Download 7.0 Protocol for Use of Physical Restraint in the

Document Title and Code:
Restraint Use Policy. NMA/RU.
Version:
3
Author:
Prepared by Nursing Matters and Associates
Adapted for local Use by:
Issue Date:
March 2016
Review date:
March 2019
Authorised by:
1.0 Policy Statement.
It is the policy of the Centre that the use of restraint will be considered as a last resort, used in
accordance with the requirements outlined in this policy and with the intention of providing a
positive outcome for the resident.
2.0 Purpose:
The purpose of this policy is to ensure that decisions regarding the use of restraint place the
needs, rights, known wishes and preferences of the resident at the centre of all decision–making
and promote the best possible outcome for the resident.
3.0 Objectives:
3.1
To outline the requirements for use of restraint, including specific procedures to be followed
where the use of restraint is deemed appropriate.
3.2
To promote an environment that minimizes the need for restraint use.
3.3
To promote alternative approaches to the use of restraint.
4.0 Scope:
This policy applies to all staff employed by or providing a service to residents in The Centre.
5.0 Definitions:
The Centre adopts the following definitions for restraint as stated in the national policy for a
restraint free environment (DOHC, 2011)
5.1
Restrictive Procedure or Restraint is broadly defined as the intentional restriction of a
person’s movement or behavior, including physical, chemical and environmental restraint.
(DOHc, 2011; HIQA, 2013)
5.2
Physical Restraint is defined as:
‘any manual method or physical or manual device, material or equipment attached or
adjacent to the resident’s body that the individual cannot easily remove that restricts
freedom of movement or normal access to one’s body’(HIQA, 2009 and 2013; DOHC,
2011).Easily remove: The device can be removed intentionally by the resident in the same
manner as it was applied by the staff considering the resident’s physical condition and ability to
accomplish the objective.
5.3
Freedom of movement: Any change in place or position for the body or any part of the body
that the person is physically able to control. While equipment which promotes the
independence, comfort or safety of a resident or which is specifically requested by the
resident may be appropriate in specific circumstances it may also constitute a physical
restraint under the definition above.
5.4
Chemical restraint: the intentional use of medication to control or modify a person’s
behaviour or to ensure a patient is compliant or not capable of resistance, when no medically
identified condition is being treated; where the treatment is not necessary for the condition; or
the intended effect of the drug is to sedate the person for convenience or for disciplinary
purposes. The appropriate use of drugs to reduce symptoms in the treatment of medical
conditions such as anxiety, depression, or psychosis, does not constitute restraint. Chemical
restraint is always unacceptable.
5.5
Environmental restraint: the intentional restriction of a resident’s normal access to their
environment, with the intention of stopping them from leaving, or denying a resident their
normal means of independent mobility, means of communicating, or the intentional taking
away of ability to exercise civil and religious liberties.
5.6
Enabler: During the course of care planning a decision may be made to use a device or item
for the specific purpose of enabling functional ability. Such an item / device would be referred
to as an ‘enabler’ or enabling device, only if it does not restrict the residents’ independent
movement and is used only for the period where enablement is required. An example of such
a device would be the use of a lap tray to promote independence with eating and / or
drinking.
However, if the ‘enabling’ device also restricts movement and cannot be easily removed by
the resident, under the national policy, this device / item would be considered both an
‘enabler’ and a restraint and its use would be subject to the same conditions and
requirements (laid out in this policy) as for any other form of restraint use.
6.0 Responsibilities.
Actions.
Responsible Person (s)
Nurses and healthcare staff will be provided with an explanation of
the policy for management of restraint use as part of an induction
Person in Charge
programme.
Nurses will maintain their competence in management of restraint use
and communicate any knowledge deficits / education needs to the
All registered nurses.
Person in Charge.
Where any form of restraint is being considered, an assessment for
All registered nurses.
same will be completed in accordance with this policy.
Where any form of restraint use is being considered, the resident as
All registered nurses.
far as he/she is able must be involved in decision-making.
Where restraint use is deemed as providing the best outcome, a plan
Designated nurse or senior
of care to include monitoring for side effects; meeting care needs and
nurse on duty in collaboration
measures to minimise or eliminate the use of restraint will be
with other nurses on duty as
documented.
well as other healthcare
professionals involved in the
resident’s care.
Where restraint is used in an emergency situation, an assessment of
the presenting problem/behaviour as per this policy will be carried out
All nursing staff on duty.
at the earliest opportunity and include completion of the restraint
assessment.
A restraints register will be maintained in The Centre.
Person in Charge.
Every episode / incident involving the use of restraint in The Centre
All registered nurses.
will be documented and reported.
Any episode involving the emergency /unplanned use of restraint will
Person in Charge.
be discussed at the next scheduled clinical governance meeting or
within 5 working days if the episode involved an incident that resulted
in injury or harm to anybody in The Centre.
Decisions regarding the use of bed rails will adhere to the
requirements of this policy with particular reference to the risk
assessment outlined.
All nursing and care staff.
7.0 Protocol for Use of Physical Restraint in the Centre.
7.1
7.1.1
Circumstances where physical restraint is not permitted.
For a resident who is wandering, unless the behaviour poses an immediate and serious
risk to the resident or others. In this case restraint must be used only as a time limited and
least restrictive intervention.
7.1.2
To prevent falls, unless the risk of harm is immediate and serious and there are no other
alternatives.
7.1.3
To impose discipline on a resident.
7.1.4
As a substitute for correct staffing levels and competence and / or environmental
deficiencies.
7.1.5
Where the resident expresses a clear and consistent wish not be restrained either verbally
or through non-verbal behaviours.
7.1.6
7.2
7.2.1
Routine or ‘as needed’ or indefinite orders for physical restraint must not be used.
Circumstances where Physical Restraint May be Used.
The physical restraint of the resident is an emergency measure when his/ her unanticipated
behaviour places him/ her in imminent danger of serious physical harm.
7.2.2
For brief provision of time limited essential or emergency care, where there is an immediate
or serious threat to the health of the resident if the care is not provided.
7.2.3
When a resident requires emergency medical care such as the presence of a life-sustaining
medical device (e.g., endotracheal tube, healing percutaneous feeding tube tract) that if
disrupted would create immediate jeopardy to the resident’s health – specifically in a
resident who is at high risk for unintentionally disrupting that device (e.g. a delirious
resident).
7.2.4
For risk of falls when the risk of falling is immediate for example for a resident who has
stroke with severe neglect or where the resident has suffered a fracture of the hip or lower
extremities and weight bearing is restricted.
7.2.5
In all of the above circumstances, the use of the physical restraint must not exceed beyond
an immediate episode and there must be evidence that alternative measures have been
unsuccessful.
7.3
Use of Enablers that are also Restraints.
In circumstances, where a device or intervention is being used as an enabler, but will limit the
residents’ movement and cannot be easily removed by the resident, this must only be used in the
following circumstances:
7.3.1
The intervention/ device is being used only for the periods of time where enablement is
needed e.g. the use of a lap tray only when eating or drinking.
7.3.2
There is a clear rationale that the benefits to the resident outweigh any adverse effects.
7.3.3
A risk assessment has been completed that identifies measures to address any potential
adverse effects.
7.3.4
7.4
A care plan is in place that details and includes the information detailed in 7.7
Conditions and Requirements for Restraint Use in the Centre.
7.4.1
The least restrictive form of restraint must be used for the shortest time possible.
7.4.2
There must be a clear rationale for the use of the intervention, which identifies how the use
of the intervention will provide a positive outcome for the resident. This must be recorded in
the restraint assessment.
7.4.3
The risk benefit analysis must demonstrate that the benefits of the proposed intervention
outweigh any potential adverse effects. This must be recorded as part of the restraint
assessment.
7.4.4
The assessment for use of restraint must include alternatives that have been tried,
including the length of time and outcomes.
7.4.5
Obtaining Consent for Use of Restraint.
7.4.6
In this Centre, residents must be supported in decision-making. This means that the nurse
considering any intervention that is deemed restraint must use all reasonable methods to
provide information to the resident in a format and language that is appropriate to the
resident’s needs.
7.4.7
The nurse considering the use of physical restraint must explain the rationale for same, the
purpose and intended benefits and risks associated with the intervention as well as the
timeframe for use eg bedrails while in bed; lap tray only during meal times.
7.4.8
The nurse must seek the resident’s views, wishes and preferences regarding the use of the
intervention, including any concerns that the resident may have and how these will be
addressed. This information must be recorded and kept with the resident’s care plan.
7.4.9
Except in emergency situations, the views and observations of the resident’s
representative/next of kin will be sought for decision –making around the use of restraint,
where the resident him/herself is unable to communicate their wishes.
7.4.10 Except in emergency situations, other relevant healthcare professionals as appropriate will
be consulted in assessment of need and decision making around the use of restraint for a
resident.
7.4.11 The consent form for use of restraint must be completed.
7.4.12 Where there is evidence that the resident is unable to make an informed decision about the
intervention, the nurse inform the person in charge and adhere to the requirements of the
Centre’s Consent and Advocacy Policy.
7.4.13 Formal discussions that have taken place with the resident, the resident’s
representative/next of kin and / or other healthcare professionals to inform decision making
must be recorded and kept with the resident’s care plan.
7.4.14 Prior to the use, staff must seek the resident’s permission each time the intervention or
device is being used eg. Each time bedrails are being raised.
7.4.15 Where the resident is unable to give consent, the nurse must record this on the restraint
assessment and the resident’s care plan.
7.4.16 The nurse must document the residents care needs in the resident’s care plan.
7.4.17 All episodes of restraint use must be recorded in the restraint register.
In all circumstances where restraint is being used, a comprehensive assessment should be
completed. This should involve the resident as far as she is able, the resident’s
representative as appropriate, nursing staff, the resident’s GP and any other relevant
healthcare professionals involved in the resident’s care planning. However, the exception to
this is where the resident’s unanticipated behaviour places her or others in imminent
danger. In this case, short term, proportionate and non –dangerous physical restraint
measures may be taken without prior formal assessment (HIQA, 2009).
7.5
Methods of restraint that must not be used in The Centre.

Pelvic, groin, vest and ankle restraints and four-point (restraint of all 4 limbs).

Use of bed tables or other furniture to restrict movement.

Use of controlling language or holding of the resident

Use of clothing to restrict movement

Use of bean bags or similar items to restrict movement.
(HSE, 2010).
7.6
Use of Lap Belts.
7.6.1
Lap belts can be used to maintain the safety and comfort of a resident and are considered
enablers if they promote function. However, if they restrict the voluntary movement of the
resident and the resident cannot easily remove the belt, the belt is also a restraint and the
conditions for the use of same as outlined in 7.4 must be met.
7.6.2
Lap belts should be used only as part of a seating plan that has been developed with an
occupational therapist to ensure that it is appropriate for the specific seating being used by
the resident. They must always have releasing buckles for use in emergency.
7.6.3
Where a lap belt in being used only to maintain a resident’s safety when they are being
transported in a wheelchair, this must be recorded in the resident’s mobility care plan.
7.6.4
Specialised chairs should only be used where the suitability of the chair for the resident has
been assessed and approved by an occupational therapist. In circumstances where the use
of a specialized chair will limit a resident’s freedom of movement, the conditions and
requirements for use of restraint must be met and all relevant documentation must be
completed.
7.6.5
Chairs used must allow the resident to engage in eating and drinking; meaningful activities
and contact with other people.
7.6.6
7.7
Bedrails. (See Section 10.0, page 10 of 13).
Care Planning.
7.7.1
A care plan must be in place to address the resident’s needs where restraint is in use.
7.7.2
The care plan must include the following information:

The intervention, details and reason for its use, including the circumstances that the
intervention is used eg. Bedrails when in bed.

The resident’s abilities relevant to the restraint eg. can tell staff if the intervention is causing
discomfort.

The residents known wishes (likes/dislikes) regarding the intervention.

Any care needs the resident has while the restraint is in use and how these will be met
such as elimination; scheduled removal of the device and so on.

Any risks associated with the restraint and how these will be managed.

Any aids or equipment the resident needs while restraint is in use eg call bell.

Any instructions regarding the intervention from other healthcare professionals involved in
the residents’ care eg. occupational therapist or physiotherapist.

Any monitoring needs the resident may have, such as the need to monitor for adverse
effects and how these must be carried out.
7.7.3
Family members should be encouraged to be involved in the resident’s care particularly
where the resident cannot communicate their wishes.
7.7.4
Where restraint has been initiated for an unplanned or emergency need, a full review be
carried out by the nurse no later than 24 hours. The resident, the resident’s representative
and the resident’s GP will be included in the review.
7.7.5
Reviews and their outcomes must be documented in the resident’s care plan
8.0 Maintenance of the Restraint Register in the Centre.
8.1
All restraint use must be recorded on the restraint register.
8.2
Where restraint has been initiated for a resident, the nurse on duty must enter the details in
the restraint register.
8.3
Where the use of the intervention or device has been used in an emergency or unplanned
situation, the nurse must document the outcome in the register.
8.4
Where the intervention is being used as part of the resident’s care plan, the nurse completing
the resident’s scheduled review should add details of the review of the intervention to the
outcome section of the register.For example, if the care plan review identifies the need for
bedrails to continue, the outcome of using bedrails and the need for continued use should be
entered onto the register.
8.5
Where the register is being printed for submission as part of the regulatory notifications, the
person in charge or his deputy will complete the outcome section of the register for each
resident on the register.
9.0 Use of restraint in Unplanned, Emergency Situations.
9.1.1
In emergency situations or where immediate action is required to safeguard the
resident or others, or for brief provision of essential care, restraint may be used
without prior assessment. However, the rationale for use of restraint must be
documented in the resident’s nursing narrative notes as soon as possible after the
event.
9.1.2
The least restrictive form of restraint must be used for a time limited period until the resident
has been assessed by a medical practitioner if appropriate or an alternative to restraint use
has been found.
9.1.3
Where a resident is unable to communicate their wishes, the nurse must still provide an
explanation of the intervention and observe the resident for any signs of distress when the
intervention is being undertaken or device applied. No physical restraint should be used
that causes discomfort or distress to the resident as evidenced by agitation, pleas
for release or attempts to release him/herself.
9.1.4
The nurse on duty must initiate a two hourly schedule for releasing the restraint every two
hours; ensuring that the resident’s needs are being met during the period of restraint use
and monitoring the resident for adverse effects.
9.1.5
Any resident who has a physical restraint applied in an emergency situation must be in
visual contact of a staff member at all times.
9.2
Use of Physical Intervention as a means of restraint (Emergency/Unplanned)
9.2.1
Physical Intervention should only be used in an emergency situation as a last
resort when the resident is at risk of harming themselves or someone else.
9.2.2
Physical intervention should be applied with care so as not to injure a resident.
9.2.3
Where possible, adequate staff should be assembled before the resident is approached,
that is, call for help.
9.2.4
Physical intervention must not be used to punish a resident or for the convenience of
staff or other residents.
9.2.5
Staff should be aware of the risks associated with physically intervening such as
positional asphyxiation, falls, strangulation, increased agitation, fractures, skin tears.
9.2.6
Staff should never attempt to disarm a resident, if a weapon is being used.
9.2.7
Staff should not attempt to protect property or possessions over their own personal
safety.
9.2.8
When using physical intervention, staff should attempt to grasp clothing rather that the
resident’s limbs.
9.2.9
During physical intervention an identified member of staff should have sole responsibility
for continuously monitoring the resident’s response to the interventions such as colour
and breathing.
9.2.10
Once the risk of harm to the resident or others is removed the physical intervention must
be discontinued immediately.
9.2.11
Following the use of physical intervention, the resident should be checked for injury,
seen by their GP or locum and /or referred to hospital. The nurse on duty should use his
/ her professional judgment as to which of these is appropriate following assessment of
the resident’s condition. Any injuries should be documented in medical and nursing
notes.
9.2.12
Staff members should be checked for injury and treated accordingly.
9.2.13
An incident form should be completed on Care Monitor ™ and the Person in Charge
notified, if he is not on duty.
During an episode of emergency restraint use and during periods of extreme behaviour, the
nurse must ensure that the resident is continuously observed.
The request / approval from a resident’s next of kin /
representative are not sufficient grounds for the use of
restraint. Where the resident cannot make a decision, it then
becomes a clinical decision.
Family members cannot insist or give permission to use
restraint. The involvement of family / representatives is to
inform decision-making.
10.0
Use of Bedrails:
Decisions regarding the use of bedrails must adhere to the same requirements outlined for
the use of any intervention that could be deemed as restraint.
In The Centre, bedrails may be used in the following circumstances:
10.1 The resident requests bedrails for safety or comfort. In these circumstances, the residents
must be given information about any alternatives and any potential risks associated with the
use of bedrails.
10.2 To reduce the risk of a resident accidentally slipping, sliding, or rolling out of bed as part of a
falls prevention plan of care agreed with the resident and / or representative in collaboration
with other healthcare professionals involved in his/her care i.e. general practitioner,
physiotherapist and occupational therapist.
10.3 The nurse must complete the restraint assessment and the risk assessment for bedrail use
prior to use.
10.4 As with every other type of restraint, even where the resident requests bedrails, the
conditions and requirements outlined under 7.4 and 7.5 must be met.
■ In The Centre, bedrails may not be used in the following circumstances:
 To prevent a resident getting out of bed.
 To prevent a resident from wandering.
 For residents who are confused and agitated.
10.5 Entrapment: Any risk to entrapment should be identified and eliminated prior to use of
bedrails. Risk of fatal bedrail entrapment usually arise when bedrails are used without an
individual risk assessment, and often involve inappropriately designed, poorly fitted or poorly
maintained bedrails, particularly in the use of ‘third party’ bed rails where gaps can be
created by unsuitable combinations of beds, mattresses and bedrails. Adverse incident
investigations in the UK (National Patient Safety Association, UK., 2007), identified the
following as being at greater risk from entrapment:
Older people, adults and children with;

Communication problems or confusion.

Dementia.

Cerebral palsy.

Very small or very large heads.

Repetitive or involuntary movements.

Impaired or restricted mobility.
10.6 Where replacement mattresses are being used, both the bedrails and mattresses must be
checked for risk of entrapment.
10.7 In The Centre, the following types of bedrails are in use:
(specify).
10.8 All bedrails should be checked prior to use for entrapment hazards by checking:
 That gaps between the lower bar of the bedrail and top of the mattress are not greater than
120mm.
 Gaps between the end of the bedrail and footboard are less than 60mm or greater than
318mm.
 Gaps between the end of the bedrail and headboard are less than 60mm.
 Gaps between the end of the bedrail and side of the mattress are not greater than 120mm.
 Bar spacing is less than 120mm.
 Distance between the top of the bedrail and top of the mattress when not compressed
should be > 220mm.
(BS EN Dimensional requirements (BS EN 60601-2- 52:2010) – from April 2013; MHRA,
2013).
10.9 Risk assessment for bedrails should include:
10.9.1 Resident assessment:
 Is a bedrail the best solution or could an alternative approach be used?
 Does the resident’s physical size, condition or behaviour present a risk to the use of
bedrails?
 Is the resident’s head or body size small enough to pass through the bars or any gaps?
10.9.2 Assessing the Bedrail for Safe Use.

Is the bedrail suitable for the bed and mattress?

Has the bedrail been fitted correctly?

Is the bedrail secure?

Are there any gaps present when it is fitted to the bed and could these gaps pose a risk of
entrapment to this resident?

Are fittings secure?

Are any parts of the bedrail missing?

Have the bedrails been properly maintained?

Does the mattress compress easily resulting in a possible entrapment risk?

Is the bed rail secure – is it possible that it will move away from the side of the bed and
mattress when in use, or fall off at one end, creating an entrapment hazard?
10.10 Use of Bedrail Protectors.
Padded bumpers are used to reduce the injury from impact against the bed rail. They can reduce
the risk of entrapment, however nurses and care staff should check bumpers for tears during
bed-making.
10.11 Bedrails in The Centre are checked every (specify) as part of the planned maintenance of
equipment in the centre. This involves checking for:
 presence of rust – this can affect the ease of adjustability of telescopic tubes
 welded joints are sound, not showing signs of cracking or failure
 cracking of paint or coating – can point to deeper structural failure
 flaking or peeling chrome plating – can cause lacerations
 missing locking handles and fixing clamps, clamp pads and other components.
 loose fixings – these affect the rigidity of the assembly. Nuts should be of the self-locking
type.
 free play in joints – this can point towards loose, worn or incompatible components
 stripped threads on bed frame clamps – does not allow them to be tightened securely
 bent or distorted components.
 damaged plastic components.
10.12 Nurses and healthcare assistants should check bedrails each time they are used and report
any of the above to the person in charge or his deputy.
10.13 Chemical restraint is the intentional use of medication to control or modify a person’s
behaviour or to ensure a patient is compliant or not capable of resistance, when no medically
identified condition is being treated; where the treatment is not necessary for the condition; or
the intended effect of the drug is to sedate the person for convenience or for disciplinary
purposes.
10.14 Medication being used as a restrictive practice to manage behaviour that is challenging must
be used under strictly controlled conditions that promote the wellbeing and interests of the
resident.
10.15 The appropriate use of drugs to reduce symptoms in the treatment of medical conditions
such as anxiety, depression, or psychosis, does not constitute restraint. Chemical restraint
is always unacceptable.
10.16 Where the use of psychotropic medication is indicated, the resident must be provided with
the relevant information about the medication so as to support informed decision-making.
Medication must be started at the lowest dosage possible, and increased slowly until either
there is a therapeutic effect, side effects emerge, or the maximum recommended dose is
reached.
10.17 Where a psychotropic medication is being used on a ‘prn’ basis, the prescription must state:
10.17.1
The indication for use /circumstances under which the medicine should be offered.
10.17.2
The intervals between doses.
10.17.3
The maximum dose to be given in any 24 hour period.
10.18 Where a resident is commenced on a psychotropic medicine, the nurse must develop a care
plan that details the rationale for the use of the medicine as per the resident’s prescription;
any risks related to the medicine and how these risks will be monitored and managed.
10.19 A resident’s psychotropic medication is subject to an initial review and then there is ongoing
monitoring and review for potential side effects, as indicated by the resident’s changing
needs and circumstances, but no less frequently than at three-monthly intervals.
10.20 Medication that is being used to manage psychological or behavioural symptoms of dementia
should be used with the purpose of providing positive outcomes for the resident.
10.21 Resident’s on psychotropic medications should have a plan of care that includes monitoring
for effectiveness and potential side effects such as hypotension; risk of falls; drug related
cognitive/behavioural function and drug related discomfort.
10.22 Resident’s on psychotropic medications should be monitored for adverse events, which
should be managed according to the medication management policy.
11.0
References.
1. Department of Health and Children (2011) Towards a Restraint Free Environment: National
Policy on Restraint.
2. Health Information and Quality Authority, (2009) National Quality Standards for Residential
Care Settings for Older People in Ireland
3. Health Act 2007 (Care and Welfare of of residents in designated centres for older people)
regulations 2013.
4. Health Information and Quality Authority (2013) Provider Guidance Restrictive procedures.
5. Australian Government, Department of Health and Ageing (2004) Decision-Making Tool:
Responding to issues of restraint in Aged Care. Accessed 01/02/2008 at
http://www.foodsecretariat.health.gov.au/internet/wcms/publishing.nsf/Content/ageingdecision-restraint.htm
6. Medicines and Healthcare Products Regulatory Agency, Department of Health, UK (2013)
Device Bulletin. Safe Use of Bedrails.
7. National Patient Safety Agency, UK (2007) Safer Practice Notice. Using bedrails safely and
effectively. Accessed 01/02/2008 at
www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=5437
8. Health and Safety Executive, UK Sector Information Minute (SIM 07/2012/06) Bed rail risk
management.
9. BS EN 60601-2-52:2010 Particular requirements for basic safety and essential
performance of medical beds. http://www.bsigroup.com
10. Hartford Institute for Geriatric Nursing. Physical Restraint. Accessed 01/02/2008 at
http://www.consultgerirn.org/topics/physical_restraints/want_to_know_more
11. Health Services Executive, (2010) Policy for the Use of Physical Restraints in Residential
Care Settings.