TITLE RESTRAINT AS A LAST RESORT - CRITICAL CARE SCOPE Provincial: Critical Care APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Senior Operating Officer, Glenrose Rehabilitation Hospital PARENT DOCUMENT TITLE, TYPE AND NUMBER Restraint as a Last Resort Policy (#HCS-176) DOCUMENT # HCS-176-07 INITIAL EFFECTIVE DATE February 1, 2018 REVISION EFFECTIVE DATE Not applicable SCHEDULED REVIEW DATE February 01, 2019 NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. If you have any questions or comments regarding the information in this document, please contact the Policy & Forms Department at policy@ahs.ca. The Policy & Forms website is the official source of current approved policies, procedures, directives, standards, protocols and guidelines. OBJECTIVES To provide direction on the use of restraint based on the principle of restraint as a last resort and the practice of least restrictive restraint to guide safety-related care decisions. To assist health care professionals in minimizing risk when patients require the use of physical, mechanical, environmental and/or pharmacological restraint to ensure their safety and the safety of the health care team. APPLICABILITY Compliance with this document is required by all Alberta Health Services employees, members of the medical and midwifery staffs, Students, Volunteers, and other persons acting on behalf of Alberta Health Services (including contracted service providers as necessary) working in Critical Care. Note: When working with Pediatric and/or Older Adult patients, refer to the Restraint as a Last Resort Acute Care Inpatient Pediatric Procedure and/or Restraint as a Last Resort Older Adults Procedure, where appropriate. ELEMENTS 1. Points of Emphasis 1.1 Use of restraint increases the need for patient observation. 1.2 In cases of extreme excited delirium, extra caution and increased monitoring is needed as restraint has been associated with increased risk of sudden cardiac death and asphyxia. Alberta Health Services (AHS) PAGE: 1 OF 6
1.3 The use of restraint has been identified as a risk factor that may precipitate: a) Aspiration; b) skin alterations; c) physical de-conditioning; d) pneumonia; e) increased agitation; and f) delirium. 1.4 Assess for underlying causes for agitated behaviour and provide patient care as appropriate (see Appendix A: Causes of Agitated Behaviour). 1.5 Indication for the use of restraint shall be communicated with the patient/alternate decision-maker during provision of care. 2. Consent 2.1 Restraint may be applied without consent to facilitate emergency health care or to prevent serious bodily harm to the patient or to another person. 2.2 In non-emergency situations, consent is to be obtained prior to restraint use. The methods, risks, and benefits of restraint and non-restraint will be discussed with the patient and/or alternate decision-maker in accordance with the Alberta Health Services Consent to Treatment/Procedure(s) policy suite. 2.3 Refusal of restraint can be made in the absence of risk of serious bodily harm to others or self but it may affect whether/how treatment can proceed. 3. Assessment a) The benefits and risks of restraint removal shall be explained to the patient and/or alternate decision-maker by the most responsible health practitioner (MRHP) and discussion documented on the patient health record prior to removal of the restraint. 3.1 Prior to restraint application the MRHP shall assess if the patient is at risk of harm to self or others. 3.2 The MRHP shall also assess the patient for causes of agitated behaviour as per Appendix A: Causes of Agitated Behaviour. 4. Orders Alberta Health Services (AHS) PAGE: 2 OF 6
4.1 A Physician or Nurse Practitioner order is required for use of all non-emergent restraints, shall be reviewed daily by the MRHP and shall include restraint type. 4.2 Temporary physical or mechanical restraint may be applied to facilitate emergency health care or to prevent serious bodily harm to the patient or to another person without a Physician or Nurse Practitioner order. Note: An order shall be received as soon as possible following the emergency application to continue the restraint. 5. Monitoring and Documentation 5.1 Refer to Appendix B: Monitoring and Documentation for specific monitoring and documentation requirements. 6. Training and Education DEFINITIONS 6.1 Staff shall receive information and training on the use and risks of restraint(s). a) Prior to applying a restraint or caring for a patient with a restraint, staff are responsible to be knowledgeable regarding alternatives to restraints, the application and discontinuation of the specific restraint being used, and the care needs of the patient being restrained. b) Whenever possible, practical information shall be made available to patients and/or family/alternate decision-maker on alternatives to restraints, the application and discontinuation of restraints, and on how to care for patients being restrained. Alternate decision-maker means a person who is authorized to make decisions with or on behalf of the patient. These may include, specific decision-maker, a minor s legal representative, a guardian, a nearest relative in accordance with the Mental Health Act [Alberta], an agent in accordance with a Personal Directive, or a person designated in accordance with the Human Tissue and Organ Donation Act [Alberta]. Family(-ies) means one or more individuals identified by the patient as an important support, and who the patient wishes to be included in any encounters with the health care system, including, but not limited to, family members, legal guardians, friends and informal caregivers. Health care professionals means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act (Alberta) or the Health Professions Act (Alberta), and who practises within scope and role. Health record means the Alberta Health Services legal record of the patient's diagnostic, treatment and care information. Alberta Health Services (AHS) PAGE: 3 OF 6
Least restrictive restraint means the lowest degree of restraint, used for the least amount of time, as appropriate given the patient s mental and physical condition, necessary to inhibit movement in order to enable treatment or support control of the patient for safety. Most responsible health practitioner means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Alberta Health Services to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of their practice. Order means a direction given by a regulated health care professional to carry out specific activity(-ies) as part of the diagnostic and/or therapeutic care and treatment to the benefit of a patient. An order may be written (including handwritten and or electronic), verbal, by telephone or facsimile. Patient means an adult or child who receives or has requested health care or services from Alberta Health Services and its health services providers or individuals authorized to act on behalf of Alberta Health Services. This term is inclusive of residents, clients and outpatients. Restraint as a last resort means all possible alternative interventions considered and rejected with consideration of the patient s mental and physical condition before deciding to use a restraint. Restraint means any measure used to limit the activity or control the behaviour of a patient or a portion of their body. REFERENCES Appendix A: Causes of Agitated Behavior Appendix B: Monitoring and Documentation Alberta Health Services Governance Documents: o Consent to Treatment/Procedure(s) Policy suite (#PRR-01) o Restraint as a Last Resort Policy (#HCS-176) o Restraint as a Last Resort - Acute Care Inpatient Pediatric Procedure (#HCS-176-05) o Restraint as a Last Resort - Older Adults Procedure (#HCS-176-01) VERSION HISTORY Date March 27, 2018 Action Taken Non-substantive change removed note and added to sentence 2.2 Alberta Health Services (AHS) PAGE: 4 OF 6
CAUSES OF AGITATED BEHAVIOUR APPENDIX A Recognition of cause for agitation may prevent further escalation of the unwanted behaviour and reduce or eliminate the need for restraint. Possible Causes for Agitated Preventative and Alternative Strategies for Patient Behaviour Management Gastrointestinal issues Check for and treat constipation. -constipation, urge to Provide toileting assistance regularly. defecate, incontinence Administer antiemetic if ordered for nausea. -nausea Untreated or under treated pain or discomfort Sensory impairment or loss Assess and monitor pain using validated assessment tools (e.g., Critical-Care Pain Observation Tool (CPOT), numeric pain scale). Administer analgesia regularly when indicated. Provided regular repositioning and mobilization. OT/PT consults. Have eye glasses, hearing aids, and dentures in place during the day. Emotional distress, depression, anxiety. Unfamiliar surroundings Malfunction of device. Delirium Abnormal blood work - hypoglycemia, hypoxemia, malnutrition, dehydration, infection. Sleep deprivation Introduce yourself. Use calm, reassuring tone of voice. Take time to listen. Allow patient more control or choices. Provide call bell. Place familiar objects in room (e.g. clock, calendar, family pictures). Encourage family visits and involvement. Reorientation to environment as required. Provide consistent caregivers. Assess for compromise to medical equipment (e.g. obstruction of urinary catheter, interstitial peripheral intravenous catheter). Frequent reorientation and education regarding purpose of medical equipment (e.g. urinary catheter, intravenous tubing, etc). Place tubing/catheters out of patient view whenever possible. Discontinue lines and catheters at earliest opportunity. Administer medication as ordered to treat delirium. Mobilize whenever possible. Monitor and correct abnormal lab values. Monitor for clinical signs of infection. Balance rest and activity. Provide environment conducive to sleep to establish sleep/wake cycle. Alberta Health Services (AHS) PAGE: 5 OF 6
Monitoring and Documentation APPENDIX B Physical Restraint Type Direct application of physical holding techniques to a patient that involuntarily restricts his or her movement. Environmental Example: crib canopy Assess & Document Assessment includes the determination of the least restrictive restraint possible or discontinuation of restraint. Ensure holding technique allows for patient airway and effective respirations. Least amount of physical force is used to keep patient and/or others safe while preparing alternative action (e.g. mechanical restraint, Code White). Document situation leading up to restraint event, description of the event and outcome. Correct position and function of restraint. Discussion with patient and/or ADM (if applicable) Frequency of Assessment, Monitoring & Documentation Continuous monitoring during event. One entry into patient care record per episode. Every 1 hour & PRN Mechanical All Indication for restraint Patient response to restraint Verify daily order on chart Discussion with patient and/or ADM (if applicable) Every (12 hour) shift & PRN Pharmacological 2- point limb 4- point limb Torso Pharmaceutical products are used to control behaviours, actions, and/or restrict freedom of movement, but which are not required to treat an identified medical or psychiatric condition. Circulation of involved limbs uncompromised by restraint (e.g., color, capillary refill, palpable pulse). Correct application site of securement. Range of motion or release of restraint, if appropriate Proper position of patient in restraint. No obstruction/compression of abdomen or chest Torso skin assessment and care with restraint release Monitoring and equipment as per AHS Parenteral Manual specific drug monographs or prescriber order. Richmond Agitation Sedation Scale (RASS) to achieve goal RASS as per prescriber order. Verify daily order on chart Every 1 hour & PRN Every 30 minutes & PRN During regular repositioning (every 2 hours) RASS assessment and documentation prior to administration, after administration, and with any additional dosing or titrations Alberta Health Services (AHS) PAGE: 6 OF 6