POLICY OF LEAST RESTRAINT

AUTHORIZATION: Page 1 of 24 POLICY 1. North York General Hospital (NYGH) supports a philosophy of least restraint/last resort based on the following four principles: administrative staff support front line staff in least restraint/last resort clinical care; all appropriate alternatives will be explored before a restraint is used; in the event that alternatives have not successfully eliminated/reduced risk factors, the decision to use the appropriate and least restrictive type of restraint will reflect a collaborative process between the Health Care Team and the patient/family or SDM as applicable; and a restraint device will be applied for the shortest period of time. 2. Restraint* is only used to prevent serious bodily harm by a patient to self or to others, and may be applied when: a Health Care Team assessment and analysis of the patient s behaviour has been completed (in emergent situations a thorough analysis may not be practical until the crisis is under control); the patient/family or substitute decision maker (SDM) has consented (in emergent situations, where consent could not be obtained, consent must be obtained retroactively); and a doctor s order has been obtained (in emergent situations, where an order could not be obtained, the order must be obtained retroactively). 3. Restraining all four limbs simultaneously is an extraordinary measure and is used only when all other measures of less restraint have been considered and/or exhausted and deemed to be ineffective (not practical). Restraint of all four limbs simultaneously, must be accompanied by constant observation. 4. NYGH is committed to providing education to NYGH staff with respect to the use of appropriate alternatives to restraint, as well as the choice and application of restraint once the decision to restrain has been made. 5. NYGH is committed to providing education and support to the patient to be restrained and/or to his or her family/sdm. 6. Quality reporting of restraint prevalence and of adverse outcomes due to restraint is an expectation. ***Restraint must be differentiated from safety devices. Safety devices are devices that remain under the control of the individual. For example, when an individual can remove a seat belt on a wheelchair or direct its removal, it is a safety device. The same device

AUTHORIZATION: Page 2 of 24 with a cognitively impaired individual who cannot remove, or direct its removal, is a form of restraint. Safety devices are not included as part of this policy. DEFINITIONS Restrain: placing a person under control by the minimal use of mechanical, chemical, or environmental restraint as is reasonable having regard to the person s physical and mental condition. Chemical Restraint: a psychopharmacologic drug used for the purpose of controlling, inhibiting, or restricting a patient s behaviour. It is not required to treat medical symptoms. Environmental Restraint: any barrier or device that limits the locomotion of an individual, and thereby confines an individual to a specific geographic area or location. For example, a geri chair used to confine patient movement is a restraint. However, arm boards for intravenous administration, stretcher straps, and self-releasing buckles for transportation are not considered to be restraints. Health Care Team: is comprised of professionals who are involved in the care of the patient and may include but is not restricted to nurses, occupational therapists, physicians, physiotherapists, and social workers. Mechanical Restraint: any physical/mechanical device, material or equipment attached to or adjacent to the patient s body that the patient cannot remove easily and which restricts free movement or access. Alternative Method: a method that imposes less control on the patient than restraint or confinement or the use of a monitoring device. PROCEDURE/PROCESS 1.0 NON EMERGENT SITUATION 1.1 The Health Care Team will conduct a comprehensive, documented assessment of the patient s behaviour including: reviewing the patient s history in relation to a prior application of restraint; evaluating the level of risk for serious bodily harm to self and/or others; assessing potential adverse effects to the patient resulting from the use of a restraint (e.g. demoralization, agitation, disorientation, incontinence, skin breakdown, pneumonia, decreased mobility, and falls etc.); and

AUTHORIZATION: Page 3 of 24 considering the conditions(s) and/or precipitating event(s) that led to the patient s current behaviour (i.e. the emotional/behavioural, pharmacological, cognitive, and physical status of patient). 1.2. Explore Alternative Methods to restraint with patient/family/sdm (refer to Appendix A). Implement interventions/alternative methods to address possible underlying cause(s) of the behaviour (e.g. verbal de-escalation, re-orientation, pain management, toileting, etc.). Document the patient s response to the Alternative Methods. 1.3. Provide the patient/family/sdm with a copy of the pamphlet Recovering in a Least Restraint Environment. These brochures can be ordered through our printing department. 1.4. In the event that restraint is indicated, the Health Care Team will: a) Discuss and document the restraint process with the patient/family/sdm, and address the following issues: - Alternative Methods that have been attempted/considered; - reason(s) for restraint; - type of restraint suggested and the associated risks; - time frame during which restraint may be necessary; and - risk(s) associated with not restraining the patient. b) Collaborate with the patient/family/sdm to develop a documented plan of care; c) Document the patient/family/sdm s choice in the patient s health record; d) Document the rationale for the application of restraint in the patient s health record; e) Obtain and document verbal consent from the patient (if the patient is capable) or from the SDM (if the patient is not capable); f) Obtain a doctor s order which includes: - type of restraint applied (mechanical/chemical/environmental); and - condition for which the restraint is being used (refer to Appendix B). 1.5. Where the patient/family/sdm refuse the use of restraint and when the need for restraint is deemed necessary and it is not an emergency situation, other strategies considered by the Health Care Team may include: a psychiatric consultation for assessment under the guidelines of the Mental Health Act; a medical consultation; consultation with the hospital ethics team; or discharging the patient.

AUTHORIZATION: Page 4 of 24 1.6. Refer to Restraint Decision Tree (Appendix C) for a summary of the steps involved in a non-emergent situation. 2.0 EMERGENT SITUATION 2.1. If necessary, call a Code White for extra support to manage patient behaviour as per NYGH s Emergency Procedure. 2.2. Choose the method of least restraint. 2.3. The Health Care Team will conduct a comprehensive, documented assessment as soon, as is reasonably possible. This assessment will include: the patient s history in relation to a prior application of restraint; and the condition(s)/precipitating event(s) that led to the initial application of restraint, e.g., emotional/behavioral, pharmacological, cognitive, and physical status of patient. 2.4. Obtain a doctor s order that includes: the type of restraint applied (mechanical/chemical/environmental); and the condition(s) for which the restraint is being used (refer to Appendix B). If an order for mechanical restraint cannot be obtained in advance, the most responsible physician writes a retroactive order within 12 hours from the time of application of the restraint. 2.5. If there is an immediate threat of serious bodily harm to self and/or others and obtaining verbal consent prior to applying restraint is not practical, obtain consent as soon as possible and within 12 hours of applying the restraint. The member of the Health Care Team, who obtained the verbal consent, records the details in the patient s health record. 2.6. Where the patient/family/sdm opposes restraint and the need for restraint continues to be necessary: - Maintain the restraint as appropriate to ensure the safety of both patient and others ; - Consult with the attending physician and request a prompt medical/psychiatric assessment; - Seek the assistance of the Crisis Team as appropriate; and - Notify the most responsible physician as appropriate. 2.7. If the SDM is insistent that the patient be restrained despite the Health Care Team advising against restraint, inform the most responsible physician and facilitate ongoing discussions between the Health Care Team and the SDM to negotiate a resolution. 2.8. Document all events, decisions and subsequent actions in the patient s health record.

AUTHORIZATION: Page 5 of 24 2.9 Refer to Restraint Decision Tree (Appendix C) for a summary of the steps involved in emergent situations. 3.0 MONITORING THE USE OF RESTRAINT 3.1. Once a restraint is applied, it is mandatory that the appropriate monitoring occur to ensure that the patient s health care needs and safety requirements are met and documented on both the Restraint Application Flow Sheet and the patient s health record. 3.2. Assessment Observation Frequency Q15 minutes until patient s behaviour stabilizes Q1hr until restraint discontinued Constant observation if 4 or 5 points restraint Criteria (brief observation) Level of consciousness, circulatory/respiratory status, patient behaviour, nutrition/elimination needs, range of motion ability, skin integrity, psychological status 3.3. Hourly clinical assessments and care of the patient must be documented on the Restraint Application Flow Sheet (refer to Appendix D). 3.4. The substantive need to continue the use of restraint must be re-evaluated regularly and documented at the beginning of every shift and at a minimum every 4 hours. The documentation will include the patient s response to the restraint, the appropriate type of restraint, and alternative measures that could be applied (refer to Appendix A). 3.5. Restraints must be re-ordered every 24 hours. The rationale for continued use must be documented (refer to Appendix C). 3.6. PRN mechanical/environmental restraint orders are not acceptable. 3.7. Discontinue restraint as soon as the patient no longer meets criteria for restraint use. A doctor s order is not required to discontinue a mechanical/environmental restraint. Document removal. 4.0 DOCUMENTATION 4.1. Complete the Mechanical Restraint Physicians Orders (Appendix B; Form 1877): when initiating restraint; when changing interventions to a greater form of restraint; and every 24 hours to medically re-new the use of restraints.

AUTHORIZATION: Page 6 of 24 4.2. Complete the Restraint Application Flow Sheet (Appendix D; Form 1880): at the initiation of restraint; and every hour while the patient is restrained. 4.3. Other documents that could be utilized in the patient s health record include: Doctor s Order Sheet; and Vital Signs Record and Fluid Balance Record. 4.4. Documentation on the kardex will include: date and time that restraint was initiated; type of restraint applied; date consent was obtained and name of person who provided consent; date consent was refused and name of person who refused to provide consent; date for next review by HCT and doctor s order to continue restraint Q24 hours; and audit tool completed as indicated (refer to Appendix E) 5.0 EDUCATION 5.1 Nurse clinicians, unit coordinators and other members of the Health Care Team orient all staff members, including physicians, who may care for patients in restraint. The education protocol will include both the guidelines regulating the appropriate use of restraint and a systematic review of the Restraint and Code White policies. 5.2. Ongoing education to unit staff includes: - alternatives to restraint; - implementation of the restraint policy; and - approved restraints and their proper application. 6.0 AUDITING 6.1. Unit Coordinators will ensure that audits are completed for all patients placed in mechanical restraint (refer to Appendix E). 6.2. The information included in the data collection form is provided by the Unit Coordinator to the program based Quality, Utilization & Risk Management (QURM) Partner. 6.3. The QURM partner reviews and tabulates the results of the unit audits in a written monthly report sent to the Unit Administrator and Nurse Clinicians/CNS. 6.4. The Unit Administrator discusses the audit reports with the clinical staff involved in the care of patients in restraint.

AUTHORIZATION: Page 7 of 24 6.5. The Nurse Clinician will identify learning needs and facilitate educational sessions to address these needs. 7.0 EQUIPMENT 7.1. Only items/materials that have been specifically designed as restraint may be used. Commercially manufactured restraints must be used as intended by the manufacturer and are not to be modified or adapted in any way. Staff must refer to the manufacturer information, including the application procedures for specific types and brands of restraint. Use of a non-approved item will lead to a practice review. Mechanical restraints banned from use include but is not limited to the following: - Bandages; - bed linen; - tape; - towels; and - Homemade devices. 8.0 ORDERING AND MAINTAINING APPROVED RESTRAINTS (Refer to Appendix F) 8.1. Units/departments/programs, where applicable, maintain an adequate supply of approved restraints. 8.2. To purchase restraint devices contact: Pinel Medical Inc. or Posey CA. 8.3. Follow the instructions on the manufacturer package inserts for use, cleaning, disposal and/or maintenance of the restraint. 8.4. For cleaning non-disposable restraints, place soiled restraint into the laundry bag clearly marked with the unit name and location, and send it to the in-house laundry at each site. 9.0 APPLICATION OF RESTRAINT 9.1 Attach restraint straps (Posey wrist, ankle, and mitts) only to the bed frame that supports the mattress not to the bed frame that supports the bed wheels. Incorrect attachment (e.g., bed rails) of the restraint straps can result in adverse patient outcomes. 9.2 If not using a universally sized restraint, choose the appropriate restraint size for the patient.

AUTHORIZATION: Page 8 of 24 9.3 Restraints must always be applied according to the manufacturer s instruction. While restrained in bed the patient must always be kept either in a fowler s position or a sidelying position with both arms and/or legs secured to the same side of the bed. NEVER PLACE A PATIENT IN A PRONE POSITION WHILE IN RESTRAINT. 9.4 Always examine the restraints before application to ensure that they are in good working order. Replace when required. 10.0 SUPPORTING DOCUMENTATION Appendix A: Alternative Methods Appendix B: Mechanical Restraint Physicians Orders Appendix C: Restraint Decision Tree Appendix D: Restraint Application Flow Sheet Appendix E: Restraint Evaluation Tool Appendix F: Approved Restraint Devices

AUTHORIZATION: Page 9 of 24 REFERENCES College of Nurses of Ontario (1999). A Guide on the Use of Restraints. Toronto, Canada. Health Care Consent Act, 1996. 2002, c. 18, Schedule A, s. 10. Ontario, Canada. London Health Sciences Centre. (Date Unknown). Use of Restraint. Policy PCC020. Ontario Hospital Association (2001). Report of the Restraints Task Force. Publication #0-88621- 302-9. Toronto, Canada. The Ottawa Hospital (2002). Least Restraint Last Resort. Policy No. Unknown. Sunnybrook & Women s Health Sciences Centre (2002). Least Restraint Policy. Policy I-I-3000. University Health Network. (2004). Clinical Patient Restraints Minimization. Policy 3.30.007.

AUTHORIZATION: Page 10 of 24 APPENDIX A ALTERNATIVE METHODS In accordance with OHA Guidelines and our policy of least restraint, restraint may be used only where, in the judgment of the health care practitioner, the behavior of the patient indicates that he or she is at risk of causing serious bodily harm to himself or herself or another person. Restraint will be used only when alternative measures have been tried and have been determined to be unsuccessful or not feasible. Do explain your care plan to patient/client Do ensure physical comfort & privacy Do reduce level of environmental stimuli, where possible Do ensure expectations don t exceed patient/client abilities Don t take patient s behaviour personally Don t argue with patient or provide any reason for anger to focus on staff Don t threaten to use restraints

AUTHORIZATION: Page 11 of 24 PRESENTING PROBLEM SUGGESTED ALTERNATIVES 1. FALLS PREVENTION Assess for risk factors for falls such as altered mental status, impaired mobility/balance/gait, weakness, altered urinary elimination, benzodiazepine or tranquilizer use, sensory impairment etc. Family supervision and/or sitter, as arranged with family Individualize care based on patient s risk factors; consult with team members Monitor mental status Medication review Toileting regularly and modification of routine if required Call bell demonstration Exercise: mobility/ambulation Routine positioning Increased participation in ADL Pain relief/comfort measures Normal schedule/individual routine Assess for hunger, pain, heat, cold Glasses, hearing aids, walking aids easily available Increase social interactions Redirect with simple commands Involve family in planning care Diversional activities: pets, music, puzzles, crafts, cards, snacks Scheduling daily naps Clutter free rooms Mattress on floor Mat on floor beside bed Room close to nursing station Chair close to nursing station Identify with purple sticker/band Include high risk status in report

AUTHORIZATION: Page 12 of 24 PRESENTING PROBLEM SUGGESTED ALTERNATIVES 2. COGNITIVE IMPAIRMENT: DEMENTIA Assess for early signs of escalating behavior (e.g. verbal abuse, conflict with others, pacing, agitation, anger, and distress). Assess underlying cause (e.g. physical illness, medication, stressors (stress threshold decreased with dementia), fear of losing control, patient feeling rights violated or needs ignored or unreasonable use of ward rules. Don t take patient s behavior personally Don t argue with patient or provide any reason for anger to focus on staff Don t threaten to use restraints Provide opportunity for patient to work through feelings in a non-threatening manner Offer choices to help patient regain control (quiet time in room to decrease stimuli; a 1:1 talk with staff, soft music or relaxation tape while remaining with patient, beverage, offer prn medication and stay with patient until settled) Kindly but firmly explain expected behavior Offer reassurance/support when patient in control Normal schedule/individual routine Gentle touch Redirect with simple commands Assess past coping strategies Ensure demands don t exceed patient abilities Q15min observation for safety and reassurance Identify your intent to help and explain actions Ensure physical comfort and privacy Reduce level of environmental stimuli prn Modify routine care as needed (e.g. delay or minimize bathing)

AUTHORIZATION: Page 13 of 24 PRESENTING PROBLEM SUGGESTED ALTERNATIVES 3. CONFUSION: DELIRIUM Consult appropriate team members Medication review Pain relief/comfort measures Toileting regularly Normal schedule/individual routine Assess for hunger, pain, heat, cold Label environment (e.g. bathroom door) Increase social interactions Redirect with simple commands Gentle touch Assessing past coping strategies Involve family in planning care

AUTHORIZATION: Page 14 of 24 PRESENTING PROBLEM 4. PREVENTING REMOVAL OF TUBES/INVASIVES SUGGESTED ALTERNATIVES Assess whether the therapy is absolutely required. How life threatening is removal/disruption and how immediate is the harm? Have the treatment benefits and restraint risks been discussed with pt/sdm? What are the patient s wishes? Are the patient s physical and emotional needs being met? Are there reversible causes of changes in mental status? Is treatment painful? Stimulation/meaningful distraction. Cover or disguise tubes with long sleeves, pants, kling bandage, wristbands etc Convert IV s to heparin locks Substitute p.o. or IM meds for IV meds Give gravol for vomiting, don t start IV Consult dietitian Use elbow splints Use intermittent catheterization not foley Try a toileting schedule or retraining Provide simple explanations and permit guided exploration of tubes Keep IV pole and bag out of patient s sight For patients with tube feedings, ask for swallowing reassessment prn Monitor and treat pain (e.g. treatment of infections/irritation, removal of crusting, provision of analgesics) Arrange family/sitter supervision Provide appropriate diversional activity If restraints are ultimately needed, choose least restrictive option.

AUTHORIZATION: Page 15 of 24 PRESENTING PROBLEM SUGGESTED ALTERNATIVES 5. WANDERING Assess reason (e.g. medication, under/over-stimulation, prior lifestyle or coping mechanism, attempts to satisfy need for food, bathroom, exercise, light, company). Assess pattern of wandering: onset, time, duration, frequency, precipitating factors etc. Meet physical, emotional and social needs Respond to the patient s feelings e.g. you must be lonely instead of you can t go home Give orienting information only on patient request or if it calms patient Post photo, sign or familiar object on door Post picture of toilet on washroom door Provide familiar objects at bedside e.g. bedspread. Adjust level of stimulation to patient s needs Disguise exits with paint or cloth Use visual barriers: stop signs, grid on floor Provide exercise (walking, bicycle pedals, rocking chair) Place patient s chair at nursing station Improve navigation skills by breaking journey into small steps Provide activities e.g. folding laundry Distract patient with food/activities at peak times Arrange family/volunteer visits at peak times Redirect the person in a positive manner e.g. come with me instead of don t go out. 6. POSITIONING Assess positioning problem e.g. sliding, leaning, falling forward, knees swept to one side, needing frequent repositioning. Assess positioning pattern e.g. length of time in chair before positioning problem occurs, tasks or time of day associated with positioning problem, patient fatigue or pain. Position hips, knees and ankles as close to 90 degrees as possible. Watch for deformities or recent surgery that may prevent this. Ensure buttocks and thighs fully supported on seat and weight not on one small area only. Ensure pelvis is flush with backrest and isn t crooked. Ensure buttocks are fully back in chair. Assist patient to lift buttocks out of chair if unable to relieve discomfort. Consider requesting OT/PT referral for pressure relief cushion. Request referral to OT/PT if patient can t mobilize in wheelchair because feet don t reach floor or hands can t grip or reach wheels. Ensure feet are well supported with feet flat on footrests or floor to prevent sliding, shifting, leaning. Consider using tilt position for rest periods. Determine if more frequent naps in bed are needed.

AUTHORIZATION: Page 16 of 24 APPENDIX B MECHANICAL RESTRAINT PHYSICIANS ORDERS FORM 1877 01/07 1. All alternatives to restraints have been attempted and documented in the Plan of Care: Yes No (Refer to Appendix C Decision Tree, and Appendix A Alternative Methods) 2. Clinical Indication for the use of restraint: Confused Agitated Impulsive Pulling at invasive lines Threatening Behaviour Wandering Unsteadiness/Falls/Positioning Maintain straight extremity Weaning from IV paralytics/sedation Unable to comply with instructions (reason): Other 3. Type of Restraint: A) Mechanical: Lap/Waist Wrist/Mitts Ankle 4 Points Other C) Other (e.g. environmental): Restraints must be re-ordered every 24 hours ALLERGIES: No Yes: PHYSICIAN S SIGNATURE: POSTED BY: DATE: TIME: DATE: TIME: YELLOW COPY TO PHARMACY NORTH YORK GENERAL HOSPITAL PHYSICIAN S ORDERS

AUTHORIZATION: Page 17 of 24 APPENDIX C Restraint Decision Tree Assess patient Risks for injury to self and/or others identified Yes Emergent situation? No Violent Patient Serious harm to self/others immediate Call Code White Non-Violent Patient Serious harm to self immediate Choose & apply method of Least Restraint HCT collaborates with patient/family or SDM to identify: Precipitating events/conditions to current behaviour; Potential interventions to reduce risk of injury to self and/or others Obtain consent & Doctor s order (within 12 hours of application) Initiate Restraint Application Flow Sheet Complete Restraint Physician Orders Document as per policy Continue to monitor behaviour Alternative Methods? No Implement Document Monitor Alternatives work? Yes Remove restraint and document as per policy Continue to monitor behaviour Is acute situation resolved? No Consult with patient/family or SDM to develop & implement plan of care Ensure method of Least Restraint Consult with patient/family/sdm to plan for application of restraints Choose method of Least Restraint Obtain consent and Doctor s order Apply restraint & implement plan of care Initiate Flow Sheet & Restraint Protocol/Orders Provide ongoing support/education to patient/family/sdm Document in clinical notes as per policy Provide ongoing support/education Maintain Flow Sheet & Restraint Protocols/Orders Document in clinical notes as per policy Continue to monitor behaviour Review/ revise use of restraint as per policy

AUTHORIZATION: Page 18 of 24 APPENDIX D RESTRAINT APPLICATION FLOW SHEET (FORM 1880; 01/07) Date: Cognitive/Emotional/Behavioural Status TIME 0730 0830 0930 1030 1130 1230 1330 1430 1530 1630 1730 1830 Oriented Confused Anxious: Agitated/Restless Defensive: Verbal Abuse/Intimidation Physically: Abusive/Intimidating Tension Reduction: Demonstrate Rational/Emotional/Physical control Other: Type of Restraint Lap/Chair Limb: R - right, L left, W wrist, A ankle Number of Points: 1, 2, 3, 4, 5 Waist Mitts indicate R hand, L hand or B - both hands Other: Monitoring & Nursing Care Monitored: Q 15 until stable and then Q 1 hr until restraints are discontinued Circulation check: Colour, Sensation, Movement: Q 15 x 1 st hr, then Q 1 hr Nourishment: Liquids & Food (wake Pt at mealtime & record all intake) Elimination: Toileting Q 2 hrs (document all BMs; watch for constipation) Skin Care: BID & PRN Hygiene: Full bath Daily & PRN Mouth Care: PC, HS & PRN Vital Signs: Q 4 hr recommended or Q hr as ordered by physician Restrained limbs rotation: Q 2 hrs Range Of Motion Exercises: BID & PRN while awake; indicate Active/Passive Call Bell within reach at all times Constant care: (required during 3, 4 & 5 points restraint) Signature & Status Initials Signature & Status Initials Signature & Status Initials

AUTHORIZATION: Page 19 of 24 APPENDIX D RESTRAINT APPLICATION FLOW SHEET (FORM 1880; 01/07) Date: Cognitive/Emotional Status TIME 1930 2030 2130 2230 2330 0030 0130 0230 0330 0430 0530 0630 Oriented Confused Anxious: Agitated/Restless Defensive: Verbal Abuse/Intimidation Physically: Abusive/Intimidating Tension Reduction: Demonstrate Rational/Emotional/Physical control Type of Restraint Lap/Chair Limb: R - right, L left, W wrist, A ankle, B-both Number of Points: 1, 2, 3, 4, 5 Waist Mitts indicate R hand and/or L hand Monitoring & Nursing Care Monitored: Q 15 until stable and then Q 1 hr until restraints are discontinued Circulation check: Colour, Sensation, Movement: Q 15 x 1 st hr, then Q 1 hr Nourishment: Liquids & Food (wake Pt at mealtime & record all intake) Elimination: Toileting Q 2 hrs (document all BMs; watch for constipation) Skin Care: BID & PRN Hygiene: Full bath Daily & PRN Mouth Care: PC, HS & PRN Vital Signs: Q 4 hr recommended or Q hr as ordered by physician Restrained limbs rotation: Q 2 hrs Range Of Motion Exercises: BID & PRN while awake; indicate Active/Passive Call Bell within reach at all times Constant care: (required during 4 & 5 points restraint) Signature & Status Initials Signature & Status Initials Signature & Status Initials

AUTHORIZATION: Page 20 of 24 APPENDIX E MECHANICAL RESTRAINT EVALUATION TOOL Data Collection Form Data Collectors: Program/Unit: / 1. Date (d/m/yr): / / 2. Sample Size: Case # Totals Results Evaluation Criteria 1 2 3 4 5 6 7 8 9 10 11 + - % of + If alternative intervention(s) were applied complete questions 1-5 1. Was a comprehensive assessment completed and documented? 2. Does the documented comprehensive assessment include: a description of the behaviour, conditions and/or precipitating events; level of risk for injury to self/others; relevant history of similar behaviour? 3. Did the Health Care Team and patient/family/sdm collaborate to determine appropriate alternative interventions? 4. Was a copy of the Least Restraint brochure given to patient/family/sdm? 5. Was the use of alternative interventions & the related outcomes documented? If restraint(s) was applied complete questions 6-13 6. Did the patient demonstrate a high risk of serious bodily harm to self /others? Was this documented? 7. Was the process of applying restraint discussed with the patient/family/sdm? Was a plan of care developed? 8. Was consent and a doctor s order obtained from the patient, family/sdm prior to the application of restraint? (non-emergent) 9. Was consent and doctor s order obtained within 12 hours of applying restraint? (emergent) 10. If restraint continued to be applied, was a doctor s order provided q 24 hours? 11. Once restraint was applied was patient monitored Q 15 minutes until behaviour stabilized? 12. Was the Mechanical Restraint Application Flow Sheet(s) initiated & completed Q24 hours as per policy? 13. Has a summary of the patient s status, behaviour, care needs & interventions been completed Q shift? + = completed - = not completed

AUTHORIZATION: Page 21 of 24 APPENDIX F Approved Restraint Devices Locked Restraint Devices The Pinel restraint devices are the approved NYGH Corporate Standard for locked restraint that can be utilized in Mental Health, ER, Critical Care and Pediatrics. All Pinel products have been approved. For complete product description, usage, maintenance and application instructions please refer to website: www.pinelmedical.com or contact Ludwig (Lud) Piron from Pinel Medical Inc. either by email at: pinel@golden.net or by calling 519-888-0997. Mental Health, ER, Critical Care and Pediatrics are responsible for determining and ordering a sufficient number of products to meet the needs of their patients/clients. Each unit will be responsible for determining how and where the devices will be stored. **Pinel recommends renewing magnetic keys every 2 years. PRODUCT CHOICES: (1) PINEL MEDICAL INC. Restraint Device Descriptive Components Model Number COMPLETE SET 1 Waist Belt, 2Button/Pin/Lanyard, I Button/Long Pin, 3 Keys, 4 Limb, 7 I Shoulder, 1 Extender, I Bed Strap WAIST 1 Waist, 2 Side Straps, 2 Button/Pin/Lanyard, 1 Button/Pin, 1 3 Key PELVIC STRAP 1 Pelvic Strap 1 Button/Pin 11 EXTENDER 1 Extender, 1 Button/Pin 2 SHOULDER BELT 1 Shoulder, 1 Button/Pin/Lanyard, 1 Large Pin/Button 3 LIMB BELT Keys are separate 1 Limb, 2 Button/Pin/Lanyard 4 BED STRAP 1 Strap, 2 Button/Pin/Lanyard 8 SIDE STRAP 1 Strap 1A BUTTON (Only) 1 Button 6A PIN (Only) 1 Pin 6B BUTTON/PIN 1 Button, 1 Pin 6 BUTTON/PIN/ 1 Button, 1 Pin joined by Lanyard 6L LANYARD MAGNETIC KEY 1 Magnetic Key 5 It is recommended that additional keys be purchased, the cost is $7.00 per key.

AUTHORIZATION: Page 22 of 24 APPENDIX F Approved Restraint Devices POSEY CA: Posey Restraint Jackets are no longer utilized at NYGH. Based on the behaviour manifestation restraint devices have been listed in order of Least to Most restrictive. Behaviour Manifestation Tube Pulling Unassisted bed exit Sliding forward off chairs Unassisted exit from chair Restraint Device Cat # Skin Sleeve for both arms and legs: assortment of 6000 to sizes and skin tones 6005 Mitts: Peek-A-Boo style recommended 2811 Limb Holders - disposible 2510 Sitter Select Alarm (attaches to beds, chairs) Roll Belt (attaches to beds) 1231 Bed Bumpers 5712 to 5714 Split Side Rail Protectors 5705 Grip non-slip matting Soft Belt (attaches to bed or chairs) 4125Q Padded Belt (attaches to chairs) 4135 Wedge Foam Pommel Cushion (used with belts protects from forward sliding off chairs) Wedge Gel Foam Cushion Wedge Foam Cushion 2-tone colour Y Belt (protects from forward sliding off chairs) 4120 Torso Support soft belt or padded belt must be 3656 worn with torso support Sitter Select Chair Pad Alarm System Sitter Select Wheelchair Belt System Sitter Select Gel Foam Cushion Alarm System Lap Hugger for desk arm & full arm wheelchairs Tabletop Hugger 6506 Wandering Door Guard Alarm 8205 Stop Sign 8209 Disposable limb restraint devices by Posey are the established standard across the organization and will be stocked on the medical carts. The number of limb restraint will be determined by the Unit Administrator and will be ordered in the same manner as other supplies are ordered for the medical carts.

AUTHORIZATION: Page 23 of 24 NORTH YORK GENERAL HOSPITAL RECOVERING IN A LEAST RESTRAINT ENVIRONMENT Your recovery during your hospitalization is important to us. Our philosophy on the use of restraints encourages independence while taking into consideration your comfort and safety. We believe that: It is important to have a safe environment for all patients, family and staff. Getting stronger and more independent speeds your recovery. A restraint should be used only when other ways to help you don t work. You and your family or substitute decision-maker will be involved in your care and in making decisions about the use of a restraint. You, your family, or substitute decision-maker can say no to a restraint unless you are at serious risk of hurting yourself or someone else. You can decide how much risk you want to take. Using a restraint may increase risk in some situations. If a restraint is needed, it will only be used with the very best of care. Patient Restraints Minimization Act, (2001) To restrain means: To place the person under control by the minimal use of such force, mechanical means or chemicals as is reasonable having regard to the person s physical and mental condition. 1 Alternatives to Restraints The team knows of many different ways to help you without having to use a restraint. You and your family may be asked for suggestions. Some examples of ways to avoid using a restraint include: Having family/friends at bedside Increasing exercise or walking Music

AUTHORIZATION: Page 24 of 24 Using hip protectors Identifying and treating pain or physical discomfort Keeping a regular routine Reviewing and/or changing medications Activating our hospital wandering policy Using reminders such as signs, staff reassurance etc. If a restraint is necessary, we will: Find out why it is needed Work with you and everyone on the health care team to try other ways to help Keep you informed Use the least restraint possible Keep a close watch Continually reassess and stop the restraint as soon as possible Continue to provide excellent and compassionate patient care tailored to meet your individual needs Questions? Feel free to ask the health care team any questions, or to share your concerns: 1. This information is adapted from The Patient Restraints Minimization Act, 2001 This flyer contains general information, which cannot be construed as specific advice to an individual patient. Adapted from The Ottawa Hospital, 2002