Mercy-Orders-DEM-Restraint.txt Mercy Hospital of Pittsburgh DEM Restraint Orders Change List The Owner of this Standing Order is Bruce MacLeod, M.D., Chair, DEM. Suggestions for changes should be emailed to Dr. MacLeod's Delegate for this Standing Order: Keith Conover, M.D. See also Mercy-Orders-Template.txt and Mercy-Orders-DEM-Signature- Template.txt for additional notes of changes that apply to all orders. Proposed changes to version 2.1 (numbered 2.0f) - Had determined originally that simply giving medication for anxiolysis, while informally termed "sedation" by ED personnel, is not truly sedation as we would use for a shoulder reduction or similar procedure, and does not require either moderate sedation paperwork, OR restraint orders. However, if the patient has to be held down to administer anxiolysis (see below), this DOES require restraint orders. - Had thought to use the DEM restraint orders in the ERC (psych ER) but as the psych ER is much more like an inpatient psych unit, decided to use the standard inpatient restraint sticker in the ERC. Therefore, the DEM restraint orders are for use only in the DEM proper. - Had thought to avoid use of restraint orders for elopment risk (see below) but more recent opinions recommend the use of restraint orders in such situations. Suspect more discussion on this issue will ensue. - Having two complete sets of the order on a single page might have saved a bit of paper, but it caused enough confusion (people are used to signing at the bottom, not in the middle, for example) that we decided to use a full single page for each set of restraint orders. - Per the new regulations, changed "emergent behavioral management" to "violent/self destructive behavior" - Per the new regulations, changed "other" (under reasons for restraint) to "Other (e.g., 'held for medication')" - changed the dual signature box at the bottom as per Mercy-Orders-DEM-Signature-Template.txt - Considered using the standard inpatient restraint sticker, as it was improved (see New-Restraint-Sticker.pdf) but still doesn't meet our needs in a few ways: 1. It was determined at the October 2006 DEM meeting that restraint orders in the DEM will require a space for noting the reason for the restraints in more detail than that available on the standard restraint sticker. This is for legal and billing reasons. 2. The standard wording "medical/post-surgical" refers to where patients are in the hospital more than the specific problems they have leading to the need for restraint, and the two examples "pulling at tubes" and "unable to follow directions" seem confusing to many in the DEM, and this has resulted in poor compliance when we used the standard stickers in the past. We therefore added the wording "Intoxication, delirium, dementia" which are how emergency physicians and nurses view the need for restraints, but have retained the "medical/post-surgical" and "pulling at tubes" and "unable to follow directions" to keep the wording close to that of the inpatient sticker. 3. There are several things on the inpatient sticker that make no sense in the ED and should be eliminated or changed to make the orders cleaner and less prone to misinterpretation: a. We do not do verbal orders in the ED, as physicians are always present in the ED. b. Some restraints (e.g., padded hand mitts, geri chairs) are not available in the ED. Full side rails, due to the height of the ED stretchers, are considered a safety measure and not a restraint. c. Seclusion is not used in the ED as a restraint. However, both Mercy procedures and policies and Federal case law require medical personnel, including nurses, who identify a patient a suicidal or otherwise a danger to self or others, to ask Security to restrain the person. This does not require a physician order, and indeed waiting for a physician order will open the nurse or other medical personnel to the liability up to and including wrongful death. However, once this has been brought to the attention of the physician, the physician should indicate on restraint orders that the patient must be restrained from leaving or committing suicide. However, this is not "seclusion" in the sense of a seclusion room on a psych ward, and calling it "seclusion" (in actual testing) only confused ED personnel. Calling this "Security watch" since this is done by Security in the ED (except for boarded admitted patients who have a sitter in concert with inpatient orders) makes sense and will result in better compliance. ******* Previous and current version is (1.0--actually no number on it), dated 8/21/05