This article will cover the important distinctions between two different types of patient/client restraints in the health care setting. In the Hospital Accreditation Standards published by The Joint Commission, 2009, the important distinctions between behavioral restraints and seclusion and non-behavioral restraints and seclusion are spelled out.

When analyzing an elder abuse or medical malpractice case involving the potential negligent application of restraints, it is important for the attorney to understand the differences between the standards of care for behavioral restraints verses non-behavioral restraints.

To assume the more stringent standard of practice put forth by The Joint Commission for the use of behavioral restraints as the breech in appropriate care, when in fact the need for the restraint is defined as “non-behavioral”, could lead a plaintiff attorney and his/her client down a path that they could regretfully find defensible. It is best to be knowledgeable in these two categories when litigation brings your firm to the topic of restraints.

Critical Definitions

The Health Care Setting is defined as: a general hospital, a free standing psychiatric hospital, and residential skilled nursing facilities owned by the hospital.

Licensed Independent Practioner (LIP) is defined as: medical doctor, this includes a psychiatrist, nurse practioner (NP) and physician assistant (PA).

Licensed Professional is defined as: registered nurse, RN, and the licensed vocational nurse, LVN (LVN has a more limited scope of practice than the RN)

Unlicensed Staff is defined as: certified nursing assistant CNA, medical assistant, MA

Behavioral Restraint Criterion

Behavior which is irrational, uncooperative, aggressive, and/or violent which does not interfere with medical or surgical procedure or medical healing.

Non-Behavioral Restraint Criterion

Behavior which is disoriented, confused, agitated, irrational, uncooperative, aggressive, and /or violent and interferes with medical or surgical procedure or medical healing.

Note: It is the situation and not the type of setting which determines the reason for the restraint.

Acute Medical and Surgical (Non-psychiatric) Care Restraint Standards

ü  Require a doctor’s order (or other LIP).

ü  May be initiated by an RN in the absence of the doctor, after which, the RN must immediately notify the doctor of this change in condition.

ü  The doctor must provide a written or verbal order for this non-behavioral restraint within 12 hours of having restrained the patient.

ü  The doctor must examine and assess this patient within 24 hours of initiation of the restraints and at that time provide a written order in the patient’s medical record.

ü  If the restraint is used for longer than a 24 hour period, the doctor must reassess the patient and renew the order every 24 hours.

ü  A hospital patient in restraints is monitored at least every two hours or more frequently when using non-behavioral restraints.

For the Acute Medical and Surgical Care Standard, The Joint Commission leaves the assessment, monitoring, and care of the patient in restraints up to the facility’s policies and procedures. The doctor must follow the hospital policies and/or provide good rational for straying from the policies.

Behavioral Health Care Restraint and Seclusion Standards

Behavioral Restraints and Seclusion Standards are more stringent.

ü  Require a doctor’s order (or other LIP)

ü  Deemed Status: if the hospital uses deemed status for accreditation (that is, Joint Commission has been granted deemed status to accredit by the Centers for Medicare and Medicaid Services, CMS), then the doctor or other LIP must arrive to evaluate the patient who is placed in behavioral restraints within one hour of application. (Assuming they were applied by the RN.)

ü  If deemed status is not used, then the doctor has a 4 hour window to arrive and evaluate the patient.

ü  The doctor must renew/reorder the use of restraints every 4 hours and the doctor must evaluate the patient in person every 8 hours while in restraint.

ü  The doctor must also evaluate the patient prior to discharge if the behavioral restraint order has not yet expired (a 24 hour expiry time) to assure safe discharge. With behavioral issues we must be certain that any follow up support and care is accounted for.

ü  PC.03.03.23 (The Joint Commission) requires the evaluation of the patient in restraint by the staff every 15 minutes while in behavioral restraints. The patient is evaluated for injury due to and/or at the site of the restraints, nutrition and hydration needs, circulation and muscle/skeletal needs, vital signs, hygiene and elimination needs, physical and psychological status and comfort needs, and the patient’s potential readiness to be discontinued from the restraints.

Behavioral restraints may not be written as standing orders or “prn” (as needed orders) but must be addressed in real time on an individual basis

For persons under 18 years of age the standards are different and require the more frequent attention of both doctors and health care staff. This is true for both types of restraints (behavioral and non-behavioral.)

When the patient/client requires ongoing restraint, standards involving the facilities clinical leaders are required and also spelled out by The Joint Commission.

Side Rails

Here is what The Joint Commission has to say,

“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).”

Reference: This entire article was gleaned from once source:

2009 Hospital Accreditation Standards (HAS), Joint Commission Resources, 2008, pp 279-302