Ordering Restraints

[dimitjm1]

Hi all,

 

I have been working as a PA on the trauma service at a level one trauma center for the past 1.5 years. In our hospital, it is common practice to restrain most patients on the ventilator for protection of the airway, as well as to restrain any patients who pose harm to themselves or others. On our service, many of our patients go through DTs and become combative. We also have some brain injured patients who are impulsive and combative. So, restraints often need to be ordered on our patients. This has never been a problem for me until recently. The order set in our electronic orders has recently been changed and restraints must be ordered every day by a "licensed independent provider". As a PA, I am unable to enter these orders. I found the following document from the AAPA when doing a little research: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Reference_Material&Template=/CM/ContentDisplay.cfm&ContentID=17070. However, hospital administration says that the Joint Commision does not allow PAs to order restraints. Do those of you who practice in the hospital setting order restraints on your patients or is it not allowed by your state or institution? I have found no state law for Ohio (where I practice) which states PAs cannot order restraints.

[rcdavis]

http://books.google.com/books?id=f_HYjDUArkMC&lpg=PA81&ots=vzRk5cG1_y&dq=joint%20commission%20standards%20on%20ordering%20restraints&pg=PA81#v=onepage&q&f=false

 

I thought that we'd solved this problem i n the past.. but apparently not. the above link from JACHO seems pretty specific about Independently Licensed Practitioners, which they define as any practitioner not normally requiring supervision.

 

Another one lost to the NP in a lot of states.

 

I am hoping David Carpenter (coloradoPA) or one of the policy wonks can tell me differently, and that the AAPA did address this as I seem to recall.. otherwisde, i think you are screwed and will have to put it in as a verbal and get the SP to sign

[EMEDPA]

our hospital form says md/do/pa/np. I order restraints all the time. my state has a specific law that says a pa may sign anything their sp can.

[coloradopa]

Try this:

http://www.saaapa.aapa.org/advocacy-and-practice-resources/practice-resources/hospital-practice/570

From 2009.

 

Basically the hospital is interpreting the word physician incorrectly. One of the ways that Medicare uses the word physician is to describe any medical provider. This includes PAs, NPs, CNM and CNS in states where they are APN. If you are getting hassled about this call Michael Powe at AAPA.

 

Here is the definition of LIP from JC by way of AAPA:

From the Comprehensive Accreditation Manual for Hospitals (CAMH) Glossary:

 

• Licensed independent practitioner:
  

Any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. When standards reference the term licensed independent practitioner, this language is not to be construed to limit the authority of a licensed independent practitioner to delegate tasks to other qualified health care personnel (for example, physician assistants and advanced practice registered nurses) to the extent authorized by state law or a state's regulatory mechanism or federal guidelines and organizational policy. [emphasis added]

CAMH Refreshed Core, January 2010, GL-16.

 

• Physician assistant:
  

An individual who practices medicine with supervision by licensed physicians, providing clients with services ranging from primary medicine to specialized surgical care. The scope of practice is determined by state law, the supervising physician's delegation of responsibilities, the individual's education and experience, and the specialty and setting in which the individual works. When standards reference the term "licensed independent practitioner," this language is not to be construed to limit the authority of a licensed independent practitioner to delegate tasks to other qualified health care personnel (for example, physician assistants and advanced practice registered nurses) to the extent authorized by state law or a state's regulatory mechanism or federal guidelines and organizational policy. [emphasis added]

CAMH Refreshed Core, January 2010, GL-24.

[crieman]

I was going to post on this today myself!

Our hospital has signs up everywhere saying that the only people who can sign restraint orders are NP's and MD/DO and specifically says no PA's may sign. While I don't mind not having to sign another sheet of paper, it is a blow to our profession. I will bring as much info as I can to our hospital administration to fix this issue. Thanks!

[Contrarian]

Pssst...........

 

 

[TABLE]

[TR]

[TD]WAC 246-918-140

 

[/TD]

[TD]No agency filings affecting this section since 2003

[/TD]

[/TR]

[TR]

[TD=colspan: 2]Certified physician assistants.

 

[/TD]

[/TR]

[/TABLE]

 

(1) A certified physician assistant may perform only those services as outlined in the standardized procedures reference and guidelines established by the commission. If said assistant is being trained to perform additional procedures beyond those established by the commission, the training must be carried out under the direct, personal supervision of the sponsoring physician or a qualified person mutually agreed upon by the sponsoring physician and the certified physician assistant. Requests for approval of newly acquired skills shall be submitted to the commission and may be granted by a reviewing commission member or at any regular meeting of the commission.

 

(2) A certified physician assistant may sign and attest to any document that might ordinarily be signed by a licensed physician, to include, but not limited to such things as birth and death certificates.

 

(3) It shall be the responsibility of the certified physician assistant and the sponsoring physician to ensure that appropriate consultation and review of work are provided.

 

(4) In the temporary absence of the sponsoring physician, the consultation and review of work shall be provided by a designated alternate sponsor(s).

 

(5) The certified physician assistant must, at all times when meeting or treating patients, wear a badge identifying him or her as a certified physician assistant.

 

(6) No certified physician assistant may be presented in any manner which would tend to mislead the public as to his or her title.

 

[emphasis added]

 

 

[klb48]

Can't sign orders for restraints at the hospital I'm at in Philadephia....but I could when I was in Massachusetts.

[dimitjm1]

Thanks for the replies. @rcdavis: interestingly, I can't even put in a verbal order from the physician for restraints (which even an RN is able to do). I have had this issue in the past with other orders and am continuing to fight the good fight for myself and other/future PAs at this hospital. I am one of very few PAs working outside the ED at this hospital. We have many more NPs than PAs, and the number of PAs is just recently increasing at this hospital, so I am constantly fighting for expanded privileges. Luckily for me, I have a supervising physician who is always willing and ready to advocate for PAs.

[crieman]

The head of this committee in our hospital was an NP.... I was assured that had nothing to do with it

[HopefulPA]

In MI midlevels can ONLY order initial restraints for pt saftey that must be co-signed by the Attending. However renewal of restraints (every 24H) can ONLY be done by a doctor.

[khbpac]

I've been in acute care inpt psyh for 12 years. I'm am allowed to order behavioral restraints, physical or chemical, upon my order, w/o calling the doc on call. The law in my state allows this as a delegated act as long at the MD signs to attest your knowledge and compentence. We've been through two JACO's since I've been here w/o issue. Check with state law, as ours is specific. But in the big picture, at 0300 I'm going to protect my staff and other patients.

[khbpac]

I truly feel your pain on the NP thing