The CCTC Standard of Care for restraint use has been developed to comply with the LHSC Standard of Nursing Care for Restraint Use.
Definition:
Restraints are any mechanical, chemical or environmental means which are intended to prevent injury or bring under control behaviours or physical movements which could cause bodily harm to patients or others.
Ensure that patient and health care provider safety standards are met during this procedure including:
- Risk assessment and appropriate PPE
- 4 Moments of Hand Hygiene
- Procedural Safety Pause is performed
- Two patient identification
- Safe patient handling practices
- Biomedical waste disposal policies
Practice Standard | |
1. | LHSC and CCTC supports a least restraint policy.
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2. | An assessment for alternative measures is done prior to the use of restraints.
See Delirium Protocol for strategies to prevent Delirium and engage family members in the prevention and treatment. Click to obtain Decision Tree for the use of restraints in CCTC. Document the alternate methods used and patient’s response.
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3. | Ensure that restraints are applied safely and are approved for use at LHSC.
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4. | The Patient/Family/Substitute Decision-Maker must consent to the use of restraints.
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5. | If the family refuses the use of restraints despite being made aware of the potential risks to the patient or others, a “Consent for the Refusal of Physical Restraints” must be signed by the Family or Substitute Decision-Makers. |
6. | Document the following in the AI record:
The Consent for Refusal for Restraint must be completed and left on the chart. Careful documentation is important to demonstrate that the patient’s dignity, rights and independence were considered while attempting to maintain a safe environment for patients, visitors and staff. |
7. | The patient must be reassessed and observed routinely while restraints are in place. Injury risks from the use of restraints have been well documented. |
8. | During initiation of restraints: The following assessments must be made q 15-30 minutes X 1 hour , then every 15 – 60 minutes:
Document findings on the A/I flowsheet. Reported complications related to restraint use have been reported and include:
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9. | During ongoing use of restraints:
The following assessments must be made q2h AND documented on the AI flowsheet:
Brachial plexus injuries can occur from stretching of the shoulder. This can lead to injuries ranging from arm and hand numbness to paralysis. |
10. | Reassess the use of restraints q24h and document daily on the AI 24-hour assessment record. Patient's restraint requirements will change and need to be regularly reevaluated. |
References:
College of Nurses Of Ontario [2000]. A Guide on the Use of Restraints. “Communique” January.
Deprospero, R.P., & Bocchino, N. [1999]. Restraint Free Care – Is It Possible? American Journal of Nursing 99[10] 27-34.
Fletcher, K. [1996]. Use of Restraints in the Elderly. AACN Clinical Issues, 7[4], 611-620.
Gilbert, M., & Counsell, C. [1999]. Planned Change to Implement a Restraint Reduction Program. Journal of Nursing Care Quality, 13[5], 57-64.
Knapp, M.B. [1996]. Physical Restraint Use in Critical Care: Legal Issues. AACN Clinical Issues, 7[4], 579-584.
Leith, B. [1998]. The Use of Restraints in Critical Care. Official Journal of the Canadian Association of Critical Care Nurses, 9[3], 24-28.
Leith, B. [1998]. Do Physical Restraints Prevent Patients form Removing Invasive Therapeutic Devices? Official Journal of the Canadian Association of Critical Care Nurses, 9[3], 31-34.
London Health Sciences Centre [2001; February].Revised February 1, 2010.Policy on the Use of Restraints, PCC020.
Maccioli, G., Mazuski, J., Kuszaj, J., Devlin, J. & Peruzzi, W. [2003]. Clinical Practice Guidelines for the Maintenance of Patient Physical Safety in the Intensive Care Unit: Use of Restraining Therapies: American College of Critical Care Medicine Task Force 2001-2002, Critical Care Medicine, 31[11], 2665-2676.
Mion, L. [1996]. Establishing Alternatives to Physical Restraint in the Acute Care Setting: A Conceptual Framework to Assist Nurses’ Decision Making, AACN Clinical Issues, 7[4], 592-602.
Reigle, J. [1996]. The Ethics of Physical Restraints in Critical Care, AACN Clinical Issues, 7[4], 585-591.