Physical Restraints. Purpose Policy Statement. Applicability

Transcription

1 Approved by: Physical Restraints Senior Vice President, Medicine Vice President, Covenant Health Rural Health Services & Executive Lead for Professional Practice and Research Corporate Policy & Procedures Manual Policy. VII-B-85 Date Approved August 2, 2011 September 21, 2011 Next Review (3 years from Effective Date) September 2014 Purpose Policy Statement To provide direction for the application and use of physical restraints. At Covenant Health facilities, restraints are used as a last resort when a patient s behaviour clearly represents a threat of bodily harm to self and/or others. Restraints are used only when all possible appropriate alternative interventions have been considered and deemed unsuccessful or inappropriate. This policy and procedure constitutes the minimum standard for physical restraint. Where appropriate, departments/units shall develop operational procedures, consistent with this document that outlines additional requirements for the types of restraints used in their area, set parameters for checks and observation, concurrent care and documentation. Applicability This policy and procedure applies to all Covenant Health acute care facilities, staff, physicians, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Physicians/nurse practitioners are responsible to expediently assess patients to determine if physical restraint is necessary, to provide written orders regarding restraints, and to discontinue restraints as soon as possible after the behaviour is diminished, disappears, or the patient regains self control. Patient care providers will demonstrate commitment to the safety of patients by ensuring that restraint devices are applied and used in accordance with the manufacturer s specification, that the restrained patient is assessed at least every fifteen minutes, or per unit/department protocol - whichever is more rigorous, that basic patient care needs are met, and that care is documented in the patient care record. Principles Covenant Health supports the principle of least restraint. Least restraint practice means that a care provider will exhaust all possible alternative interventions before deciding to use a restraint. Least restraint practice requires careful consideration of assessment findings to determine what is causing a difficult behaviour that may result in a decision to use a restraint. 1 The use of restraints, whether physical, chemical or environmental, should always seek the person s greater freedom and functioning and be done with scrupulous observance of due legal process. 2 Physical restraints are used only as a last resort when; appropriate assessments have deemed them necessary for the purposes of preventing harm by the patient to self or others, and where less restrictive methods have been evaluated and have been determined to 1 CARNA, Position Statement on the Use of Restraints in Client Care Settings, June Health Ethics Guide, Articles 29, 42, Ottawa: Catholic Health Association of Canada, 2000.

2 Policy. VII-B-85 Page 2 of 7 be unsuccessful or inappropriate for that purpose all other reasonable alternative interventions have been ineffective there is an imminent risk of harm to self or others Covenant Health staff will notify the patient s family/substitute decision maker (if known), as soon as possible, of the restraint and its purpose. Safe and supportive care is provided to the patient in restraint, including ongoing attempts to determine the underlying cause of the agitation, elimination of precipitating factors, consultation with other health care professionals, attending to basic needs, providing clear communication, evaluating for discontinuation of restraint and providing the patient a supportive atmosphere. Contraindications to physical restraints should be assessed on a case-by-case basis prior to the use of restraints. At a minimum, patients in restraints will be checked every fifteen minutes; however, each patient should be assessed on an individual basis to determine if more frequent observation is appropriate. This policy and procedure does not include instances of informed risk when, in the absence of risk to others, patients or their substitute decision-maker have the right to pursue a request to refuse restraints with the healthcare team. Information on the outcome of the request must be documented on the Patient Care Record. Procedure Refer to Appendix 2 Decision Tree for Least Restraint Patient Care Orders: 1. A timely and explicit patient care order for restraints is required. Patient care orders must be reviewed/reassessed a minimum of every 24 hours, or as per the frequency determined by departmental procedure (whichever is more rigorous), and revised as needed to appropriately address changes in the patient s condition and needs. 2. In an emergency situation where there is significant risk to the patient or others, the Nurse in Charge may approve the application of a restraint until a patient care order is received. Types of Restraints: 3. Restraint devices shall be applied and used in accordance with the manufacturer s specifications. 4. Modifications to the restraint device are not permitted and items not intended to be used as a restraint (for example, bed sheets) will not be utilized. tification of the Family / Substitute Decision Maker 5. As soon as possible, notify the patient s family or substitute decision maker. Explain the purpose and the reason(s) for the restraint(s), or the possible use of the restraint(s) if they are likely to be used. Document on Patient Care Record.

3 Policy. VII-B-85 Page 3 of 7 Assessment and Care of a Patient in Restraints: 6. During the application of the restraint, reassure the patient by explaining that restraints are being applied for safety and will be released when the target behaviour or self-control has been achieved. 7. Check for placement and circulation to hands and feet immediately following application of limb restraints; every fifteen minutes, or per unit protocol whichever is more rigorous. 8. Ensure physical needs of patient are attended to as part of their ongoing care, in accordance with basic nursing care standards. a) respiration b) circulation c) nutrition and hydration d) elimination e) skin integrity f) range of motion / repositioning 9. The need for the restraint must be assessed at every check and by the treatment team at least daily during which preferred options for patient management shall be discussed and attempted. 10. As appropriate, provide a call bell to the patient or ensure the patient has ready access to staff. Evaluation: 11. Evaluate the following on an ongoing basis and provide appropriate intervention. Document assessments and interventions. a) effectiveness of the restraint b) response of the patient to restraint c) behaviours indicating need for continuing restraint d) psychological educational support to patient and family e) if restraints can be discontinued and patient response Document on the Patient Care Record type of restraint reason for the restraint (i.e. type of behaviour exhibited by patient and early interventions) time applied and removed notification of patient s family or substitute decision maker time and name of physician notified or written physician order frequency of observation (minimum every 15 minutes or as per unit policy)

4 Policy. VII-B-85 Page 4 of 7 release and repositioning circulation of the limb and condition of the skin (as appropriate) comfort of the patient; including nutrition and elimination. Restraints that are not single-use must be cleaned after each use. Definitions Substitute decision-maker means a person who is authorized to make decisions with or on behalf of the patient. These may include an agent pursuant to a personal directive, legal guardian pursuant to the Adult Guardianship and Trusteeship Act (AGTA) and the Child, Youth and Family Enhancement Act, co-decision maker pursuant to the AGTA, specific decision-maker pursuant to the AGTA, or family members in the following order as set forward in the AGTA: 1. Spouse or interdependent partner; 2. Adult son or daughter; 3. Father or mother; 4. Adult brother or sister; 5. Grandfather or grandmother; 6. Adult grandson or granddaughter; 7. Adult uncle or aunt; 8. Adult nephew or niece. In the absence of any of the above, the substitute decision maker will be the public guardian. Restraint: A physical, mechanical, or environmental factor that restricts a patient s freedom of movement, limits activity, and/or controls behaviour. For the purpose of this policy and procedure, the following are not included in the definition of restraints : immobilization of a part of the body as required for medical treatment, such as splints and casts temporary immobilization of a part of the body while a procedure or intervention is being performed on that part of the body temporary immobilization during transportation, such as belts on stretchers devices that are used to maintain desired positioning or improve body alignment (such as standard [front-closing] wheelchair seatbelts, and straps or shoulder harnesses) devices that enhance patient safety or improve the patient s quality of life and/or provide the patient a more normal life experience (eg. sitting up to eat or to look out the window). devices that enhance treatment or reduce risk of co-morbidities (eg. pneumonia) Related Resources Seniors Delirium Protocol Form #09628( ) Covenant Health, Consent to Treatment Policy and Procedures: Policy, #VII-B-50 Adults with Capacity, #VII-B-55 Adults with Impaired Capacity, #VII-B-60 Formal Patients and Persons Subject to Community Treatment Orders under the Mental Health Act, #VII-B-65

5 Policy. VII-B-85 Page 5 of 7 Minors / Mature Minors, #VII-B-70 Human Tissue and Organ Donation, #VII-B-75 References CARNA Position Statement on the Use of Restraints in Client Care settings. June EDT Effective De-escalation Techniques Edmonton Acute Mental Health Program Aggression Management Training. Stuart, G. & Laraia, M. (2009). Principles and Practice of Psychiatric Nursing. Mosby, Inc. St. Louis, Missouri. Potter, P. & Perry, A. (2010). Clinical Nursing Skills & Techniques. Harcourt Canada Ltd., Toronto, Ontario David Thompson Health Region P/P #CC-VI-20, Restraints Park M, Hsiao-Chen Tang J, Ledford L. Changing the practice of physical restraint use in acute care. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Centre, Research Translation and Dissemination Cord; 2005 v. 47 p. [146 references]. Health Ethics Guide, published by the Catholic Health Association of Canada (Ottawa, 2000), and approved by the Canadian Council of Catholic Bishops. JBI, 2002 Physical Restraint - Pt 2: Minimization in Acute and Residential Care Facilities, Best Practice Vol 6 Iss 4, Blackwell Publishing Asia, Australia. Stubbs, B., Leadbetter, D., Paterson, B., et al. (2009). Physical intervention: a review of the literature on its use, staff and patient views, and the ipact of training. Journal of Psychiatric and Mental Health Nursing, 16, Park M, Hsiao-Chen Jang J, Ledford L. Chaing the practice of physical restraint use in acute care. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Centre, Research Translation and Dissemination Cord; 2005 v. 47 p. [146 references]. Revisions N//A

6 Policy. VII-B-85 Page 6 of 7 APPENDIX 1; RESTRAINT ALTERNATIVES Environmental Changes Improved lighting Easy to turn on lights n-slip strips on the floor Ensuring a path clear of furniture Easy access to safe outdoor areas Locked exit doors Cloth barriers across doorways attached with Velcro Structural design of units modified to enhance visibility of residents Safety in Bed Concave mattress Bed boundary markers to mark edges of bed, such as mattress bumpers rolled blanket or swimming noodles under sheets Water mattress to reduce movement to edge of bed Positioning cushions to prevent movement to edge of bed Use of body length pillows to aid positioning Soft floor mat or a mattress by the bed to cushion any falls Person at risk to sleep on mattress on the floor Individualize bed height Bed height adjusted to lower leg length bedrails, or half bedrails with low beds Removal of wheels Chair or table at bedside to help with transfer n-slip strips on floor by bed Trapeze to enhance mobility in bed Visual reminders to encourage the patient or resident to use call bell Seating and Position Chairs with deep seats Rockers or recliners Large pillows(like bean bags) on the floor High back or supportive chairs Removal of wheels Pillows on seats Bean bag cushions for chair to reduce risk of slipping for person with continuous jerky movements to stop them moving out of chair Customized seating (wedge cushions, D-placement cushions or with hole in centre) Wheelchair arm cushion to prevent sideways slumping/leaning of person with CVA Activities and Programs Developing rehabilitation and exercise program that involve teaching the resident safe transfer techniques Development of an ambulation program Physical, occupational and recreational therapies Exercise incorporated into the daily plan of care Night time activities for those who wander at night Individual and group activities Recreational and social activities Appropriate outlets for industrious or anxious behaviour Structured daily routines Wandering should be permitted Toileting and Continence Frequent assistance with toileting Individual elimination rounds Toileting schedule Cleaning promptly after soiling Incontinence evaluation Indentify bathroom with picture Bedside commode Alterations to Nursing Care Additional supervision and observation Evaluate and monitor conditions that can alter behaviour Increase staffing levels Individual needs of person known to staff Nursing assistants learning to anticipate and pre present during transfers Call bell within reach At risk patients near nurses station Change bothersome treatments, such as initiate oral feeding instead of IV or NG and removal of catheter and drains as soon as possible Individualized person centered care Facilitated napping Limit time spent in bed to sleep time Psychosocial Alternatives Companionship Active listening Increased visiting Encourage staff and resident interaction Provide companionship using family, friends, or volunteers Familiar staff Increase social interaction Therapeutic touch Massage Relaxation techniques Behaviour modification Reality orientation White noise for insomnia Sensory aids Quiet room Sensory stimulation Decreased sensory stimulation Reduced environmental noise Physiological Alternatives Treatment of infections Reduce pain/schedule analgesics Schedule analgesia to help overcome insomnia Checking medication Remove any physiological causes of mental state impairment Alarms Bed, chair or wrist alarms for cogitatively impaired Alarms to manage wandering Exit door alarm Electronic sensor system

7 Policy. VII-B-85 Page 7 of 7 Decision Tree for Least Restraint APPENDIX 2 Assess patient behavior Is pain Is anxiety Provide analgesia Is restlessness Assess and treat other causes of agitation: -Sleep deprivation -Hypoxemia or hypercapnia -Malfunction of devices (catheter, epidural, vent) -Electrolyte imbalance -Acute withdrawl -Ready to extubate -Drug interaction/reaction -Constipation or wants to have bowel movement -Needs to urinate -Hungry Provide anxiolytics Is restlessness Continue to monitor behavior Is behavior management achieved? Continue to monitor behavior Implement alternative measures: -Diversion/redirection/reorientation -Decrease sensory stimuli -Allow rest/sleep -Cover IV sites -Hearing aids/glasses -Family member to sit with patient Are alternate measures appropriate? Implement restraints as per policy: -Apply appropriate restrains -Monitor, document and reevalulate -tify family/alternate decision maker Is behavior management achieved? Is behavior management achieved? Remove restraint Continue to monitor behavior Continue appropriate restraint -Monitor -Document -Reevaluate -Continue to explore alternatives