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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
PURPOSE
This protocol specifies the conditions under which personal restraint minimisation is used for
patients causing safety concern and ensures compliance with the Bay of Plenty District
Health Board (BOPDHB) policy 1.2.4 Restraint Minimisation and Safe Practice.
Security should always be called to any situation of safety concern. Refer to:
Patient Causing Safety Concern Flowchart (Appendix 1)
AGGRESSION Emergency Action Card (coloured yellow) for the BOPDHB procedure in
this situation.
In a situation where the individual is in possession of a weapon and expresses the
intention to use this, staff safety is paramount and Security / the Police should be called.
Restraint must not be attempted.
Personal hold may be used as an enabler, the details of which are covered in Clinical
Practice Manual protocol CPM.E1.1 Enablers. Enablers are only used when communication,
comforting and distraction techniques have all failed. They should be the least restrictive
option, consent should be obtained and the risks discussed with the patient and / or family if
possible or appropriate.
STANDARDS TO BE MET
1. Criteria For Using Personal Hold Restraints
a) Personal hold as restraint when a person is causing safety concern is used only after
de-escalation has been attempted and found to be inadequate to prevent harm to
patients, staff or members of the public.
b) The decision to restrain must be made by a registered health professional on the
basis of clinical best practice and must be utilised within the limits of the legislation.
c) The following are situations where restraint may be
indicated, when an individual:
i. Behaves in a manner which indicates potential risk to self or others
ii. Attempts self-harm
iii. Attempts to attack another person
iv. Compromises the environment e.g. wilful damage
v. Or when it is necessary to give prescribed essential medical treatment to an
individual who is resisting, and this is deemed absolutely essential by the medical
officer in charge of the individual’s care
d) Medication used as a form of chemical restraint is considered to be abuse and is not
supported by BOPDHB.
e) All staff need to be familiar with BOPDHB policy 1.1.1 Informed Consent.
2. Level Of Competency Of Staff Involved In The Use Of Personal Hold As Restraint
a) The person applying personal hold as restraint must be trained and assessed as
competent in the use of personal hold techniques, e.g. Mental Health personal hold
restraint training, or equivalent as approved by Practice of Restraint Advisory Group
(PRAG).
Issue Date:
May 2017
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Review Date:
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
3. Risk Assessment And Management
Potential Risks
Risk Management
1
Potential for physical and psychological harm Staff trained in use of personal hold
or injury to patient / client requiring restraint
techniques
Documented process for the initiation of
personal hold restraint
2
Positional Asphyxia
See
Appendix 1
3
Restraint used when not indicated or justified
Ongoing assessment and review of
personal hold restraint use
4
Restraint continued longer than necessary
Assessment and evaluation of use of
personal hold restraint and risks
5
Potential infection risk to staff
Standard precautions used by staff
4. Procedure For Using Personal Restraint
Patient requirements for the use of Personal Hold as restraint is assessed according to
the BOPDHB policy 1.2.4 Restraint Minimisation and Safe Practice Standards
STEP
ACTION
RATIONALE
1
Assessment and documentation of the use of
Personal Hold as restraint
Assess patient needs for personal hold
To ensure that a restraint is initiated in
restraint using the Patient Causing Safety
a timely manner, is used appropriately,
Concern Needing Intervention Flow Chart
results in a desired outcome and
Appendix 1: All possible alternatives to the
maintains safety for patients and staff
application of personal hold restraint must be
considered prior to proceeding to personal
hold restraint
Assessment of requirement for personal
To maintain safety for individual and
restraint will include:
staff
- Safety considerations for patient and staff
involved in restraint
- Degree of urgency and danger
- Available resources to manage the situation
safely
Seek advice from Mental Health & Addiction
Services (MH&AS) staff in event of known
client or presumed mental health issue
Assessment is ideally completed in
partnership with family / whānau and
To ensure informed consent is
significant others
obtained and cultural needs are met.
If the use of personal hold as restraint is
indicated on completion of assessment
commence documentation of the restraint use
on the Incident Management form and in the
patient care plan. Refer to Flowchart
(Appendix 1)
Issue Date:
May 2017
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NOTE: The electronic version of
Review Date:
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
STEP
ACTION
RATIONALE
2
Application and use of personal hold restraint
Personnel who are formally trained in personal To reduce risks to patient / client and
hold techniques may only apply this form of
staff
restraint.
To ensure ongoing effective
A restraint leader is identified for all instances
communication with the patient / client,
of personal hold restraint
staff member and others including
family / whānau during the procedure
3
Process and frequency for monitoring /
reviewing the use of personal hold restraint
Monitoring of patient
Continual assessment including observation
To ensure patient / client physical
and care of the individual’s airway, breathing,
safety is maintained throughout the
circulation, level of consciousness, discomfort,
procedure
skin colour, limb and body positioning
Continual assessment of the level of risk that
To ensure patient safety and evaluate
the individual poses and the response of the
the effectiveness of the use of personal
individual to the restraint
hold restraint
Formal review of the use of personal hold
restraint
This will be ongoing as well as at the end of
the restraint use and will focus on:
- Response of the individual to the restraint
- The level of risk the individual poses to self,
others and environment
4
If injury or adverse effect occurs:
An Incident Management Form is completed
To maintain patient and staff safety
with full details of incident
5
Discontinuation of the use of personal hold
restraint
The decision to end restraint is communicated To evaluate the effectiveness of the
to the personnel holding the patient / client by
use of personal hold restraint
the Restraint Leader
Ongoing planning for patient management as
clinically indicated
Complete an Incident Management form.
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Restraint Minimisation & Safe Practice controlled
documents
Bay of Plenty District Health Board policy 0.0 Glossary of Terms / Definitions
Bay of Plenty District Health Board policy 1.1.1 Informed Consent
Bay of Plenty District Health Board policy 2.1.1 Risk Management
Bay of Plenty District Health Board policy 2.1.2 protocol 2 Controlled Document
Development Standards
Bay of Plenty District Health Board policy 2.1.2 protocol 6 Controlled Document Review
Standards
Bay of Plenty District Health Board policy 2.1.3 Hazard Management
Issue Date:
May 2017
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Review Date:
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
Bay of Plenty District Health Board policy 2.1.4 Incident Management
Bay of Plenty District Health Board policy 5.4.7 Threatening Behaviour, Bullying,
Harassment and Violence in the Workplace - Management
Bay of Plenty District Health Board policy 7.104.1 protocol 3 Care Delivery – Observing
Patients
Bay of Plenty District Health Board Practice of Restraint Advisory Group (PRAG) Terms
of Reference
Bay of Plenty District Health Board Incident Management Form
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May 2017
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
Appendix 1: Patient Causing Safety Concern Flowchart
Patient Causing Safety Concern Needing Intervention
KEY POINTS
Flow Chart of Decisions and Action
ASSESSMENT POINT
Assess:
Assessment may be
Patient Mental State
carried out by any
Patient Behaviour
Health Professional
Level of Risk
Identify Restraint Leader
Only
a
Registered
Health
Professional
NO
ARE WE ALL SAFE?
YES
can decide to carry
out restraint
ACTION
ACTION
Use de-escalation
Organise back up i.e.
YES
techniques with
call 777 for security
individual
Focus
of
restraint
support
Identify Restraint
should
always
be
Continue reassurance
Leader
maintaining safety in
the least restrictive
manner
for
the
situation
Is it likely to escalate?
Partial Restraint –
holding
patient
by
Are de-escalation
YES
arms only patient can
techniques effective?
still walk.
NO
Full Restraint – only
NO
to be used as a last
resort
planned
3-4
Debrief and document
person
team
ASSESS: Restraint level
required
approach – patient on
YES
DECIDE: Full or partial
floor or bed/trolley.
restraint
Use approved restraint technique:
FULL RESTRAINT
‘
Restraint Leader’ -
ACTION
Continue restraint until de-escalation
designated
health
Use approved restraint
sufficiently to end or otherwise
professional
who
technique:
resolved e.g. specialist intervention,
PARTIAL RESTRAINT –
Police
leads decision making
attempt to de-escalate,
reassure, meet needs
Reference:
ARE WE ALL
Restraint Minimisation
NO
SAFE?
& Safe Practice Policy
1.2.4
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
Appendix 2: Positional Asphyxia
(Reference: UK Ministry of Justice. Prison Service Order 1600. Use of Force. Positional
Asphyxia)
Physical restraint can lead to harm and even death. The person being restrained must have
close observation by a member of medical or nursing staff including A B C at all times.
There are a number of potential adverse effects of the application of restraints. These
include; being unable to breathe, feeling sick or vomiting, developing swelling to the face and
neck, and the developments of petechiae (small blood-spots associated with asphyxiation) to
the head, neck and chest.
Restraining an individual in a position that compromises the airway or expansion of the lungs
(i.e. in the prone position) may seriously impair an individual’s ability to breathe and can lead
to asphyxiation. This includes pressure to the neck region, restriction of the chest wall and
impairments of the diaphragm. When the head is forced below the level of the heart,
drainage of the blood from the head is reduced and brain swelling can result. Swelling of the
head and neck and bloodspots (petechiae) are signs of reduced drainage of blood from the
head and neck. They are warning signs of actual or impending brain injury.
Pressure should not be placed on the neck, especially around the angle of the jaw or the
windpipe. Pressure on the neck, particularly in the region below the angle of the jaw (carotid
sinus) can disturb the nervous controls to the heart and lead to a sudden slowing or even
stoppage of the heart.
A degree of positional asphyxia can result from any restraint position in which there is
restriction of the neck, chest wall or diaphragm.
This risk is increased where:
The head is forced downwards towards the knees
The subject is immobilised seated (the angle between the chest wall and the lower limbs
is already decreased).
The torso is compressed against or towards the thighs (restricts the diaphragm and
compromises lung inflation).
In prone restraints the body weight of the restrained person acts to restrict movement of
the chest wall and the abdomen (restricting diaphragm movement).
Factors that predispose a person to positional asphyxia and sudden death under restraint
include:
Drug/alcohol intoxication (because sedative drugs and alcohol act to depress breathing
so reducing oxygen taken into the body)
Physical exhaustion (or any factors that increase the body’s oxygen requirements, for
example a physical struggle or anxiety)
Obesity
Warning signs related to positional asphyxia:
An individual struggling to breathe
Complaining of being unable to breathe
Evidence or report of an individual feeling sick or vomiting
Swelling, redness or bloodspots to the face or neck
Marked expansion of the veins in the neck
Individual becoming limp or unresponsive
Sudden changes in behaviour (both escalated and deescalated)
Loss of, or reduced levels of, consciousness
Issue Date:
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Protocol
RESTRAINT – USE OF PERSONAL RESTRAINT
CPM.R2.9
CLINICAL PRACTICE
MANUAL
Respiratory or cardiac arrest.
Where warning signs are present the restraint must immediately be released or modify
the restraint as far as practicable to reduce body wall restriction, and call 777.
No person should be restrained face down (or in the case of a pregnant person, on her side)
for longer than is absolutely necessary to gain control. There must be continuous observation
of a person following relocation in the prone position until such time as the person is no
longer lying face down (or in the case of a pregnant person, on her side).
There is a common misconception that if an individual can talk then they are able to breathe,
this is NOT the case. An individual dying from positional asphyxia may well be able to speak
or shout prior to collapse.
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