Reflective Journal Due April 26th

This week I learned about how to care for a patient who needs to be physically restrained. We were presented with the following case study and asked several questions about what we would do after the situation and what we would do in the future to prevent similar situations.

"A 27 year old male patient was brought to the emergency department (ED) by paramedics.  The Patient was intoxicated, agitated and aggressive. The patient was a frequent flyer in the ED. The patient's behavior limited the RN and ED staff from completing a comprehensive initial assessment. For the patient's safety. Four point physical restraints were orders by the ED Physician.  The RN requested that ED security apply the restraints, in accordance with hospital policy. Policy dictated that security preform a check of the patient for contraband.

The RN assigned the patient to a quiet seclusion room to decrease stimulation.  The hope was to allow the patient to sleep and clam the patient. Per protocol the RN assigned to care for the patient preformed monitoring and assessment checks every 15 minutes. The RN missed one check due to a critically ill patient having complications.  The RN documented the missed check along with all the completed checks in the patient's medical record.

Shortly after the last documented 15 minute patient check, the patient was resting and appeared more comfortable in the four pint restraints, the patient attempted to free himself from restraints by burning the restraints with a cigarette lighter.  The linen on the gurney caught fire, resulting in 2nd, 3rd and 4th degree burns to 25% of the patient's body. Both hands were burned, with the loss of two finger on one of the hands.  The patient required multiple surgeries and was left permanently disabled.  The source of the cigarette lighter remains undetermined. (Modified from Nurses Service Organization)."

These are the ideas I had: 

• I would interview the staff on shift that night, each individually, to investigate further. Who went in to check on the patient? Did any of the staff see anyone enter the room? Did the nurse or anyone else watch the security guards do a contraband search of the patient? Did the nurses see anything suspicious, etc. I would ask staff what they thought would help to avoid these situations in the future.
• I would interview the patient to see if he had visitors and who entered his room that night. I would ask if he was searched for items and if the security guards had him empty his pockets. I would ask where he got the lighter, etc.
• I would ask the hospital what their protocol is for such situations and how they want to prevent similar situations in the future.

And to prevent future events: 

• Conduct contraband search in compliance with facility policy to ensure the safety of patients at risk of injuring themselves or others. I would make sure there is at least 1 other witness watching and conducting the contraband search to ensure all items are found.
• Maintain restrained patients in a controlled environment to facilitate
• quiet, calm surroundings for the patient and to prevent contact with non-staff who may introduce contraband or unsafe items to the patient.
• Perform frequent monitoring and clinical assessment of restrained patients or those who are otherwise deemed unstable and/or at risk for injury to themselves or others in accordance with the patient’s condition, patient care orders, state regulations and facility policies and protocol.
• Document all patient monitoring, assessment and clinical findings.
• Document any variation in patient monitoring and assessment protocoland include the assessment findings upon resumption of the monitoring and clinical assessment protocol.
• If assigned nurse will be unavailable, have that nurse assign another to nurse to check on, assess patient, and document that they have done so.

After reading my teams responses, I learned a lot more about what should have been done to prevent the event: 

• If the patient is cooperative, we would undress the patient and have them put on a gown, putting all their belongings in a bag. If the patient is not cooperative, then restrain them and take them their clothing off when they're restrained. The bag would be placed out of reach of the patient.
• The patient would be put on a 1:1 (depending upon the situation, with a CCT or a security guard)
• The physician would be notified and an official order would be put in by the physician and the physician would come assess the patient
• The physician would blue slip the patient
• Fire retardant material (linens, gowns, etc.) would be available
• If a check will be missed, the nurse needs to delegate it to another to ensure continuity of care. The change needs to be documented.

After this assignment, I feel a lot more comfortable about what I should do in these situations. I've never come across a situation where I needed to physically restrain a patient; I felt out of my element answering this question, but was especially grateful for one of my team member's comments as she is an ER nurse and has experienced similar situations first hand.