1. Physical Restrain- Last Resort Salamma Sabu John Female Psychiatry Unit RH, Dubai

2.  Introduction  Definition  Objectives  Background  Literature Review  Strategies  Implementation  Outcome  Challenges /Lessons Learnt  Summary

3. Introduction

4. Definition  Physical Restrain is a manual method that restricts freedom of movement or normal access to one’s body, contingent on maladaptive behaviours that is used when there is an imminent risk of harm to the individual or others

5.  To improve the practice of physical restrain use in patient care  To reduce the length of stay for patients on physical restrain  To improve safety for both patients and the staff in a psychiatric unit. Objectives of the Study

6. Aknowledgement  Ms.Salamma Sabu John  Ms.Florence Okonkow  Ms.Joyce Saldanha  Ms.Sini Nair  Ms.Felma Ison  Ms.Libeth Dipasupil  Ms.Jhoanna Lapez  Ms.Jasmin Suico NS-Ms.Sumini John

7.  Physical restrain had been used as 1 st resort  Many patients were on physical restrain for a longer period of time.  All admitted psychiatric patients had restrain as a PRN order!!  Alternative interventions not implemented before placing the patient on restrain.  Improper restrain devices used.  No standard policy & monitoring system for physical restrain.

9. Pre-Study Audit Findings (Sept 2007-Jan 2008)  Non compliance to existing policy  No physician order  No documentation regarding the reason for using restrain  Improper monitoring

10.  A study conducted in Ontario, use of restraints in health care organization is restricted using least restraint, to encourage the use of alternative methods of physical restraint whenever possible.  Physical restraint should be used as a last resort,and only when the potential benefits are greater than the potential harm secondary to the enforced immobility of restraint. College of nurses of Ontario (2004) practice standard: restraints. Toronto, Ontario, Canada

11. To minimize the risk of injury:  Ensure the correct application of the restraint device according to the manufactures recommendations.  Maintain appropriate observation during the time that a person is restrained.  Provide staff orientation and in-service education on the correct use of physical restraint devices.  Once initiated, the need for physical restrain should be reviewed regularly THE JOANNA BRIGGS INSTITUTE, Volume 6, Issue 3, page 5, 2002

12.  Staff orientation & education  Encourage the nursing staff to use other alternatives to avoid physical restrain use.  To introduce standard restrain device  To revise the current policy according to the best practice.  To reinforce the staff to comply the existing policy.  To monitor implementations – development of KPI

13.  Conducted Education session-consequence related to physical restrain & importance of proper monitoring & attending needs of the patient while on physical restrain.  Introduced non-physical restrain strategies like de-escalation technique, chemical restrain etc.  Introduced standard physical restrain device.  Revised physical restrain policy.  Monitored compliance to policy by chart audit.

15.  Policy revised according to evidence based practice. ◦ Physical restrain used as last resort ◦ No PRN orders ◦ One-one observation for all patients on physical restrain. ◦ Each psychiatric episode of restraint valid for 4 hrs only  Improved staff knowledge /awareness about the consequence/risk related to physical restraint.  New KPI implemented to measure the length of stay in physical restrain by each patient,(2011).

16.  Length of time - Approval for the revised policy (multi-disciplinary policy) ◦ Resistance to change from the physicians ◦ Lack of Compliance to policy from the nurses ◦ Constant reinforcement & monitoring ◦ New KPI monitoring for Physical Restrain

17. Summary  To avoid the use of Physical Restrain  Conduct timely assessment & reassessment- improve the clients overall status.  Implement other intervention like de-escalation technique.  If Physical Restrain used  Follow organization policy  One-one observation  Attend the needs of the patients  Reduce the length of stay in restrain

18. Take away message Physical Restrain must be used as a last resort when there is an ‘imminent risk’ AND all other interventions have been applied & have proven failed