Can you still use med/surg standards?
October 1, 2000 3 minutes read
Can you still use med/surg standards?
Previously, the Joint Commission on Accreditation of Healthcare Organizations allowed medical/surgical standards to be used for restraint in the ED, says Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a health care professional consulting firm in Marblehead, MA, specializing in regulatory compliance.
"The ED was allowed to treat restraint the same way as it was treated on the regular nursing units," she says. "That’s no longer the case as of Jan. 1, 2001."
Now, as with the Health Care Financing Administration (HCFA), the more stringent behavioral restraint requirement applies wherever the patient happens to be if the patients are aggressive, combative, or at risk of harming themselves or others, says Catalano. "Thus, in the ED, if a patient is at risk of harming anyone, the behavioral standards apply and must be followed," she says. "As of Jan. 1, 2001, the medical/surgical restraint standards no longer apply in the ED for this type of patient."
The new standards require that behavioral health standards be used for those patients, says Catalano. "Now, a patient who is combative, aggressive, unmanageable, or a danger to himself, herself, or others, will be placed in restraint under the behavioral health standards," she explains.
Previously, Joint Commission allowed nurses to initiate restraint and get an order after the fact, Catalano explains. "Under the old standard, the physician had to be notified within 12 hours of initiation of restraint, and the order had to be signed by the physician within 24 hours," she says.
Now, HCFA and Joint Commission say that a patient who is aggressive, combative, or a danger to himself, herself, or others will require behavioral restraint, says Catalano. "This means that a trained individual must assess the patient and evaluate the need for restraint."
Under the Joint Commission and HCFA standards, it doesn’t matter where the behavior occurs, says Catalano. "Any patient behavior that is violent and aggressive and causes the patient to be a danger to himself, herself, or others is considered behavioral. So regardless of where the behavior occurs, restraint use will be treated as behavioral," she says.
Formerly, "behavioral health" referred to a place, a psychiatric unit, a psychiatric hospital, says Ann Kobs, president and CEO of Type 1 Solutions, a Fort Myers, FL-based compliance consulting firm specializing in preparation for accreditation surveys. "Now, in concert with the Patients Rights Act, the term refers to behavior, regardless of location," she says. "That is, behavior that endangers self or others."
The medical/surgical standards still can be used for patients who are not aggressive, combative, or dangerous to themselves or others, says Kobs. "Often, patients come in who are pleasantly confused. They may have no idea where they are, but they are not aggressive," she explains. "They forget what you tell them, for example, don’t get off this cart, and they try to get off and wander around."
Here are examples of when each standard should be used, from HCFA’s Hospital Interpretive Guidelines for Patient Rights:
• Behavioral management standard. A restraint or seclusion for behavior management is used only as an emergency measure and is reserved for those occasions when severely aggressive or destructive behavior places the patient or others in imminent danger. While different factors may precipitate that type of psychiatric, behavioral, and physical outburst for an individual patient, the need for rapid assessment and continuous monitoring is applicable in each case.
Example: A patient with Alzheimer’s disease has a catastrophic reaction where he/she becomes so agitated and aggressive that he/she physically attacks a staff member. The patient cannot be calmed by any other mechanisms, and the behavior presents a danger to him/herself, staff, and other patients.
• Medical and surgical care standard. Restraint used for acute medical and post-surgical care, and where the hospital wishes to restraint a patient to address the risk of a fall or to control wandering, falls under the medical and surgical care standard. This standard is used to restrain nonviolent, nonaggressive, otherwise cooperative patients.
Example: A patient diagnosed with Alzheimer’s disease has surgery for a fractured hip. Staff determine that it is necessary to immobilize the hip to prevent reinjury. The use of less restrictive alternatives have been evaluated or were unsuccessful.
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