24 hours again even if it didn't cause a restraint.  It had to be reported to the regional office and it's a patient die within 7 days and the restraint caused the death then it had to be reported.  So, they made one amendment to that.  If a patient dies and they only have on one or two soft wrist restraints, then you don't have to report it if they have one or two soft wrist restraints then you have to have an internal log and I'll show you what has to be in the internal log later and then you would document in the medical record that the CNS internal restraint log was completed as required by CNS.  Otherwise you have to fill out this form and you don't want to send it to your state agency you send it to your regional office okay.

And this was a memo that they send out this is the one I mentioned if you want to go back and take a look at it that talked about the reporting requirements and we have ten regional offices and they wanted to read and offices to let him know fill out the form, then fax it in, email it in, you want me to leave a message on the voice mail.  What do you want me to do and again the regional offices would again fill out the…and then this is the top of what the form is and this is the website so that you can get the forms and you have to actually print it off and then write on it unless your IS can make this a printable form that you can do and then on the bottom, cause of death, the restraint information, and then we’ll talk about these.

Side rails, we’ll talk about when a side rail is, and it is not a restraint.  If they died and all they had on was wrist restraints, hard restraints.  You notice they do not use the word leather because leather, unless it’s the faux leather, we couldn’t clean it.  And one time we were doing an interesting thing, we took the one we had in our emergency department forever and we cultured it and you don’t even want to know all the stuff that was going on that.

So, four-point hard restraints, if I have to get an order and all of a sudden, this patient goes berserk and they are throwing furniture and they are swinging at you and I get an order for the medication and the patient is not going to hold still and I have to hold the patient down to give him medicine, then I get an order for the force medication on therapeutic hold.  It used to be if a child was acting out you could hold them for 30 minutes without it being restraint, that is no longer true.  

So, if I have to hold this child down to settle down.  That’s a therapeutic hold, I still have to have an order.  Now please remember that you have in your policy, and that is an emergency and you're going to go ahead and do it and then get the order and I had this question just recently where the hospital got in trouble because the ED had a patient that was violent, self-destructive.  They put him in restraints by the time to doctor got in to see him.  They had calmed down and then the doctor didn't write the order.   Well they're not in now.  Well you need to write the order and then see it because of your policy?

So again, you need to make sure that you're writing those orders and then take down this is why they want all of our security to have at least an 8-hour training class because what do we?  Security stat to the emergency department.  And also, if they're not adequately trained those are the ones that we've seen.  We’ve seen examples where they were face down.  I'm not saying you can never use a face down but the prone position where they didn't secure them, and they died.

In fact, in our behavior health unit the hospital where I was legal counsel.  Nobody was allowed to go into the room of a patient who was violent, self-destructive unless CNS mentions CPI by name.  I will tell you there are other companies out there, but you know they had to have an 8 hours training course and no one was allowed to go in the room and we also trained our housekeepers because there are people that are trained in our security.  All were trained in how to do a staged takedown and then enclosure your bed.  So, I will talk about that because they're if they're in an enclosure bed and they can't get out when they want.  That's a restraint.

That's restraints when I've been doing a light program, I have 95% of the hospitals tell me they are no longer using them anymore.  Elbow immobilizers and then I don't know why number 13 is on here, because CNS specifically says has to the Joint Commission has all of the accreditation organizations that shackles and handcuffs that are used as part of law enforcement and we've got a policy that indeed they are not restraint.

So, as I mentioned there are 50 pages of standards.  That's amazing, 50 pages.  Now I'm going to tell you that, if you read these 50 pages or if you've tried to sit down and read these.  They weren't organized very well, and they were little hard to read so when we decided to start doing educational programs.  My friend who's also a nurse attorney and then another friend of mine who is a very experienced healthcare lawyer, reread these three times and then we went into a room and we said how could we organize these in to make it a little bit easier and we found out that there were 21 rules.  And if you follow these 21 rules, you would be able to understand what was in the restraint and seclusion.  

Also, it's going to make it again as we walk you through, it's going to make it a little clear and after you've been through the program today, if you go and pick up these 50 pages of restraint and seclusion, it's going to actually make some sense.  So again, we've talked about when you have to report to CNS and again with the exception of us, they just die and all they have on is one or two soft wrist restraints, did it cause the death and that is when you fill out the internal log that you fill out.  So again, we are starting at tag 154 just like what we said.  And it will be rule number one.  So, rule number one is that patients have a right to be free from unnecessary restraint and seclusion.  So, a lot of times when I go to a hospital I’ll see where they stayed a patient has a right to be free from restraint and seclusion.

And I will say do you have any patients restrained today?  Yes, we have three or four or whatever.  And what they meant to say was unnecessary restraint and seclusion.  And I've done a lot of programs with surveyors and one time I was doing a program in Maryland and then a surveyor said, oh, I just got out of the hospital last week.  And what it says is it is only going to be used when necessary, never for coercion, discipline, convenience or retaliation, so there was a patient who spit on a physician and that is so, that just bothers us and that’s why we have spittle’s and stuff.  Anyway, the physician was so angry that he put the patient in restraint and seclusion for two days.  And CNS felt that he was retaliating for that patient’s bad behavior but again, the patient had behavior health issues and then when they're no longer necessary.  We're going to take them off, and as I mentioned they apply to all hospital patients.  Even if there on behavior health unit.

Now I will tell you that one time I was at a hospital and we had a ten-bed behavior.  health unit and most of your states will have a specific state law for a specific units of behavior health units and ours did.  So, when I wrote our policy and procedure I made it in three parts.  So, part one, this is a policy that only to the behavior health unit and then the second part was this policy applies to any patient outside the behavioral health unit that is violent and or self-destructive in parenthesis a behavioral health patient.

And then the third part was this is a patient outside the behavior health unit who is nonviolent non-self-destructive and again.  I did that again because of the way that CNS defines it and the Joint Commission finds it.

So, we add this to our patient right statement that says that they have a right to be free from unnecessary restraint and seclusion.  You should make sure that patients get a copy of their patient rights in writing.

And remember I said that when I first got out of nursing school that in 1975 if patients fell, I would automatically put the call light on and the nursing assistant or the ward clerk would bring me back two soft restraints on 100% of patients got restrained if you do that now you will be cited because there are so many other things that we can do with you know sitters and having low beds and having padded matts than and we had wedges that we could put underneath it, so they didn't slide out and we had a perimeter alarms and I do want to say a little bit about perimeter alarms or alarms.  They haven’t said this yet, only for nursing homes, but I suspect it's coming down the pike.

But if you have a sensor in every time it is so sensitive that every time that patient moves it's going to go off that could be seen as a restraint of their movement and now a lot of the new ones like they rang out to the nurse.  And the perimeter alarms, the nurse can see it on it, like a little cell phone or picture or whatever, that would be okay, but again, you know, if we've got a sensor on them because you know, we are afraid they're going to fall or something like that.  I have besides having a lot of degrees at three nursing degrees and every time I went back I went to the behavior Hospice in town and I wanted to spend a semester there, to, you know just to renew you know what's in with behavioral health and the psyche hospital in town was really a big one and instead of taking the patients that were involuntary admissions down to the courthouse and you know to probate them, they had two courtrooms in the basement how far is that.

And so, I saw this on the Internet where it said you could take this person to court or whatever.  I know there were some facilities that are in a couple of states that didn't like these but I kind of thought, gee, this is great because if a patient is going to court in the probate court downstairs and they're not kicking then I don't use or need to use the leg ones.  If they are not swinging at me or they've had a stroke on the right-hand.  I don't have to combine the stroke one, but also because I could see their chest and I could make sure that they were still breathing or whatever.

Rule number 2 is that just like the Joint Commission CNS amended it and said you know our hospital leadership has a role, responsibility to create a culture that makes sure that people are following the rules and not using them unless they're necessary.

So, the director of our behavior health unit is responsible to make sure his staff is following that.  Our chief nursing officer, is responsible for making sure that staff are following the rules and in compliance with all 50 pages.

And we monitor we do QAPI, so there are different audits that can be done.  There's a whole bunch of different ones, and really just didn't really help us because remember when we used to have for example, Joint Commission had incubation protocol.  And the bottom line is when the patient is initially intubated they are on a Propofol or Depravin drip.  They're not going to pull on anything they are too sedated.  But it's rather when we're trying to lighten up to sedation, and they don't quite meet the expiation requirements and then if they start to tug at their tube than the other nurse and I will run over, and we will put on 2 soft wrist restraints, but we still have to call and get an order, so it really didn't help us at all because you still need to have the order.

And as I mentioned the decision to use it is not driven from their diagnosis or from the department that they're in, by the assessment so again this patient is as violent selfdestructive.  He's swinging, he's kicking, he is picking up and throwing furniture around then that constitutes you know when they are violent and or self-destructive and again Joint Commission called the behavioral health in behavioral health and that's why I kind of wrote it in my policy.

And rule number 3 is pretty important, it's know what the definition of restraint is so any manual method, again, anything that immobilizes, restricts the body, their arms or legs, their bodies, their heads.  No belt restraint jackets cuffs are ties and most hospitals like I said, no longer use restraint vests, because those are the ones that were really having an adverse event and having patients that died.  If I manually hold down a patient who's acting out for behavior health reasons.  It is a restraint.  I'm going to show you in a minute that if it's for medical reasons, it's an exception to the rule so the bottom line is you want to have in your policy a definition of what is a restraint and also what is not a restraint.  Which is what I'm going to talk about in just a second and then CNS also focuses in on when a drug or medication is or is not a restraint.

And the bottom line is if I use a medicine and it is two or three times the dose, it's probably going to be used or considered to be a restraint or if I use something that off label use.

So, there are four things that you can put in your policy that will help your staff understand when it is.  And when it's not so let's take the example of a patient.  We call it a new name, substance use disorder, but say that the patient is having alcohol withdrawal symptoms and we prescribe Ativan, that is not a drug used as a restraint that's exactly if you and so.

These are the four things, so if I read the package insert, it says that Avidin is used for alcohol withdrawal symptoms.  It's a national practice standard.  It is used to treat a specific condition and it enables the patient to get up and join life.

So, it meets these, the section that is standard treatment and again this first one, is you know you look at up in the PDR are whatever or the FDA drug list and it tells you yes, this is what the medicine is used for?

So, seclusion.  So first of all, they provide a definition of seclusion and, seclusion is not being confined for example, if you're on a locked unit because a lot of behavior health units are locked units.  That's not seclusion and if I lock him in the room, that's seclusion.

If I post a security guard who says man you're not leaving this room that is seclusion.  Okay and seclusion can only be used if there is basically their violent end or selfdestructive again a danger to themselves or others.

Okay?  Now, if I tell them let’s take a time out, and I tell them to go down to the end of the lounge and take a 15-minute time-out.  That's not seclusion.  Now, if they get up.  I may yell at them.  Your 15 minutes isn’t up, you go back there, and sit and think about what you've done.  It's not locked so that would not be seclusion.  And CNS mentioned this document for a long time.  It's a resource to help us with behavior health patients learning from each other.  And different tools that you can use to do that, so again they are still propagating these success stories in reducing restraint and seclusion.

And again, if they if they're in seclusion, time limited orders apply which will talk about in just a second and you have to do a face to face evaluation.  We're going to talk about that.

But somebody had emailed a question in advance and asked if I would address that and I said yes, I would.  But face to face is only done if the patient is violent or self-destructed.

A face to face within one hour, the time the behavior starts does not have to be done on a patient who is nonviolent non-self-destructive and against therapeutic holds are a form of restraint and seclusion, so if this child starts acting out or trying to attack another child and we have to do a therapeutic hold that is a form of restraint again.  We would have to get in order for that, so remember I said in your policy includes white noise.  It does include and what it doesn’t include?  Remember I mentioned that this is under tag 154, restraint forensic restraints are not restraints, according to CNS.

So, anyone used by the police law enforcement handcuff shackles are not restraints.  Now I worked at one hospital for 20 years and even though I had a full-time risk and legal job, I used to do two or three shifts a week to stay current in our hospital had a couple of contracts with the prisons.  So, we saw the prisoners so if I did have a prisoner and they came in with handcuffs or are shackled first of all, I had to make sure that that was not compromising my patient’s care so one day I was triaging a patient and he had been tackled by the police and his handcuffs were behind him and it was putting pressure on his shoulder.  

And I had to ask a policeman to shackle him in the front.  Because I thought he had a dislocated or an injured shoulder or you know to the cart or something, so we still have to maintain the care of that patient.  And then I pulled out my restraint and seclusion documentation and again, I said on here, then I'm just using it to monitor the patient for safety reasons and that the handcuffs or shackles don't constitute restrained, according to our policy and accreditation of CNS.

So, again I still want to make sure they didn't get too tired or causing lesions or whatever and then restraints don't include prescription prescribed orthopedic devices, so they've got a cast on and they've got a double shunt dressing on.  Or they've got a burn dressing on their right leg or they had brain surgery and they have a protective helmet.  CNS also creates an exception for our patients that have a seizure history, so if we're ordering seizure precautions and ours used to be these green, they were one long one-piece forms with 2 pieces of Velcro and they would have you have to have both side rails up for them to connect to it, so again padded side rails you have to put all four side rails up that's an exception.

And then this is an important one.  A lot of our, especially our ICUs and CCUs and to have these symptoms.  CNS has 14 hospital-acquired conditions in which there is no additional payment, including pressure alters for Medicare patients, though.  We have those air mattress is that go up and down or whatever and you can put out all four side rails up and you don't need to have an order for that and the thinking was that when the air goes up and down if you don't have the rails on it, they can slide right out in some of those are pretty slippery.  A little bit.  I mean, we put a sheet on it, obviously, but that is an exception.  And so, I mentioned that if I have to hold somebody down for medical reasons, that's an exception to the rule.

So, this child is having an LP, I'm going to hold that child, this child is having an IV because we think he has an infection and we need to start antibiotics.  So, if you're holding somebody down for medical reasons that is not a restraint.

And then those narrow carts that we see in places like the emergency department they usually have one solid rail if you don't pull them up they will fall out of the bed because there's so narrow that has always been an exception.

And if they have an IV in and then you can pull it an IV board on function don't tie it down.  Somebody asked me the other day when we put these IV boards on their elbows and I'm like no that's a restraint.

If you had an IV in a cubital area and you had one IV board on that would be okay.  But you can't put them on both arms and you can't, if you have them on, you can’t tie them down and then postural support so I'm going to the operating room today.  And I'm having knee surgery and they have my knee suspended out that is not a restraint.  That's a postural support or I go to radiology for an MRI and they have my knee MRI’d in this machine.

On slide number 70, again, if I hold a child down to give them a shot their vaccine or whatever that's not a restraint, but now if I'm holding a child down to force medications because they're violent self-destructive than again that would be a restraint...............

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