TITLE RESTRAINT AS A LAST RESORT SCOPE Prvincial APPROVAL AUTHORITY Clinical Operatins Executive Cmmittee SPONSOR Senir Operating Officer, Glenrse Rehabilitatin Hspital PARENT DOCUMENT TITLE, TYPE AND NUMBER Nt Applicable DOCUMENT # HCS-176 INITIAL EFFECTIVE DATE February 1, 2018 REVISION EFFECTIVE DATE Nt applicable SCHEDULED REVIEW DATE February 01, 2019 NOTE: The first appearance f terms in bld in the bdy f this dcument (except titles) are defined terms please refer t the Definitins sectin. If yu have any questins r cmments regarding the infrmatin in this dcument, please cntact the Plicy & Frms Department at plicy@ahs.ca. The Plicy & Frms website is the fficial surce f current apprved plicies, prcedures, directives, standards, prtcls and guidelines. OBJECTIVES T prvide directin n the use f restraint based n the principle f restraint as a last resrt and the practice f least restrictive restraint t guide safety-related care decisins. T prmte cnsistency in the decisin-making prcesses regarding restraints. T supprt a balance between the safety f the patient and thers and the limitatin impsed n the patient s persnal liberty when decisins are made regarding restraint. PRINCIPLES Using a patient centred care apprach eight (8) prcedures have been develped t accmpany this plicy based n specific patient ppulatins and different care team requirement(s). Cnsent is required fr all nn-emergent restraint use. Alberta Health Services is cmmitted t the principle f restraint as a last resrt. Restraint shall be used nly when ther strategies have been deemed ineffective r inapprpriate in the circumstances. All reasnable effrts shall be made t identify and apply a nn-restraint strategy. When restraint is indicated the least restrictive restraint suitable t achieve the intended utcme shall be used. Restrained patients shall be mnitred with sufficient frequency t minimize risk f any ptential harm which varies depending n the patient and care area but at a minimum is Alberta Health Services (AHS) PAGE: 1 OF 9
required every eight (8) hurs f cntinuus restraint particularly while sleeping (see relevant prcedure fr each care area fr mre specifics). Once restraints are applied they shall be remved at the earliest and safest pprtunity. Restraints shall be used in a manner that allws fr quick release in an emergency situatin (e.g., cdes). Staff caring fr patients at risk fr the use f restraints (r all patients with ptential r real behaviral challenges) shall receive educatin n apprpriate restraint use and applicatin. Prgram areas shall identify training requirements fr staff. Restraint shall be used nly in circumstances where: There is an immediate threat t the safety f patients, caregivers, r thers (e.g., physical assault, self-harm) and immediate actin is necessary t prevent serius bdily harm t the persn r t anther persn; Emergency treatments must be prvided, including but nt limited t resuscitatin, emergency assessment and transprt; An apprved treatment regimen r care plan must be fllwed because the patient is unable t cperate in the care setting (e.g., ICU care, severe cgnitive impairment); The patient s behaviur is severely disruptive and/r interferes with the prvisin f care t ther patients; and/r It is necessary as part f the patient s treatment plan fr patient safety, such as lap belts n wheelchairs. APPLICABILITY Cmpliance with this dcument is required by all Alberta Health Services emplyees, members f the medical and midwifery staffs, Students, Vlunteers, and ther persns acting n behalf f Alberta Health Services (including cntracted service prviders as necessary). This plicy des nt apply t restraint by nn-ahs Crrectins Authrities fr purpses f custdy, detentin, and public safety reasns. ELEMENTS 1. Cnsent 1.1 Cnsent is nt required in emergency situatins, including but nt limited t: a) risk f serius bdily harm t patient r thers; b) immediate threat t safety; r Alberta Health Services (AHS) PAGE: 2 OF 9
c) emergency treatment being prvided. 1.2 Cnsent shall be btained in all nn-emergency circumstances. Cnsent shall be btained in accrdance with the AHS Cnsent t Treatment/Prcedure(s) plicy suite. 1.3 Physician r Nurse Practitiner rders are required fr nn-emergency restraints. 1.4 When a restraint is used in an emergency situatin, Physician r Nurse Practitiner rder shall be btained as sn as pssible if restraint is nging. 2. Principles Nte: Pharmaclgical restraints cannt be used withut an rder. 2.1 Fur (4) principles that guide the use f restraint(s) are: a) Respect fr persns: (i) (ii) (iii) The patient s dignity shall be respected at all times and under all circumstances. Infrmed cnsent (in accrdance with Cnsent t Treatment/Prcedure(s) plicy suite) and the principle f chice are applied in all pssible circumstances. Early interventin may be able t cntrl difficult behaviur befre the situatin escalates and a patient may be able t participate and chse less restrictive ptins. b) Maximum benefits and minimum harm: (i) (ii) (iii) Restrictin f mvement limits the patient s liberty and is thus ptentially harmful. The safety benefits f restraints shall be weighed against the harm they cause prir t making a decisin regarding the restraint. Patients shall be carefully bserved in rder t immediately address harm. Patient respnse t restraint shall be tracked, dcumented and reviewed t assist further decisin making. c) Minimal restrictin: When restraints are deemed t be necessary, the least restrictive restraint shall be used, fr the least amunt f time. This must be balanced with ensuring safety and respecting liberty. As restraint may take away the patient s ability t care fr themselves, staff may need t take ver the respnsibilities that have been taken away frm the patient. Alberta Health Services (AHS) PAGE: 3 OF 9
3. Types f Restraint d) Fairness and cnsistency: Health care teams shall apply this plicy cnsistently acrss health service settings. In all patient encunters care teams shall wrk with patients and/r the alternate decisin-maker t use restraint as the last resrt. 3.1 Alberta Health Services recgnizes the use f the fllwing types f restraint: a) Pharmaclgical: the use f pharmaceutical prducts t cntrl behaviurs, actins, and/r restrict freedm f mvement, but which purpse in the situatin is nt t treat an identified medical r psychiatric cnditin. b) Envirnmental: any barrier r device that limits the lcmtin f an individual, and thereby cnfines an individual t a specific gegraphic area r lcatin. c) Mechanical: any device, material, r equipment attached t r near a patient which cannt be cntrlled r easily remved by the patient and which prevents a patient s free bdy mvement and/r a patient s nrmal access t their bdy. d) Physical: the direct applicatin f physical hlding techniques t a patient that invluntarily restricts their mvement. 4. Restraint Decisin-Making Cmpnents 4.1 Restraint shall nt be used fr discipline r cnvenience. 4.2 Clinical evaluatin f each individual patient situatin will determine: a) if there is a need fr restraint; b) the type f restraint t be used; c) when t discntinue the restraint; and d) hw effective the restraint was. 4.3 In nn-emergency situatins alternatives t restraints shall be first attempted r implemented, assessed, and dcumented. a) If alternatives t restraint are nn-effective this shall be dcumented prir t the implementatin f restraint. Alberta Health Services (AHS) PAGE: 4 OF 9
4.4 Except fr emergent circumstances, the fllwing are required prir t restraint use: a) identificatin f factrs cntributing t the actins r behaviurs that are perceived t require restraint and acting where reasnably pssible t eliminate r reduce these factrs; b) immediate situatinal assessment f patient status and their ability and/r willingness t cntrl their actins and/r behaviurs perceived t require restraint; c) identificatin f any existing and ptential risks t the patient, thers and the envirnment; d) evaluatin f ptential risks f restraint and nn-restraint; e) cnsent shall be btained if restraint is required fr patient s treatment plan and fr all nn-emergency restraint use. This will include a discussin abut the methds, risks, and benefits f restraint and nnrestraint with the patient and/r alternate decisin-maker in accrdance with the AHS Cnsent t Treatment/Prcedure(s) plicy suite. Cnsideratin f alternative less restrictive strategies have been r are understd by staff t be ineffective r inapprpriate in the circumstances, having regard t the patient s physical and mental health; f) a Physician r Nurse Practitiner rder which has been rdered and reviewed as indicated in the applicable restraint prcedure; and g) cnsider ratinale fr restraint use: (i) (ii) (iii) (iv) (v) intended utcmes f restraint; ptential effects f restraint; frequency f mnitring and dcumentatin review; frequency and cnditins fr use f restraint; and criteria and timelines fr discntinuatin f restraint. 5. Restraint as a Last Resrt Prcedures 5.1 The fllwing practice settings within AHS will prvide prcedures pertaining t the use f restraint (see references fr prcedure(s) titles): a) Emergency/Urgent Care; b) Adult Inpatient; c) Pediatric Inpatient; Alberta Health Services (AHS) PAGE: 5 OF 9
6. Dcumentatin DEFINITIONS d) Critical Care; e) Addictin and Mental Health - Inpatient; f) Acquired Brain Injury and Rehabilitatin - Adult; g) Older Adults; h) Prtective Services; and i) ther(s) as required. 6.1 Dcument assessment, ratinale, cnsent btained and plan in accrdance with applicable sectr prcedure. Alternate decisin-maker means a persn wh is authrized t make decisins with r n behalf f the patient. These may include, specific decisin-maker, a minr s legal representative, a guardian, a nearest relative in accrdance with the Mental Health Act [Alberta], an agent in accrdance with a Persnal Directive, r a persn designated in accrdance with the Human Tissue and Organ Dnatin Act [Alberta]. Restraint as a last resrt means all pssible alternative interventins cnsidered and rejected with cnsideratin f the patient s mental and physical cnditin are exhausted befre deciding t use a restraint. Least restrictive restraint means the lwest degree f restraint, used fr the least amunt f time, as apprpriate given the patient s mental and physical cnditin, necessary t inhibit mvement in rder t enable treatment r supprt cntrl f the patient fr safety. Lcmtin means the mvement f an individual frm place t place/rm t rm. Order means a directin given by a regulated health care prfessinal t carry ut specific activity(-ies) as part f the diagnstic and/r therapeutic care and treatment t the benefit f a patient. An rder may be written (including handwritten and r electrnic), verbal, by telephne r facsimile. Patient means an adult r child wh receives r has requested health care r services frm Alberta Health Services and its health services prviders r individuals authrized t act n behalf f Alberta Health Services. This term is inclusive f residents, clients and utpatients. Restraint means any measure used t limit the activity r cntrl the behaviur f a patient r a prtin f their bdy. Alberta Health Services (AHS) PAGE: 6 OF 9
REFERENCES Appendix A: Infrmatin t Cnsider Alberta Health Services Gvernance Dcuments: Cnsent t Treatment/Prcedure(s) Plicy suite (#PRR-01) Restraint as a Last Resrt - Acute Care Inpatient - Adult Prcedure (#HCS-176-04) Restraint as a Last Resrt - Acute Care Inpatient - Pediatric Prcedure (#HCS-176-05) Restraint as a Last Resrt - Addictin and Mental Health - Inpatient Prcedure (#HCS- 176-06) Restraint as a Last Resrt - Acquired Brain Injury and Rehabilitatin - Adult Prcedure (#HCS-176-02) Restraint as a Last Resrt - Critical Care Prcedure (#HCS-176-07) Restraint as a Last Resrt - Emergency/Urgent Care Prcedure (#HCS-176-03) Restraint as a Last Resrt - Older Adults Prcedure (HCS-176-01) Restraint as a Last Resrt - Prtective Services Prcedure (HCS-176-08) Nn-Alberta Health Services Dcuments: Mental Health Act (Alberta) Persnal Directives Act (Alberta) Adult Guardianship and Trusteeship Act (Alberta) VERSION HISTORY Date Click here t enter a date Actin Taken Optinal: Chse an item Alberta Health Services (AHS) PAGE: 7 OF 9
Infrmatin t Cnsider The fllwing infrmatin shuld be cnsidered when restraint is used: 1. Clinical Assessment 1.1 medical symptms, and patient s actins and/ r behaviur leading t cnsideratin f restraint use; APPENDIX A 1.2 functinal status/cntributing factrs leading t cnsideratin f restraint use; and 1.3 methds/strategies used t address medical symptms, and patient s actins and/r behaviurs prir t cnsideratin f restraint use. 2. Envirnmental Assessment 2.1 envirnmental factrs cntributing t behaviurs leading t cnsideratin f restraint use (e.g., nise, lighting, prcedures, peple). 3. Planning 3.1 any discussin with the patient r alternate decisin-maker; 3.2 ratinale fr and gals f restraint use; 3.3 least restrictive restraint selected; and 3.4 plan fr reducing r eliminating restraint use. 4. Implementatin 4.1 recmmended timeline t ntify Physician r Nurse Practitiner and btain rder needed (as sn as pssible); 4.2 infrmed cnsent (in accrdance with AHS Cnsent t Treatment/Prcedures(s) plicy suite) and rder; 4.3 use f Prtective Services and/r number f staff invlved; 4.4 search and remval f ptentially harmful persnal pssessins; 4.5 use f restraint (type, size, perid f time, dcumentatin review); and 4.6 mnitring. 5. Review and Evaluatin 5.1 review f need fr cntinued use f restraint r fr the discntinuatin f restraint; Alberta Health Services (AHS) PAGE: 8 OF 9
5.2 effectiveness f chsen restraint; 5.3 patient s respnse t restraint, including debriefing with the patient, if pssible; and 5.4 add relevant infrmatin t the Reprting and Learning System (recmmended). Alberta Health Services (AHS) PAGE: 9 OF 9