EAST TEXAS
MEDICAL CENTER
Managing Behavioral Restraint or
Seclusion in the Hospital
Knowledge-Based Physician Training
Revised 2-13
Required Training

CMS Rule: 482.13(e)(11)
Physician and other LIP training requirements
must be specified in hospital policy. At a
minimum, physicians and other LIPs authorized
to order restraint or seclusion by hospital policy
in accordance with State law must have a
working knowledge of hospital policy regarding
the use of restraint or seclusion.
 Joint
Commission: PC.03.03.03
The hospital has written policies and
procedures that guide the use of
restraint and seclusion for behavioral
health purposes which include staff
competence and training
 Texas
Administrative Code:
25 TAC 415.257
Physicians authorized to give
orders for restraint or seclusion
must receive training and
demonstrate competency
DEFINITION OF RESTRAINT
Any manual method, physical or
mechanical device, material, or
equipment that immobilizes or
reduces the ability of a patient to
move his or her arms, legs, body, or
head freely
THREE TYPES OF
RESTRAINT
•MEDICAL
OR NON-BEHAVIORAL
•BEHAVIORAL
•FORENSIC
MEDICAL RESTRAINT
Examples:
Definition:

Any method of
holding or securing a
patient for the
purpose of conducting
tests, exams, or
procedures or to
protect the pt. from
falling out of bed or
to prevent injuring
themselves in some
type of activity









Orthopedic devices
Helmets
Surgical dressings
IV arm boards
Devices used to achieve
body alignment
Soft foam wrist or ankle
straps or hand mitts
Side rails (2) or crib rails
Safety belts
Physical escorts from
which the patient can
escape
FORENSIC RESTRAINT
 DEFINITION:
Application of handcuffs, ankle cuffs,
or belly chains by peace officers for
the purpose of security, detention, or
public safety; individuals in forensic
custody with these types of devices
must be maintained and monitored
by peace officers.
BEHAVIORAL RESTRAINT
 Any
method (physical, mechanical, or
chemical) of restricting a patient’s
freedom of movement (incl. seclusion),
physical activity, or normal access to his
or her body, and is not done as a part of
a medical-surgical condition or
procedure.
TYPES OF BEHAVIORAL
RESTRAINTS
 Physical
Hold (maximum of 15 min.)
 Mechanical
•Restraint Chair
•Restraint Net
 Seclusion
 Chemical (not used )
PHYSICAL HOLD RESTRAINT
The application of body pressure by
another person to the body of a
patient in such a way as to limit or
control movement of the whole or a
portion of a patient’s body. The
various techniques such as “physical
hold” or “take down” procedures are
considered forms of physical
restraint.
Bear Hug
Type of
Physical
Hold
MECHANICAL RESTRAINT
This is any device used to restrict the
movement of the whole or a portion
of a patient’s body. It can be in the
form of ankle or wrist straps, a body
net or a restraint chair.
Caution: Geri Chairs and Side rails (4) can
be considered a mechanical restraint if
the patient cannot control egress
Example
Of
Mechanical
Restraint
Adult
In the
Body Net
Restraint
RESTRAINT
CHAIR
Type of
Mechanical
Restraint
SECLUSION
Seclusion is the confinement of the
patient alone in a locked room or
alone in an identified area from
which egress is prevented. Patients
in seclusion must be monitored by a
trained staff member at all times.
Seclusion Room
at BHC
CHEMICAL RESTRAINT
Use of medication is considered a
chemical restraint when it is used as
a restriction to manage the patient’s
behavior or restrict the patient’s
freedom of movement and is not a
standard treatment or dosage for the
patient’s condition or diagnosis.
Chemical restraints are not used at
BHC.
CRITERIA FOR BEHAVIORAL
RESTRAINT
• All less restrictive measures were
attempted and failed
• No time to attempt less restrictive
measures
• Must be evidence of eminent danger
Definition of a
“Least Restrictive Measure”
This is a term that is used extensively
in mental health and in patient rights
issues. It simply means “the least
intrusive or restrictive service or
treatment that can effectively and
safely address the patient’s needs
and stated preferences”. All less
restrictive measures must be tried
and documented before a behavioral
restraint or seclusion is ordered.
EXAMPLES OF LESS
RESTRICTIVE MEASURES

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Making a contract for safe behavior
Helping the patient to identify the stressor
causing the behavior
Redirecting the patient’s attention by suggesting
another activity
Reducing the noise level and light intensity
Allowing the patient to speak to a patient
advocate, minister, supervisor, or family
Deep breathing exercise
Negotiating a solution based on options available
Offering medications to assist in reducing
agitation/anxiety
EMINENT DANGER
There must be evidence that there is
“eminent” danger to the patient or
others in order to justify the need for
a behavioral restraint or seclusion.
Threatening to do something is not
acceptable. Patients must be in the
“act of” or “process of attempting” to
do something that could result in
injury or damage.
TIME LIMITS FOR RESTRAINT
AND SECLUSION BY AGE
•
•
•
•
•
Physical Hold: 15 minutes for all
ages (child-adult)
8 yrs. of age and younger: 1 hour
9-17 yrs. of age: 2 hours
18 yrs. and older: 4 hours
Patient must be released as soon as
the risk of harm to self or others no
longer exists.
MONITORING REQUIREMENTS EVERY
15 MINUTES WHILE IN RESTRAINT OR
SECLUSION
Circulation
 Respiration Rate
 Heart Rate
 Blood Pressure
 Oxygen Saturation
 Behaviors
 Food/Fluid Needs
 Elimination Offered

ROM Provided
 Hygiene Needs Met
 Physical Comfort
Provided
 Psychological
Support Offered
 Signs of Injury
 Evaluated for
Release

PHYSICAN REQUIREMENTS
Face-to-Face Evaluation of Patient within
one hour of the onset of the R/S
 Completion the Physician Order Set for a
behavioral restraint
 Completion of Physician Progress Note for
a behavioral restraint
 Notification of attending physician if
physician ordering the R/S is not the
attending

Physician
Order Set For
Behavioral
Restraint
(located in red
folder with all
other physician
orders)
Physician
Progress
Note for a
Behavioral
Restraint or
Seclusion.
CONGRATULATIONS!
You have completed the physician
Training module for Restraint and Seclusion.
Please print the certificate below and sign
and date as indicated. Submit this document
to the medical staff office to be filed in your record.
Thank you.
Certificate of Training
RESTRAINT AND SECLUSION
Physician Name______________________ Date:________
Print
Physician Signature:_____________________________