Behavioral Health Issues — Restraints — Clinical Pathway: Emergency

Behavioral Health Issues Clinical Pathway — Emergency Department

Manual Holds or Restraints: Behavioral Health Code

General Considerations

  • Restraints should be a last-resort intervention, used when all de-escalation strategies have failed, and the child is at risk to self or others
  • Keep in mind many children have a history of trauma
  • Treat a restraint event as a Behavioral Health Code, similar to medical codes with clear role definitions and communication strategies
  • Prepare for a staged approach as other team members arrive
  • Any team member who notices potential triggers should raise awareness to the team, including Charge RNs, FLOCs, and Social Work
  • The team should debrief after each restraint event

Staff Roles in Restraint Response

The Psych Tech, Bedside RN and Attending/FLOC determine need for restraints.

Role Responsibilities/Actions
Bedside RN
  • Identify 3 CPI-trained team members
  • Notifies Charge RN and FLOC
  • Medication preparation
Psych Tech
  • Communication with child
  • Performs CPI-hold and directs other CPI members
FLOC
  • Listens to summary statement of recent events
  • Provides summary of medical concerns
  • Assesses child in room when safe
  • Orders PRN medications and restraints
Charge RN
  • Partner with FLOC to organize BH Code process
  • Ensure bedside BH Code Cart is accessible
  • Ensure RN documentation
Security
  • Reviews case with code leads
  • Swaps out with local team members to provide CPI holds
  • Activates Violent Restraint Rapid Response Team when needed

Behavioral Health Code Process

Initial Response — Local Team diagram Security Arrives diagram All Team Members, Ideal Response diagram

Behavioral Health Code Carts

Contents in ED
Drawer 1 Nitrile gloves, masks w/face shields
Drawer 2 Kevlar sleeves, Kevlar gloves, TAT restraints
Drawer 3 Isolation gowns
Drawer 4 Laminated job aids and tip sheets related to restraint application and documentation

Restraints

Manual Physical Holding Holding an agitated BH child and restricting their freedom of movement to deliver an IM medication or to move to a restraint device
Physical or Mechanical Device
  • Twice-as-Tough Cuffs (TATs), No-Nos, Peek-a-Boo/Posey Mitts, Limb Holders
  • Any device can be used for either violent or nonviolent restraint depending on the intent of use and the size/safety needs of the child.

Behavioral Health Restraint Orders, Documentation

Treat a response for violent restraint the same as trauma/resuscitation response.

Violent Restraint FLOC Actions
  • Use ED BH Epic Order Set
  • Initial Restraint Order
    • Place initial order before, during or immediately after restraint placement
  • Subsequent Restraint Orders
    • Timing is based on restraint initiation time, not the time of initial order
    • Age ≤ 8 yrs: new restraint order required hourly
    • Age > 9 yrs: new restraint order required every 2 hrs
  • Safety Observation Order
    • Assure order placed
    • Child with violent restraints must have visual and arm's length observation
  • Evaluation
    • Perform face-to-face evaluation of child as soon as possible, must be within 1 hr after the initiation
  • Document Evaluation in Epic
    • Use the .RESTRAINT note template
    • Do not alter template
  • Additional Evaluations
    • Another face-to-face evaluation is needed if continuous restraint for 24 hrs
Violent Restraint RN Actions
  • Assess/document physical and emotional well-being at least every 15 min using Epic Violent Restraint Flowsheet
    • Pulse
    • Respiratory rate
    • Circulation/skin integrity
    • Behaviors warranting the need to continue restraint
    • Physical comfort /proper application and fit of device (if applicable)
    • Observable child's behavior
  • Assess/document additional comfort needs at least every 2 hrs in Epic Violent Restraint Flowsheet
    • Range of motion
    • Nutrition and fluid needs
    • Toileting and hygiene needs