policy - saskatoon health region · see shr policy consent/informed consent. violation of the...

of 29

POLICY

Number: 7311-60-012

Title: Least Restraint - Mechanical and

Environmental

Authorization

[ ] President and CEO

[X] Vice President, Finance and Corporate

Services

Source: Director, Nursing Professional Practice

and Education

Cross Index: 7311-30-007; 7311-50-002

Date Approved: October 19, 2009

Date Revised: June 12, 20141

Date Effective: July 18, 2014

Date Reaffirmed:

Scope: SHR & Affiliates

Any PRINTED version of this document is only accurate up to the date of printing. Saskatoon Health Region (SHR) cannot guarantee the

currency or accuracy of any printed policy. Always refer to the Policies and Procedures website for the most current versions of

documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part

of this document may be reproduced in any form for publication without permission of SHR.

OVERVIEW

Traditionally, restraints have been used with the best intentions to protect clients from harm. Research has

shown that restrained clients are eight times more likely to die than those who aren’t restrained

(Napierkowski, 2002). Using restraints has resulted in strangulation and can cause and exacerbate hazards

of immobility such as constipation, functional decline, and skin breakdown. Other hazards of restraint use

include incontinence, impaired circulation, loss of dignity and freedom, and worsening aggression and/or

confusion. Applying restraints does not help prevent falls or alleviate fall risks but rather may increase the

risk of falls and severity of injury from falls. SHR does not support the use of restraints to restrict a client from

coming out of his/her bed or chair. There may be circumstances when the temporary use of least restraints

will lead to a safer environment. These circumstances relate to clients who are at risk of harming themselves

or others, physically aggressive or imminently aggressive behavior, and where all alternative measures to

manage the client’s and staff’s safety have been exhausted.

SHR’s Least Restraint policy balances client and family centred care, the client’s rights and the safety of

others as a last resort temporary measure. Ethical principles of respect for autonomy, beneficence, justice

and maleficence are applied in the decision making process.

The principles of least restraint apply to Security Services.

This policy does not apply to use of restraints by law enforcement personnel.

At this time this policy does not address the use of chemical restraints. This will be incorporated at a later

date.

DEFINITIONS

Alternative to Restraint means an intervention that is used in place of or reduces the need for a restraint

device. Examples: bed/chair alarms, hip protectors, exit door alarms, therapeutic management

techniques (i.e. Gentle Persuasive Approach, Workplace Assessment Violence Education, Professional

Assault Response Training).

Client means an individual, patient, client or resident.

1 Editorial updates only Jan 2015

of 29

De-escalation means a complex range of skills designed to abort the assault cycle during the escalation

phase, including both verbal and non-verbal communication skills (NCCNSC, 2005).

An emergent situation means a situation where immediate action is necessary to prevent serious bodily

harm to the client or others.

Extended use means a least restraint is required for period of time greater than or equal to one week.

Least restraint means:

The physical, mechanical, or environmental means which are intended to prevent injury, manage

responsive behaviours or physical movements which could cause significant bodily harm to the

client or others.

Applying the least restrictive method to limit a client's freedom of movement or to immobilize the

client. This includes using a device or garment (mechanical least restraint), holding or bodily

maneuver (physical least restraint), or restriction of space (environmental least restraint) to physically

control, subdue, and/or calm a client who exhibits behaviour that presents a risk of harm to

themselves, others or property.

All alternative measures are to be exhausted before least restraint options are considered.

Physical Restraint means the direct application of physical holding techniques to a client that

involuntarily restricts his or her movement. This does not include briefly holding, without undue force,

a client in order to calm the client, or using redirection/holding techniques to escort the client safely

from one area to another.

Mechanical Restraint means any device, material, or equipment attached to or near a client which

cannot be easily removed by the client and involuntarily restricts the client’s freedom of movement

or normal access to his or her body.

devices used solely for the purpose of positioning or realigning are not considered a restraint

(i.e. trunk belt, front fastening seatbelt and/or braces).

A postural support/positioning device could be considered a restraint if the device limits,

restricts, controls and deprives the liberty and inhibits voluntary movement of the client.

NOTE: The INTENT of the device defines whether it is a restraint or not.

For example:

If a tray table is being used to assist someone with eating it is not a restraint. However, if the

tray table is being used to prevent someone from getting up and wandering it is considered

a restraint.

A side rail would be considered a restraint if the intent is to prevent the client from coming

out of their bed rather than being used for the purposes of positioning or accessing the bed

controls.

It is a restraint if the client is unable to unlock or remove it by him or herself or if they are

unable to request it to be removed. This includes locked tables on a gerichair if they are

used to restrain a client from freedom of movement, rather than as a positioning device.

It is not a restraint if you use a positioning device with the client’s permission. For example: if

you use a mechanical aid to assist in walking a client; use side rails with the client’s

permission; use chair wedges or other positioning devices.

Examples of postural support or positioning devices:

o Wheelchair with front opening seatbelt

o Safety belts with front openings

o Stretcher belts

o Transfer belts

o Lap top table

o Assistive bar, trapeze or pole

o Arm/foot boards for intravenous therapy

o Side rails and side rail covers

of 29

Environmental Restraint means any barrier or device that limits or controls the locomotion of an individual

and thereby confines an individual to a specific geographical area or location.

Examples of environmental restraints may include: lockable client room, half doors, restriction to a specific

area. This does not include a secured entrance to the unit or facility. Refer to Appendix D for approved

environmental restraints.

Postural support/positioning device means a device used to provide the client with a sense of security and

comfort when transporting a client or in an attempt to maintain proper body alignment and balance.

Proxy means a person who, pursuant The Healthcare Directives and Substitute Decision Maker’s Act, is

appointed in an advanced care directive that designates this person to make health care decisions for the

person in our care.

Restrain means to limit, restrict, control, and deprive of liberty and inhibit voluntary movement.

SHR Staff means employees, professional staff, practitioner staff and affiliate employees.

Substitute Decision Maker (SDM) means a person who, pursuant to The Health Care Directives and

Substitute Decision Makers Act, is entitled to make health care decisions on behalf of the client.

Team means the client/family/SDM/proxy, physician and nursing staff. Depending on the situation, other

members of the team may include occupational therapist, physical therapist, recreational therapist, social

worker, students and volunteers.

1. PURPOSE

The purpose of this policy is to:

1.1 Promote the practice of least restraint and a culture that is respectful of an individual’s rights.

1.2 Identify what a restraint is.

1.3 Facilitate safe and appropriate use of least restraints.

1.4 Minimize and reduce the use of restraints.

1.5 Assist staff, clients and family/SDM/proxy to understand their responsibilities and make

informed decisions regarding the use of least restraints.

2. PRINCIPLES

2.1 SHR adheres to the practice of “least restraint”. The establishment of a therapeutic

relationship between the care team and client and family/SDM/proxy is beneficial for

minimizing restraint use; maximizing client independence; improving quality of life; minimizing

risk of injury; and preserving client self-worth and dignity.

2.1.1 The least restrictive form of the most appropriate restraint is used first. If this is

unsuccessful, progression from least to most restrictive restraint is implemented.

2.1.2 The restraint will be used for the least amount of time.

2.1.3 In an emergent situation refer to procedure 2.1.4.

2.2 SHR staff will provide a collaborative and supportive atmosphere for clients who require

restraints. An environment will be created that adheres to informed decision making in

regards to restraint use. All staff will be respectful of the choices that

clients/families/SDM/proxies make about restraint use and alternatives to restraints.

2.3 The decision to use restraints is made as a result of collaboration with members of the team.

2.4 Staff are encouraged to evaluate their beliefs, attitudes, and practices regarding the use of

restraints and place a high priority on client concerns and perspectives in the provision of

client centred care.

of 29

2.5 The policy will be applied with fairness and consistency throughout SHR.

3. POLICY

3.1 Least restraints are only used when all other possible alternative measures have proven

ineffective and the use of a restraint will result in a safer environment for the client, visitors

and staff. Preventative and alternative strategies should be used prior to least restraint

initiation in order to promote an environment that limits restraint use to only clinically

appropriate and sufficiently justified situations. Only after all alternatives have been tried

unsuccessfully, should restraints be considered.

3.2 When a restraint is indicated, the least restrictive restraint suitable to achieve the intended

outcome shall be used.

3.2.1 Least restraint use is an acceptable alternative for clients at risk of harming

themselves or others related to physically aggressive or imminently aggressive

behaviour.

3.2.2 Least restraint interventions will not be initiated or maintained arbitrarily as a substitute

for treatment, as punishment, for the convenience of staff or to prevent falls.

3.2.3 The use of any restraint is considered to be a temporary and unusual measure.

3.2.4 Restraint use shall be monitored, documented and evaluated (see procedure 2.8 for

required intervals).

3.2.5 Restraints must be removed at the earliest and safest opportunity.

3.2.6 Restraints must be used in a manner that allows for quick release in an emergency

situation.

3.3 Informed consent will be obtained from the client for the use of restraints. See SHR Policy

Consent/Informed Consent. Violation of the client’s rights may result in legal action against

the staff and/or their employer if restraints are used without informed consent.

3.3.1 If the client is unable to give informed consent the family/SDM/proxy will act on the

client’s behalf.

3.3.2 If consent is refused by the client/family/SDM/Proxy see procedure 2.3.

3.4 The following criteria need to be met for restraint usage to be implemented on a client

without their informed consent:

3.4.1 Involuntary status under Section 24 of the SK Mental Health Services Act (2004);

and/or

3.4.2 Under Section 16 of the Health Care Directives and Substitute Health Care decision

makers Act (2004); and/or

3.4.3 In the case of a client who has a Personal Guardian legally appointed under the

Adult Guardianship and Co-decision-making Act (2011); consent may be sought

from the guardian; and/or

3.4.4 The family/SDM/proxy shall be contacted by the health care team to inform them of

the need for restraint use in order to maintain the safety of the client/co-

clients/staff/visitors.

3.4.5 Environmentally restrained to a locked room in the ER while awaiting appropriate

psychiatric assessment and disposition under Sections 18 and 19 of the MHSA.

3.5 Restraints may be used in an emergent situation when there is inadequate time to complete

the least restraint use procedure (see Procedure 2.1.3 - Emergent Situations).

3.6 Documentation will include the assessment, decision to use and the rationale to restrain,

type of restraint used, ongoing monitoring and evaluation and the outcome of restraining.

3.7 Debriefing with the team will occur in a timely manner when a restraint has been applied

and discontinued, and/or as soon as possible following application of restraints in an

emergent event.

of 29

3.8 Initial and ongoing education regarding alternatives to least restraints and the appropriate

use of restraints will be provided to the team.

3.9 Restraints will be applied following manufacturer’s instructions and will be maintained as per

manufacturer’s recommendations.

3.10 The least restraint procedure does not apply for safety measures used only for the duration of

a procedure or test and shall be discussed with the client/family/SDM/proxy beforehand.

3.10.1 During transportation and completion of medical/surgical/diagnostic procedures.

Examples such as:

Medical - a pediatric swaddle wrap is necessary for suturing

Medical – side rails on a stretcher in the emergency room following medical

treatments as part of approved practice (i.e. sedation in conjunction with the

other required nursing interventions including close observation and SaO2

observation)

Surgical – limb least restraints are needed to maintain a sterile field while

performing surgery

Diagnostics – a least restraint may be required to ensure an accurate result of the

diagnostic test for proper diagnostics

Nursing -- Side rails used on stretchers or beds during transport of a client following

surgery or between ER and diagnostics or on transfer from one unit/room to

another

3.10.2 During motor vehicle transportation, clients must wear seatbelts and pediatric clients

must be properly restrained in a car seat with shoulder harness.

3.11 Given the developmental and cognitive stages that must be considered when working with

children and adults, temporarily restricting their activities to ensure their safety during their

care may be both necessary and appropriate: i.e. following surgery, an elderly client with

dementia makes attempts to remove his bandages, IV tubing, oxygen mask, and attempts

to get out of bed, which may result in increased pain, fear and risk of falls.

3.11.1 Age or developmentally appropriate protective interventions (i.e. stroller safety belts,

swing safety belts, high chair lap belts, raised crib rails and crib covers) that a safety

conscious child care provider outside a healthcare setting would utilize to protect an

infant, toddler, or preschool aged child would not be considered a restraint.

4. ROLES AND RESPONSIBILITIES

4.1 Most Responsible Physician (MRP), Nurse Practitioner RN(NP) or Resident

4.1.1 Collaborate and communicate with team members in relation to assessment and

decision to restrain.

4.1.2 Complete the Least Restraint Use Consent/Physician Order Form # 103694.

4.1.3 Collaborate with team members in the review and ongoing evaluation of the

restraint. Refer to Appendix A ‘Least Restraint Use Algorithm’.

4.2 Team

4.2.1 In collaboration with the client/family/SDM/proxy, any licensed team member can

obtain consent for the use of restraints.

4.2.1.1 Client/family/SDM/proxy work as part of the team to make appropriate and

informed choices and decisions related to least restraint use.

4.2.2 According to skills, knowledge and ability ensure that restraint usage is appropriate

and all other alternatives have been tried prior to the implementation of the least

restraint.

4.2.3 Perform ongoing monitoring and evaluation of the client.

4.3 Registered Nurse (RN), Registered Psychiatric Nurse (RPN), and Licensed Practical Nurse

(LPN) (in collaboration with the RN/RPN)

of 29

4.3.1 Collaboratively perform a comprehensive assessment of the client with the team

(including a description of behavior and the risks involved), identify alternative

interventions tried and the outcome, and document the decision to restrain.

4.3.2 Application of mechanical restraints: Other team members may apply or remove as

appropriate, if educated.

4.4 Security Services (where available)

4.4.1 Respond to a ‘Code White’.

4.4.2 Apply restraints at the direction of a physician or psychiatrist.

4.5 All staff

4.5.1 Maintain an awareness of the potential risks associated with the use of restraints. It is

the responsibility of all staff to familiarize themselves and comply with this policy and

procedure.

5. POLICY MANAGEMENT

The management of this policy including policy education, monitoring, implementation and

amendment is the responsibility of Director, Professional Nursing Practice and Education.

6. NON-COMPLIANCE/BREACH

Non-compliance with this policy will result in, at a minimum, a review of the incident. Non-

compliance may also result in disciplinary actions up to and including termination of employment

and/or privileges with SHR.

7. REFERENCES

Alberta Health Services. (2012). Restraint Policy Draft V-04. Alzheimer Society of Canada. (2007).

Restraints. Retrieved from http://www.alzheimer.ca/en/About-dementia/For-health-care-

professionals/Tough-issues

Capital Health. (2012). Policy CC65-031 Use of Rapid Physical Restraint on Acute Care Mental Health

In client Units. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx

Capital health (2007). Appendix C Learning Supplement for Least Restraint. Retrieved from

http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx

Capital Health. (2007). Interdisciplinary. Interdisciplinary Clinical Manual Policy & Procedure #CC-05-

030 Least Restraint. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx

Division of Developmental Disabilities. (2012). Policy 5.11-Restraints. Washington State Department of

Social &Health Services

Government of Saskatchewan. (2013). Regional Health Services Policy & Procedure manual 15.10

Restraints. Community Care Branch

Heartland Health Region. (2011). Policy # C01-39.01 Least Restraint. Heartland Health Region

Regina Qu’Appelle Health Region. (2008). Policy #1001-Adult Least Mechanical Restraint. Regina

Qu’Appelle Health Region

Registered Nurses Association of Ontario. (2012). Clinical best practice guidelines-Promoting safety:

alternative approaches to the use of restraints. Retrieved October 19, 2012 from

http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-

Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

http://www.alzheimer.ca/en/About-dementia/For-health-care-professionals/Tough-issues





http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

of 29

Saskatchewan Registered Nurses’Association. (2010). SRNA position Statement use of restraints in

client care. Saskatchewan Registered Nurses’ Association

The Hospital for Sick Children. (2008). Policy, Procedure & Guideline Least Restraint. The H

ospital for Sick Children

The Health Care Directives and Substitute Health Care Decision Makers Act, SK., 1997

The Adult Guardianship and Co-decision-making Act, 2011

of 29

PROCEDURE

Number: 7311-60-012

Title: Least Restraint – Mechanical and Environmental

Authorization

[ ] President and CEO

[X] Vice President, Finance and Corporate

Services

Source: Director, Nursing Professional Practice and

Education

Cross Index: 7311-30-007; 7311-50-002

Date Approved: October 19, 2009

Date Revised: June 12, 20141

Date Effective: July 18, 2014

Date Reaffirmed:

Scope: SHR & Affiliates

1. PURPOSE

The purpose of this procedure is to establish the process to facilitate safe and appropriate use of

least restraints.

2. PROCEDURE FOR MECHANICAL AND ENVIRONMENTAL LEAST RESTRAINTS

2.1 Assessment

2.1.1 Clients should be assessed by RN, RPN, or LPN (in collaboration with the RN/RPN) on

admission for the potential and/or the presence of predisposing and precipitating

factors that put the client at risk for the use of least restraints.

2.1.2 If the client/family/SDM/proxy requests a restraint and the client has been assessed

and the use of a restraint is not clinically indicated, the restraint will not be applied if

the risks outweigh the benefits.

2.1.3 Non Emergent Situations

2.1.3.1 The RN, RPN or LPN (in collaboration with the RN/RPN) performs a

comprehensive assessment of the client and their environment, including a

description of the behavior(s) and the risk(s) involved, alternative interventions

and the decision whether to restrain or not. Decisions will be based on this

assessment resulting in an individualized plan of care. Refer to:

Appendix A ‘Least Restraint Use Algorithm’

Appendix B ‘Alternatives to Restraint Use’

Appendix C ‘Algorithm for Use of a Client Attendant’ (where available)

2.1.3.2 Select the most appropriate least restraint based on the assessment. Refer to:

Appendix D ‘Approved Least Restraints’

Appendix E ‘Side Rail Pathway’ – for LTC only

2.1.3.3 Indications to restrain may include:

Alternative interventions not effective or not available.

Individual is at risk of harm to self or others

Plan of care to which client/family/SDM/proxy have consented

2.1.4 Emergent Situations:

2.1.4.1 Attempt to de-escalate the behavior if appropriate using violence

management training. (Refer to SHR Violence Management Policy).

2.1.4.2 A “Code White” will be called for extra support. Refer to site specific

Emergency Preparedness Plans.

1 Editorial updates only Jan 2015

of 29

2.1.4.3 The consent and physician order for the use of restraints must be obtained

within 12 hours.

2.1.4.4 The restraint should be used for the least amount of time.

2.1.4.5 Provide ongoing care, monitoring (2.8) and documentation (2.12) as outlined

in the sections mentioned.

2.1.4.6 Least restraint use will be reviewed/reordered at minimum every 24 hours or

sooner in emergency situations.

2.2 Obtain Informed and Written Consent (Refer to Appendix F)

2.2.1 Licensed staff, in collaboration with the client/family/SDM/proxy will obtain

consent.

2.2.2 Discuss the following with the client/family/SDM/proxy:

2.2.2.1 The reason for the restraint

2.3.2.2 Potential risks if restraint not used

2.3.2.3 Potential risks of restraint use

2.3.2.4 The intended outcome of using restraints

2.3.2.5 The type of restraint recommended

2.3.2.6 The duration of time the restraint will be used

2.3 Refusal of Consent

2.3.1 If the client/family/SDM/proxy does not consent to the use of restraints and the other

team members have determined that restraints are required for the client safety or

safety of others, the following will occur:

2.3.1.1 Document the refusal on the consent form

2.3.1.2 In an emergent situation apply appropriate least restraint as stated within the

procedure 2.14.

2.3.1.3 Provide ongoing monitoring of the client as per 2.8 below.

2.3.1.4 Continue to collaborate with the client/family/SDM/proxy for alternatives to

restraints, providing information to facilitate their understanding regarding the

rationale for and the types of restraints used.

2.4 Obtain Written Practitioner Orders

2.4.1 From the MRP, RN(NP) or Resident.

2.4.2 Pro re nata (PRN) orders for restraints will not be accepted.

2.4.3 A new order must be written every 24 hours for the first 7 days and at each review

point with extended use (refer to appendix H ‘Extended Restraint Use Algorithm’)

For those LTC homeswhere a MRP or RN(NP) is not physically present or available

to write a new order, a telephone or faxed order can be received from the MRP

or RN(NP).

2.4.4 A separate order must be written for mechanical and environmental restraint(s).

2.4.5 The written orders should specify:

The type(s) of restraint device

The duration of the restraint application

The reason for the restraint

2.5 Application of the Mechanical Restraint

2.5.1 The type of restraint used is based on the client assessment and physician order.

2.5.2 Refer to Appendix D ‘Approved Least Restraints’ for a list of SHR approved restraints

and manufacturers’ websites regarding correct application of the restraint. Apply

mechanical restraints according to manufacturer’s instructions and follow the Health

Canada and SHR safety alerts regarding restraint usage.

2.5.3 Restraints shall be used according to approved instruction and/or guidelines and

shall not be modified independently.

of 29

2.5.4 Restraints shall be applied so that the client is comfortable and can breathe easily

but yet be snug. Mechanical restraints shall be applied in a manner that allows

comfort, safety, movement and good alignment.

2.5.5 A client who is at risk for seizures or aspiration shall be placed in a side lying position

when restrained in bed.

2.5.6 Use knots which can be easily released and/or ensure shears/scissors/magnet or

other tools needed to facilitate restraint removal in an emergency are present.

2.5.7 Secure the restraint to the bed frame, never to the side rails. When securing a

restraint to a bed, ensure that when the head of the bed is elevated, the restraint

allows the client to move with the bed.

2.5.8 The following will not to be used as a restraint. If it is not designed and sold or

marketed as a restraint device, it should not be used as a restraint. Please note, that

this is not an exhaustive list:

bed sheets, draw sheets or other linens

clothing

bandaging materials (i.e. Kling®, Kerlix®)

jackets or vests

transfer belts

2.6 Use of Environmental Restraints

2.6.1 The type of restraint used is based on the client assessment and physician order.

Client and/or family/SDM/proxy should be included in the decision making process.

2.6.1.1 In long term care, consultation with the Behavioural Support Team should

occur where possible prior to use.

2.6.2 Refer to Appendix D ‘Approved Least Restraints’ for a list of SHR approved restraints

and manufacturers’ websites regarding correct use of the restraint. Environmental

restraints must have appropriate safety measures in place and must meet fire,

building and provincial/city/town codes and/or regulations with applicable permits

obtained. Environmental restraints will be used according to manufacturer’s

instructions and follow the Health Canada and SHR safety alerts regarding restraint

usage.

2.7 Maintenance of Mechanical and Environmental Restraints

2.7.1 Each facility/unit is responsible to ensure the restraints are in good condition and will

be inspected after each client use and maintained as per manufacturer’s guidelines.

Refer to Appendix D for specific manufacturer’s recommendations as to repair or

replacement.

2.8 Monitoring of Client while Restraint in Use

2.8.1 On-going care, observation, and documentation of the client must occur each time

a restraint is applied. Refer to Appendix G ‘Least Restraint Observation Record’ for

documentation.

Note: Documentation of respirations is required only if the restraint has the potential

to affect normal breathing.

Note: Monitoring and documentation can be completed by the individual team

member (RN, RPN, LPN, CCA) or a combination of team members involved in

the ongoing care of the client.

Note: Monitoring and documenting guidelines will be provided to the CCAs by the

licensed RN, RPN and LPN.

2.8.2 If monitoring/documentation requirements cannot be met then the restraint should

not be used. Consider alternatives.

2.8.3 Frequency of observation/documentation

With initial application of a restraint, a team member will check the client after 15

minutes

Following this every 30 minutes until the restraint is removed. May be more

frequent as indicated by the client’s condition.

of 29

With each reapplication of the restraint, the team member will check the client

after 15 minutes followed by every 30 minutes until the restraint is removed.

2.8.4 Based on individual assessment and care plan, clients who are restrained will have at

minimum:

Circulation/extremity/skin checks every 30 minutes

Limb release/reposition/range of motion every 1 hour while awake

Offered assistance to the toilet every 2 hours while awake

Fluids offered/mouth care every 2 hours while awake

Ambulation every 8 hours while awake

2.9 Extended Use of Least Restraint

2.9.1 Follow Appendix H ‘Extended Least Restraint Use Algorithm’.

2.9.2 Review points/re-evaluation are 1 week, 2 weeks, 1 month, 3 months as well as each

time a significant/adverse event has occurred and/or there has been a change in

the client’s condition.

2.9.3 With each review point/re-evaluation complete the procedure for least restraint use

including an assessment, practitioner orders and appropriate documentation.

Documentation of the review must be completed including the reason for continued

use or discontinuation.

2.9.3.1 If after thorough reassessment and with:

no significant adverse events or

no changes in the client condition and

the restraint use is still appropriate and

the most appropriate least restraint is still being used and

the desired outcome is being achieved, proceed to the next review point

for re-evaluation

2.9.3.2 If there has been a change in any of the above or a different type of least

restraint has been used the next reassessment will occur within 7 days.

2.9.4 The extended use of a least restraint should never be for a period of greater than 3

months without thorough assessment being completed.

2.9.5 If a restraint has been discontinued, refer to de-restraining process outlined below.

2.10 De-restraining/Discontinuing

2.10.1 The RN, RPN and LPN in collaboration with the team, assess whether to continue with

least restraints or begin the process of de-restraining.

2.10.2 Collaborate and plan with the client/family/SDM/proxy the de-restraining process.

2.10.3 Consider a trial period to assess the client’s ability to manage behavior without a

restraint. The trial period should be at least a two hour period or longer.

2.10.4 Following restraint removal, assess the client’s behavior at least every thirty minutes

for one hour.

2.10.5 The RN, RPN and LPN and /or the MRP, RN(NP) or Resident will determine the level of

client monitoring required after restraints are discontinued.

2.10.6 Upon discontinuation clean and disinfect the restraints.

2.11 Debriefing Huddles for Emergent Situations

2.11.1 Following an emergent situation as soon as time permits, the Manager or designate

will conduct a debriefing huddle with the team including the client/family/SDM/proxy

(as appropriate and available).

2.11.1.1 The manager/rural site leader or designate will provide support to

other clients and debrief as necessary and appropriate while

maintaining confidentiality.

2.11.1.2 The manager/rural site leader will provide reassurance of unit safety

and security.

2.11.2 Debriefing huddles will be held:

2.11.2.1 Following an emergent situation where restraints were used

of 29

2.11.2.2 Following an adverse/significant event with use of a restraint (i.e. fall,

client or staff injury).

2.11.2.3 At time of review.

2.11.2.4 During the huddle review and the most appropriate team member

documents:

How the situation was handled

The reasons for the use of restraints

If the use of restraints achieved effective outcome

Other alternatives that were considered and tried

Were there any adverse/significant events

What went well

Action that could have improved or prevented the outcome

What impact did the incident have on other clients, the unit and facility

The perspective of the client/family/SDM/proxy of the situation

2.12 Documentation

2.12.1 Documentation in the Progress Notes will include:

Circumstances which precipitated the least restraint use

Client assessment and alternatives tried and their effectiveness

Client/family/SDM/proxy understanding related to least restraint use

Time restraints applied and type of restraints used

Time restraints discontinued

Client’s response to the restraint

Outcome

2.12.2 The most appropriate team member should initiate an adverse event report/safety

alert as indicated.

2.12.3 The clients care plan will be completed including:

Alternatives to least restraints being used

Type of restraint used and when it is to be used

Any changes to care plan from previous and ongoing assessments

2.12.4 The nursing staff will complete Appendix G ‘Least Restraint Observation Record’ as

indicated in Procedure 2.7

2.12.5 On removal or discontinuation of restraints the following will be documented:

The change in client’s behavior since the application of the restraint

Any alternative interventions currently effective

On-going reassessments of the client’s condition to ensure safety

2.12.6 If Security Services is involved, Security Services staff document in the Security

Information Management System (SIMS).

2.13 Education

2.13.1 Provide the client/family/SDM/proxy education regarding the alternatives,

complications/potential risks and outcomes from the use of least restraints and

expectations for ensuring safety from harm to client and staff. Refer to Appendix I

‘Least Restraint Information for Families’.

2.13.2 Provide staff education regarding the processes, principles, policy and procedure to

promote the practice of least restraint and prevent or reduce the use of restraints.

2.13.3 Provide staff with education on the proper application of restraints.

3. PROCEDURE MANAGEMENT

The management of this procedure including procedures education, monitoring, implementation

and amendment is the responsibility of Director, Professional Nursing Practice and Education.

of 29

4. NON-COMPLIANCE/BREACH

Non-compliance with this procedure will result in, at a minimum, a review of the incident. Non-

compliance may also result in disciplinary actions up to and including termination of employment

and/or privileges with SHR.

5. REFERENCES

Alzheimer Society of Canada. (2007). Least restraints. Retrieved from


Capital Health. (2012). Policy CC65-031 Use of Rapid Physical Least restraint on Acute Care Mental

Health In client Units. Retrieved from


Capital Health (2007). Appendix C Learning Supplement for Least Restraint. Retrieved from


Capital Health. (2007). Interdisciplinary Clinical Manual Policy & Procedure #CC-05-030 Least

restraint. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx

Division of Developmental Disabilities. (2012). Policy 5.11-Least restraints. Washington State

Department of Social &Health Services

Government of Saskatchewan. (2013). Regional Health Services Policy & Procedure manual 15.10

Restraints. Community Care Branch

Heartland Health Region. (2011). Policy # C01-39.01 Least restraint. Heartland Health Region

Regina Qu’Appelle Health Region. (2008). Policy #1001-Adult Least Mechanical Least restraint.

Regina Qu’Appelle Health Region

Registered Nurses’ Association of Ontario. (2012). Clinical best practice guidelines-Promoting safety:

alternative approaches to the use of least restraints. Retrieved October 19, 2012 from

http://rnao.ca/sites/rnao-ca/files/Promoting_Safety__Alternative_Approaches_to_the_Use_of_Least

restraints_0.pdf

Saskatchewan Registered Nurses’Association. (2010). SRNA position Statement use of least restraints

in client care. Saskatchewan Registered Nurses’ Association

The Hospital for Sick Children. (2008). Policy, Procedure & Guideline Least restraint. The Hospital for

Sick Children





http://rnao.ca/sites/rnao-ca/files/Promoting_Safety__Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

http://rnao.ca/sites/rnao-ca/files/Promoting_Safety__Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

of 29

Client Assessment – “Describe the Behavior”

Identify the specific behavior (e.g. striking out at staff, spitting at staff, etc.) Explore the reasons for the behaviour:

What issue is the behaviour communicating? • What is the unmet need? • What are the triggers for the behaviour?

Assessment should include: • Client's age • Mental status (oriented, confused, agitated) Acute changes? Fluctuates? • Level of cognitive impairment (moderate-severe dementia , trauma) • Assess for triggers of delirium (medications, metabolic imbalance, infection, pain, exacerbations

of chronic illnesses) • Alcohol/drug withdrawal • Responsive behaviours (aggression, risk of injury to self or others , anxiety, challenging/disruptive

behaviours, restlessness/wandering) • Decreased or inability to communicate (sensory impairment, aphasia) • Unmet physical needs (toileting, hunger, thirst, fear) • History of falls/fear of falls • Increasing dependence (decline in mobility, increasing dependence for activities of daily living) • Interference with life support equipment • Environmental triggers (noise, music, temperature, unfamiliar environment) • Consult with client's family, physician and other health care tea m members • Activities and interests • Availability of family or client attendant

Reflect on the following criteria : • What is the potential harm and to whom? • What are the detrimental risks of using the restraint on the client? • Does the potential benefit of using a restraint outweigh the risk of harm?

What steps can we take to eliminate or change the behaviour so as to avoid the use of restraints? Consider the use of a recommended assessment tool

Are Alternatives to Restraints Possible?

Least Restraint Use Algorithm Appendix A

Are Alternatives to Restraints Possible? Review the Alternatives to Restraints (see Appendix B) What has been done in the past? What need to change?

yes no

• Initiate alternatives in collaboration with client/family/health care tea m

• Assess needs of the client (e.g. pain, nutrition, etc.)

• Communicate and collaborate with tea m • Ongoing assessment, documentation and

monitoring of effectiveness of alternative interventions as per policy

Alternative Not Effective

• Attempt de-escalating strategies through the use of violence management training (e.g. Workplace Assessment Violence Education (WAVE), Gentle Persuasive Approach (GPA) , Professional Assault Response Training (PART))

• Use of Code White as required • Consider the type of restraint required ( environmental,

mechanical or physical) • Continue to implement alternatives • Assess need for Client Attendant where available (see Appendix C) • Communicate and collaborate with team ASAP • Initiate restraint as per policy • Ongoing assessment, evaluation

of 29

Appendix A

Ongoing Reassessment of the Need for Least Restraint

Reassess every 24 hours for the first 7 days then at each review point or when a

significant change in client (e.g. client attempted to climb over side rails)

Extended Restraint Use: Refer to Appendix H

• Code White as required • Consult health care team • Trial new alternative • Re-evaluate least restraint • Re-order restraint as per policy • Ongoing assessment, documentation and

monitoring as per policy • Communicate and collaborate with team

Yes No

• Discontinue restraint • Ongoing assessment of client’s behaviour • Document decision and monitor • Communicate and collaborate with team

Adapted from:

Alzheimer Society of Canada. (2007) Restraints. Retrieved from


Capital Health. (2007). Least Restraint, interdisciplinary Clinical Manual.

The Hospital for Sick Children. (2008). Least Restraint, Hospital – wide Client Care Policy, Procedure

and Guideline.

Registered Nurses’ Association of Ontario. (2012). Promoting Safety; Alternative Approached to the

Use of Restraints. Toronto, ON: Registered Nurses’ Association.


of 29

SASKATOON HEALTH REGION Saskatoon, Saskatchewan

RUH SCH SPH Other _____________

ALGORITHM FOR USE OF A CLIENT ATTENDANT (SITTER, COMPANION) Page 1 of 2

Appendix C

Assessment of Risk Behaviours

Elopement

Wandering

Confusion or Dementia

Agitation

Agression

Suicidal Ideation

Check off

identified

behaviours

Interventions

Moved patient to more visible location

Bed adjustment (lowest position, side-rails)

Programming for elderly

Contributing physiological factors (i.e. infection,

dehydration, electrolyte imbalances, medications)

Regular toileting / commodes at bedside

Vision / hearing aids

Remove disruptive stimuli

Medication review / Psychiatric consult

Minimum restraint (i.e. Broda chair with table)

Check off

interventions used

Low Risk

Risks minimized

Document impacts/responses to interventions on reverse

Medium Risk

Request family

assistance

Utilize volunteers

Increase daytime programming

Determine client attendant needs

for certain hours (document on

reverse

High Risk

Assess client

attendant

requirements

(constant,

Security, etc.)

(document on reverse)

Request family assistance

Assess for mechanical restraints

Re-Assessment

Re-evaluate client attendant

requirements Q 24 hours

(document on reverse)

Word Form # 102892 08/07 Category: Care Plans/Outcomes

of 29

ALGORITHM FOR Patient Name: ________________________________ USE OF A CLIENT ATTENDANT (SITTER, COMPANION) Page 2 of 2 HSN: ____________________ DOB: ______________

Intervention Assessment Documentation

If patient remains at medium or high risk, document the interventions used (and/or why they are not

applicable) and the impact(s) / response(s) to those interventions.

Review of Client Attendant Requirements

If patient (at medium or high risk) requires a client attendant for certain hours of the day, this requirement

must be reviewed and documented every 24 hours.

Day/Time: Assessment Review:






of 29

Appendix D

APPROVED LEAST RESTRAINT

Note: The intent of the device defines whether is a restraint or not

Not all restraints are available or applicable for all areas.

Please check with your supervisor before using.

Mechanical Restraints

• Disposable soft least restraints

• Pinel least restraint applied to bed or chair

• Pinel gap covers

• Broda Chair with table belt or thigh restraint belts

• Wheelchair seatbelts

• Soft cloth T-seat least restraint

• Lap belt (secure across the client’s thighs and attaches to the bed or chair)

• Body point belt

• Tray tables

• Wheelchair table

• Vail bed

• Posey foam pelvic holder

Environmental Restraints

• Half doors, locked doors

Websites for Least Restraint

Pinel Least Restraint System:

http://www.pinelmedical.com/sef/page/id/14.html

Vail Bed:

http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotiuces/PublicHealthNotifications/UC

M062046.pdf

Broda Chair:

http://www.brodaseating.com/

Disposable Limb Holder:

Instructions for application come in the package from www.DJOglobal.com (Procare),

http://www.djoglobal.com/search/apachsoir_search/limb%20holders

http://www.pinelmedical.com/sef/page/id/14.html

http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotiuces/PublicHealthNotifications/UCM062046.pdf

http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotiuces/PublicHealthNotifications/UCM062046.pdf

http://www.brodaseating.com/

http://www.djoglobal.com/

http://www.djoglobal.com/search/apachsoir_search/limb%20holders

of 29

Appendix E

Side Rail Pathway

Appendix F

RUH SCH SPH

Other ________________

LEAST RESTRAINT USE CONSENT/PHYSICIAN ORDER FORM Page 1 of 2

A) CONSENT FOR RESTRAINT DEVICES (each category needs a separate consent form)

Type of Restraint: Mechanical Environmental

Specify each type to be used:

_______________________________________________________________________________________________

Purpose of Restraint:

Frequency and duration of restraint application: ________________________________________________

I have read the definitions, potential benefits and potential risks of restraint use, understanding

the potential benefits and risks of restraint use and the healthcare professionals’ evaluation:

I DO consent to the use of restraints as outlined above.

I understand that I have the right to refuse the use of restraints or can revoke this consent at any time.

I DO NOT consent to the use of restraints as outlined above and understand the related risks.

ADDITIONAL CONSIDERATIONS

__________________________________________________________________________________________

_________________________________________________________________________________________________

Client Signature Date

OR

Proxy Personal Guardian Substitute Decision Maker

Other

2 Physician Signatures(if no proxy)

Signature Date

Signature of Witness Date

B) PHYSICIAN’S ORDER (required every 24hr x 7 days, then in 2 weeks, then in 1 month, then quarterly

from date of application)

Date & Physician Signature

Day 1 Date Signature







2 weeks post application: Date due______________Signature _____________________________________

1 month post application: Date due______________Signature_____________________________________

Quarterly: Date due ______________Signature ___________________________________________

Date due ______________Signature ___________________________________________

Word Form # 103694 01/14 Category: Consent/Release/Transport

Addressograph / Label

NAME: _________________________ HSN: __________________________

D.O.B.:

__________________________________

of 29

LEAST RESTRAINT USE CONSENT/ PHYSICIAN’S ORDER FORM Appendix F

Page 2 of 2

RESTRAINT DEFINITIONS

Mechanical:

Any device, material or equipment attached to or near a client which cannot be easily removed

by the patient and involuntarily restricts the client’s freedom of movement or normal access to his

or her body (references: AHS, HHR, MDS)

Environmental:

Any barrier or device that limits or controls the locomotion of an individual and thereby confines

an individual to a specific geographical area or location.

POTENTIAL BENEFITS

Managing agitation and aggression

Managing the safety of client and others

Provision of necessary medical treatment

Other:

POTENTIAL RISKS

Behavior Alterations

Death

Hydration & Nutritional Status Alterations

Injury or Entrapment

Pain

Psychological

Cardiovascular System Alterations

Decreased Functional Status

Infection

Musculoskeletal Alterations

Perceptions of Self

Skin Integrity Alterations

PRINCIPLES

SHR staff will provide a collaborative and supportive atmosphere for clients who require restraints. An

environment will be created that adheres to informed decision making in regards to restraint use. All

staff will be respectful of the choices that clients make about restraint use and alternatives to

restraints.

SHR adheres to the practice of “least restraint”. The establishment of a therapeutic relationship

between the care team and client and family/SDM is beneficial for minimizing restraint use;

maximizing client independence; improving quality of life; minimizing risk of injury; and preserving

patient self-worth.

Addressograph / Label

NAME: _________________________ HSN: __________________________

D.O.B.:

__________________________________

of 29

RUH SCH SPH

Other _

LEAST RESTRAINT OBSERVATION RECORD

Addressograph / Label NAME:

HSN:

D.O.B.:

DATE: TYPE OF RESTRAINT(S): _

REASON FOR RESTRAINT Risk of self-injury Physical threat to others Other:

TIME Resp Circulation Care Given Behavioral Response

COMMENTS (i.e. restraint applied, restraint removed)

(i.e. 15min check after application)

INITIALS

0730 0800 0830 0900 0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530 1600 1630 1700 1730 1800 1830 1900

Note: Each time the restraint is applied, monitoring must be completed in 15 minutes, followed by q30 min monitoring until the restraint is removed. With each application the same monitoring must occur. The 15 minute check can be noted in the comments section

Documentation of respirations is required only if the restraint has the potential to affect normal breathing.

KEY: MINIMUM CARE REQUIRED Range of motion/limb release q1h Toileting q2h Fluids/mouth care q2h Ambulation q8h

CIRCULATION Poor = p Fair = f Good = g

RESPIRATIONS L = low (<12) N = Normal (12-20) H = High (>20)

CARE GIVEN No Care = nc Repositioned = rp Repositioned self = self Skin Care = sc Ambulated = amb Range of Motion = rom Toileting = t Fluids given = fl

BEHAVIORAL RESPONSE Sleeping = s Calm = c Agitated = a Confused = cd Combative = com Resistive = res Restless = r Impulsive = imp Memory problems = mem

Appendix G

Word Form # 102213 01/14 Category: Flow Sheets

of 29

RUH SCH SPH

Other _

LEAST RESTRAINT OBSERVATION RECORD

Addressograph / Label NAME:

HSN:

D.O.B.:

DATE: TYPE OF RESTRAINT(S): _

REASON FOR RESTRAINT Risk of self-injury Physical threat to others Other:

TIME Resp Circulation Care Given Behavioral

Response COMMENTS (i.e. restraint applied, restraint removed)

INITIALS

1930 2000 2030 2100 2130 2200 2230 2300 2330 2400 0030 0100 0130 0200 0230 0300 0330 0400 0430 0500 0530 0600 0630 0700

Note: Each time the restraint is applied, monitoring must be completed in 15 minutes, followed by q30 min monitoring until the restraint is removed. With each application the same monitoring must occur. The 15 minute check can be noted in the comments section

Documentation of respirations is required only if the restraint has the potential to affect normal breathing.

KEY: MINIMUM CARE

REQUIRED Range of motion/limb

release q1h

Toileting q2h

Fluids/mouth care q2h Ambulation q8h

CIRCULATION Poor = p Fair = f Good = g

RESPIRATIONS L = low (<12)

N = Normal (12-20) H = High (>20)

CARE GIVEN No Care = nc Repositioned = rp Repositioned self = self Skin Care = sc Ambulated = amb Range of Motion = rom Toileting = t Fluids given = fl

BEHAVIORAL

RESPONSE Sleeping = s Calm = c Agitated = a Confused = cd Combative = com Resistive = res Restless = r Impulsive = imp Memory problems = mem

Word Form # 102213 01/14 Category: Flow Sheets

Appendix H

of 29

Appendix I

Least Restraint Information for Families

policy - saskatoon health region · see shr policy consent/informed consent. violation of the...

Documents