2. Background Patient Restraints Minimization Act (2001): MOHLTC College of Nurses Practice Standard: Restraints (2009) RNAO Clinical Best Practice Guidelines - Promoting Safety: Alternative Approaches to the Use of Restraints: RNAO (2012) The hospital has a legal and ethical responsibility to support a least restraint policy that provides a safe and therapeutic environment consistent with the above legislation & standards Nurses, physicians, and other RHP must recognize the risk-to-benefit of each decision to use restraints. Liability is based upon the failure to provide care consistent with professional & regulatory standards.

3. WHCA Least Restraint Policy Goal is to provide safe patient centered care Support a philosophy of least restraint – respecting the dignity, rights and independence of the patient while ensuring a safe, therapeutic environment for patients, staff and others Use of Restraints Exceptional and temporary Alternative methods will be explored prior to restraining Considered a last resort The least restraint necessary to maintain quality care for the patient is employed

4. What is a restraint? To place a person under control by the minimal use of such force, mechanical means or chemical, as is reasonable having regard to the person’s physical and mental condition. (Patient Restraints Minimization Act, 2001) Physical restraint Involuntarily restrain the person by restricting their physical activities Chemical restraint Use of pharmacological agents not required to treat medical symptoms, for any purpose of discipline or convenience Environmental Restraint Barrier or device that limits the locomotion of an individual For example: geri-chair, bed rails, removing a person’s walker or cane, private quiet room

5. When is a restraint NOT a restraint? The following items are NOT a restraint because of the intent behind their use Devices used for transport, positioning or procedures eg: surgery, stitches, diagnostic imaging Raised bedrails used to ensure safe patient care eg: sedated patients following surgery, ER procedures, SCU Infant cribs A device to assist the patient to which they agree: eg: table top on geri-chair to facilitate meals or seat belt in wheelchair or wheelchair brakes

6. Criteria for Least Restraint To prevent serious bodily harm to self or others To enhance the freedom or enjoyment of life for the patient To enable the patient to conform to a plan of treatment to which he/she or the family/SDM has given consent (Patient Restraint Minimization Act, 2001). ANY regulated health professional (RHP) may initiate restraints following the established criteria up to, but not including 4-point & chemical restraint Physician’s order should be obtained as soon as possible after restraints are initiated Physician consult and order is required to initiate 4-point restraints and greater, chemical and/or private quiet room restraint

7. Procedure – Assessment Plan of Care Evaluation Ordering Restraints Consent Application of Restraints Patient Assessment and Monitoring Release of Restraints (Care & physical needs) Reordering of Restraints Discontinuation of Restraints DOCUMENTATION of all aspects of above Education / Training – annually Evaluation – quarterly audits

8. Consent Consents are not required in an emergency situation Informed consent is required at all other times, and obtained after discussion with the family or substitute decision maker (SDM) of the following: Rationale for restraint use Type of restraint recommended Alternate methods attempted and results Risks and benefits associated with restraints Risks of NOT restraining Process for ordering restraints, facility monitoring policy, repositioning, observation etc Anticipate time frame restraints may be needed

9. Consent (continued) DOCUMENT informed consent obtained and from whom on the Least Restraint Documentation Record If the patient or family/SDM do not provide consent for restraint use, the most responsible nurse must clearly DOCUMENT and indicate that the patient and or family/SDM are aware of the risks associated with their decision Use hand out to reinforce informed consent process

10. Restraint Application Use only approved restraints as per manufacturer’s instructions Appendix C – Least to Most Restrictive Restraints NEVER modify or adapt restraints Information on how to use PINEL restraints can be found: In the manual: New copies available for each unit On the Intranet: Education tab to - educational videos - to videos - enter “Pinel” in search box – leads to Pinel de-restraint video In Mosby’s Skills: Physical Restraints – instruction + link to video

11. Patient Monitoring & Care At initiation – assess q 15 x4 or until settled, then q 30 min x 1 hr followed by hourly observation Constant observation required for 4 point or greater Q 15 minute observation required for seclusion / private quiet room Physical Needs Standard of Care Restraints must be removed / released q 2h x 10 min and prn for ROM, toileting, intake, repositioning 4 point restraints require a rotation of individual restraint removal and documentation q hour

12. Least Restraint Documentation Record

13. Discontinuance of Restraints No order is required * Any member of the health care team can recommend removal of restraints based on their assessment of the patient Restraints are discontinued when: - The patient’s behaviour changes and they no longer meet the criteria for least restraint - Alternatives are successful - No consent or reorder to continue restraints

14. Emergency Situations Attempt de-escalation strategies Call Code White as needed Initiate restraints as needed to maintain safety for patients and or staff DOCUMENT date, time, precipitating behaviours, de-escalation strategies employed, type of restraint used Record ongoing observations on Least restraint documentation record Obtain informed consent if possible asap (COMMUNICATE with family or SDM) & DOCUMENT Following emergency reassess patient behaviour and need for ongoing restraint or reduction in restraints employed & DOCUMENT

15. Items to note in this process Restraint orders are only valid for 24 hours. The patient must be reassessed for alternatives every 24 hours RHP may initiate restraints following Least Restraint Criteria & obtain order as soon as possible (within same shift) 4 point restraint or greater needs Dr’s order or call MD immediately for consult & order Follow Least Restraints Decision Tree (laminates and in policy) Refer to Policy and Appendices for assistance with alternatives and types of restraints DOCUMENT, DOCUMENT, DOCUMENT

16. What do you need to Document? Documentation must include: Date and time Description and assessment of patient behaviour Possible causes & alternatives explored Type of restraint chosen, including number & location of restraints chosen Informed consent & family discussion immediately or asap within 12 hours of applying restraints Ongoing observations on Least Restraint Observation Record Physician’s order must include date, time and type of restraint

17. Resources - Policy on the Intranet

19. *Special Considerations Consistent with the Patient Restraints Minimization Act, 2001, staff may restrain or confine a patient if this action is necessary to prevent serious bodily harm to the patient or to another person. As such, this policy does not preclude restraint of a patient who is currently being held under a Form 1 (under the mental health act) and who must be restrained, with or without consent in order to protect the patient from self harm or to protect others from potential harm form the patient.

20. Audits Audits are a required practice Monitoring for adherence to best practice Least Restraint Policy & required documentation Use of restraints need to be flagged by placing a patient label on the Restraint Use Record Log Log sheets will be collected and audits completed by the Professional Practice Manager quarterly

21. Least Restraint Review I have reviewed the slide presentation with regard to the WHCA Least Restraint Policy, and am aware of the process involved. I have reviewed proper application of PINEL restraints either on Mosby’s Skills or the Hospital Intranet: Educational Videos I know where to access the full policy, observation forms and patient handouts I know where the Restraint Use Logs are kept on my unit and understand that I am required to flag restraint use for audits Name _____________________ Unit ___________ Date ___________