Clinical Practice Guideline: One Hour Face to Face Assessment

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Clinical Practice Guideline One Hour Face to
Face Assessment

• Marlene Nadler-Moodie
• MSN, APRN, BC, CNS
• Clinical Nurse Specialist

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Introductory comments

• Future goal is a restraint-free environment
• What this presentation is and is not

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Evaluation Includes (CMS rule)

• The patients immediate situation
• The patients reaction to the intervention
• The patients medical and behavioral condition
  and
• The need to continue or terminate the restraint
  or seclusion.

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Four Key Elements of Evaluation

• 1) Physical risks of loss of life.
• 2) Physical dangers and discomforts.
• 3) Psychological State Mental Status.
• 4) Legal and Ethical Considerations.

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1) Physical Risks of Loss of Life

• Restraint Asphyxia
• Compromised respirations cause hypoxia
• Choking from positional airway compromise
• Aspiration potential from positioning, excess
  salivation
• Airway and chest obstruction due to positioning
  and/or pressure
• Obstruction of the mouth and nose

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Physical Risks of Loss of Life-2

• Agitated Delirium/Acute Excited State
• Combination of agitation, aggression and
  hyperpyrexia
• Cocaine intoxication
• Adrenal catecholamine rush

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Physical Risks of Loss of Life-3

• Cardiac Complications
• Cardiac compromised condition
• Arrhythmias
• Catecholamine release is followed by epinephrine
  and norepinephrine output
• Stress and exertion
• Psychopharmacological component
• Q-T Prolongation
• Cardiac Collapse
• Physical trauma

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Warning of Cardiopulmonary Arrest

• Cessation of the struggle against the restraints
  and shallow or labored breathing

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Comparative risks related to positioning
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2) Physical Dangers Discomforts

• Observe total physical positioning and condition
• Mechanical restraint checks
• Potential for laceration, bruising
• Body Position
• Potential for strangulation
• Clothing and bedclothes
• As above

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Physical Dangers Discomfort-2

• Obesity-high risk associated with
• Multiple cases have been identified as having
  negative outcomes
• Nerve Damage
• Secondary to positioning and body/restraint
  applications
• Head Trauma
• Either self induced or sustained from others
• Pressure Ulcers
• Associated with prolonged restraint application

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General Medical Condition

• Specific to this patient
• Consider ANY and ALL medical problems in the
  context of the restraint episode and the
  proceeding behavioral emergency
• Vital Signs as soon as possible
• Review history and physical
• Current laboratory values

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Environmental observations

• Room temperature
• Safety hazards
• Seclusion
• Room check

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3) Psychological State Mental Status

• Observation and Assessment
• Condition prohibiting interview-observation is
  used
• Possible formal mental status via interview?
• Based on patients condition
• Return at a later time
• Comparative to previous and future

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Communicating with the Team

• Ensure safety of staff
• Physical
• Emotional
• Discuss the events
• Proceeding the restraint
• During the restraint

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Discontinuation

• Consider earliest termination
• Stability of the patient
• Criteria for release
• Debrief potential

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4) Legal and Ethical Considerations

• Current laws, regulatory, facility policy
• CMS, Department of Health Regulations
• JCAHO
• Policies and Procedures
• Best Practices

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Competency Demonstration

• RNs may now perform the One Hour Face to Face
  Assessment of a Patient in Restraints for a
  Behavioral Emergency
• The following are suggestions for specific
  verification methods for the competencies which
  are needed to perform the evaluation.

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Competency Demonstration for One Hour Face to
Face Competency Statement
Verification Methods

• Successfully demonstrates ability to assess for
  the need for basic life support (BLS)
• Successfully demonstrates ability to perform
  cardio-pulmonary resusitation (CPR)

• Current BLS (or higher) Certification
• ____________
• (Expiration Date)

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Competency Statement
Verification Methods

• Demonstrates ability to assess a variety of
  potential physical problems related to patients
  in restraints.
• Demonstrates correct principles related to the
  safe application of restraints.

• Passes Quiz
• Completion of 8 or 16 hour course Pro-Act, CPI,
  in house or other____________
• completion date

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Competency Statement
Verification Methods

• Applies critical thinking skills to assessing
  mental status and the psychological state of a
  patient in restraints.

• Exemplar
• Case Review

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Competency Statement
Verification Methods

• Role models leadership skills working with and/or
  leading the team when the use of restraints is
  necessary.
• Identifies the earliest opportunity for
  discontinuation.

• Successful demonstration of skill observed by
  supervisor.
• Successful demonstration of skill, observed by
  supervisor.

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Competency Statement
Verification Metods

• Evidence of knowledge regarding regulations by
  outside agencies and facility policy and
  procedure.

• Passes Quiz

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Summation

• Good luck in your restraint reduction efforts!
• Remember its a journey, a culture change and
  doesnt happen immediately.
• Contact me at moodienurse_at_yahoo.com