Patient Safety Update
NEW OE Prompts Renewal of Restraint Orders
Information Systems upgraded BWH’s Order Entry (OE) to include prompts for physicians and nurse practitioners to review restraint orders and renew the order if indicated. This is an effort to improve patient safety and to better support timely orders and renewals for the use of restraints on inpatient units. The upgrade occurred the first week in November.
Restraints ordered for inpatients for medical or surgical reasons, or non-primary behavioral issues, remain effective for 24 hours. With the OE upgrades, the licensed practitioner who ordered the restraint will be prompted at the 12th hour of the order to evaluate whether to renew or discontinue the restraint.
Restraints ordered for psychological reasons or behavior management remain effective for four-hour intervals. However, with the changes, OE will prompt the ordering physician or NP to evaluate the order at the second hour to either rewrite the order or discontinue it.
With both behavioral and non-behavioral restraints, it is the responsibility of the ordering clinician to evaluate the patient’s need for continued restraint from the bedside at the time of the OE prompt. Also, physicians and NPs should consult with nursing staff during rounds and when evaluating whether or not to renew or discontinue a restraint order and to discuss alternatives. Unit staff will be able to see when the order is up for renewal on Pod Monitor in the clinical areas.
When a restraint comes up for renewal the word “renewals” or the letter “R,” depending on how many other items are shown, will be displayed in the “Order Status” column next to the patient’s name on the pod monitor. Providers will receive the reminder when they open the order entry screen for that patient.
“We have a responsibility to our patients to keep them safe and comfortable, and it’s becoming less about restraints and more about an interdisciplinary approach to improve quality of care,” said Colleen Crumlish, MD, who co-chairs BWH’s delirium task force with Monique Mitchell, APRN BC, program manager of the Psychiatric Nursing Resource Service.
BWH has made strides in the past two years to transition from the use of restraints to alternative techniques, and much of that work has been shouldered by staff nurses. Prevalence rates for restraint use have decreased significantly in the last two years as alternatives to restraints, such as diversionary activities, are employed more regularly.
But when it comes to use of restraints, BWH remains below hospital compliance goals and Joint Commission requirements. When a nurse initiates a restraint, the patient’s physician or NP must evaluate that patient within an hour. According to recent chart reviews, physician restraint evaluation within an hour occurs at a rate of 68 percent, well below the hospital’s 90 percent goal, a Joint Commission requirement.
The rate for evaluations for renewal or discontinuance at the half-way point of the initial order is a little higher at 75 percent, but still below the 90 percent compliance mark.