POLICY
Number: 7311-60-012
Title: Least Restraint - Mechanical and
Environmental
Authorization
[ ] President and CEO
[X] Vice President, Finance and Corporate
Services
Source: Director, Nursing Professional Practice
and Education
Cross Index: 7311-30-007; 7311-50-002
Date Approved: October 19, 2009
Date Revised: June 12, 20141
Date Effective: July 18, 2014
Date Reaffirmed:
Scope: SHR & Affiliates
Any PRINTED version of this document is only accurate up to the date of printing. Saskatoon Health Region (SHR) cannot guarantee the
currency or accuracy of any printed policy. Always refer to the Policies and Procedures website for the most current versions of
documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part
of this document may be reproduced in any form for publication without permission of SHR.
OVERVIEW
Traditionally, restraints have been used with the best intentions to protect clients from harm. Research has
shown that restrained clients are eight times more likely to die than those who aren’t restrained
(Napierkowski, 2002). Using restraints has resulted in strangulation and can cause and exacerbate hazards
of immobility such as constipation, functional decline, and skin breakdown. Other hazards of restraint use
include incontinence, impaired circulation, loss of dignity and freedom, and worsening aggression and/or
confusion. Applying restraints does not help prevent falls or alleviate fall risks but rather may increase the
risk of falls and severity of injury from falls. SHR does not support the use of restraints to restrict a client from
coming out of his/her bed or chair. There may be circumstances when the temporary use of least restraints
will lead to a safer environment. These circumstances relate to clients who are at risk of harming themselves
or others, physically aggressive or imminently aggressive behavior, and where all alternative measures to
manage the client’s and staff’s safety have been exhausted.
SHR’s Least Restraint policy balances client and family centred care, the client’s rights and the safety of
others as a last resort temporary measure. Ethical principles of respect for autonomy, beneficence, justice
and maleficence are applied in the decision making process.
The principles of least restraint apply to Security Services.
This policy does not apply to use of restraints by law enforcement personnel.
At this time this policy does not address the use of chemical restraints. This will be incorporated at a later
date.
DEFINITIONS
Alternative to Restraint means an intervention that is used in place of or reduces the need for a restraint
device. Examples: bed/chair alarms, hip protectors, exit door alarms, therapeutic management
techniques (i.e. Gentle Persuasive Approach, Workplace Assessment Violence Education, Professional
Assault Response Training).
Client means an individual, patient, client or resident.
1
Editorial updates only Jan 2015
Page 1 of 29
De-escalation means a complex range of skills designed to abort the assault cycle during the escalation
phase, including both verbal and non-verbal communication skills (NCCNSC, 2005).
An emergent situation means a situation where immediate action is necessary to prevent serious bodily
harm to the client or others.
Extended use means a least restraint is required for period of time greater than or equal to one week.
Least restraint means:

The physical, mechanical, or environmental means which are intended to prevent injury, manage
responsive behaviours or physical movements which could cause significant bodily harm to the
client or others.

Applying the least restrictive method to limit a client's freedom of movement or to immobilize the
client. This includes using a device or garment (mechanical least restraint), holding or bodily
maneuver (physical least restraint), or restriction of space (environmental least restraint) to physically
control, subdue, and/or calm a client who exhibits behaviour that presents a risk of harm to
themselves, others or property.

All alternative measures are to be exhausted before least restraint options are considered.
Physical Restraint means the direct application of physical holding techniques to a client that
involuntarily restricts his or her movement. This does not include briefly holding, without undue force,
a client in order to calm the client, or using redirection/holding techniques to escort the client safely
from one area to another.
Mechanical Restraint means any device, material, or equipment attached to or near a client which
cannot be easily removed by the client and involuntarily restricts the client’s freedom of movement
or normal access to his or her body.

devices used solely for the purpose of positioning or realigning are not considered a restraint
(i.e. trunk belt, front fastening seatbelt and/or braces).

A postural support/positioning device could be considered a restraint if the device limits,
restricts, controls and deprives the liberty and inhibits voluntary movement of the client.
NOTE: The INTENT of the device defines whether it is a restraint or not.
For example:

If a tray table is being used to assist someone with eating it is not a restraint. However, if the
tray table is being used to prevent someone from getting up and wandering it is considered
a restraint.

A side rail would be considered a restraint if the intent is to prevent the client from coming
out of their bed rather than being used for the purposes of positioning or accessing the bed
controls.

It is a restraint if the client is unable to unlock or remove it by him or herself or if they are
unable to request it to be removed. This includes locked tables on a gerichair if they are
used to restrain a client from freedom of movement, rather than as a positioning device.

It is not a restraint if you use a positioning device with the client’s permission. For example: if
you use a mechanical aid to assist in walking a client; use side rails with the client’s
permission; use chair wedges or other positioning devices.

Examples of postural support or positioning devices:
o Wheelchair with front opening seatbelt
o Safety belts with front openings
o Stretcher belts
o Transfer belts
o Lap top table
o Assistive bar, trapeze or pole
o Arm/foot boards for intravenous therapy
o Side rails and side rail covers
Page 2 of 29
Environmental Restraint means any barrier or device that limits or controls the locomotion of an individual
and thereby confines an individual to a specific geographical area or location.
Examples of environmental restraints may include: lockable client room, half doors, restriction to a specific
area. This does not include a secured entrance to the unit or facility. Refer to Appendix D for approved
environmental restraints.
Postural support/positioning device means a device used to provide the client with a sense of security and
comfort when transporting a client or in an attempt to maintain proper body alignment and balance.
Proxy means a person who, pursuant The Healthcare Directives and Substitute Decision Maker’s Act, is
appointed in an advanced care directive that designates this person to make health care decisions for the
person in our care.
Restrain means to limit, restrict, control, and deprive of liberty and inhibit voluntary movement.
SHR Staff means employees, professional staff, practitioner staff and affiliate employees.
Substitute Decision Maker (SDM) means a person who, pursuant to The Health Care Directives and
Substitute Decision Makers Act, is entitled to make health care decisions on behalf of the client.
Team means the client/family/SDM/proxy, physician and nursing staff. Depending on the situation, other
members of the team may include occupational therapist, physical therapist, recreational therapist, social
worker, students and volunteers.
1.
PURPOSE
The purpose of this policy is to:
1.1
Promote the practice of least restraint and a culture that is respectful of an individual’s rights.
1.2
Identify what a restraint is.
1.3
Facilitate safe and appropriate use of least restraints.
1.4
Minimize and reduce the use of restraints.
1.5
Assist staff, clients and family/SDM/proxy to understand their responsibilities and make
informed decisions regarding the use of least restraints.
2.
PRINCIPLES
2.1
SHR adheres to the practice of “least restraint”. The establishment of a therapeutic
relationship between the care team and client and family/SDM/proxy is beneficial for
minimizing restraint use; maximizing client independence; improving quality of life; minimizing
risk of injury; and preserving client self-worth and dignity.
2.1.1 The least restrictive form of the most appropriate restraint is used first. If this is
unsuccessful, progression from least to most restrictive restraint is implemented.
2.1.2
The restraint will be used for the least amount of time.
2.1.3
In an emergent situation refer to procedure 2.1.4.
2.2
SHR staff will provide a collaborative and supportive atmosphere for clients who require
restraints. An environment will be created that adheres to informed decision making in
regards to restraint use. All staff will be respectful of the choices that
clients/families/SDM/proxies make about restraint use and alternatives to restraints.
2.3
The decision to use restraints is made as a result of collaboration with members of the team.
2.4
Staff are encouraged to evaluate their beliefs, attitudes, and practices regarding the use of
restraints and place a high priority on client concerns and perspectives in the provision of
client centred care.
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2.5
3.
The policy will be applied with fairness and consistency throughout SHR.
POLICY
3.1
Least restraints are only used when all other possible alternative measures have proven
ineffective and the use of a restraint will result in a safer environment for the client, visitors
and staff. Preventative and alternative strategies should be used prior to least restraint
initiation in order to promote an environment that limits restraint use to only clinically
appropriate and sufficiently justified situations. Only after all alternatives have been tried
unsuccessfully, should restraints be considered.
3.2
When a restraint is indicated, the least restrictive restraint suitable to achieve the intended
outcome shall be used.
3.2.1 Least restraint use is an acceptable alternative for clients at risk of harming
themselves or others related to physically aggressive or imminently aggressive
behaviour.
3.2.2 Least restraint interventions will not be initiated or maintained arbitrarily as a substitute
for treatment, as punishment, for the convenience of staff or to prevent falls.
3.2.3 The use of any restraint is considered to be a temporary and unusual measure.
3.2.4 Restraint use shall be monitored, documented and evaluated (see procedure 2.8 for
required intervals).
3.2.5 Restraints must be removed at the earliest and safest opportunity.
3.2.6 Restraints must be used in a manner that allows for quick release in an emergency
situation.
3.3
Informed consent will be obtained from the client for the use of restraints. See SHR Policy
Consent/Informed Consent. Violation of the client’s rights may result in legal action against
the staff and/or their employer if restraints are used without informed consent.
3.3.1 If the client is unable to give informed consent the family/SDM/proxy will act on the
client’s behalf.
3.3.2 If consent is refused by the client/family/SDM/Proxy see procedure 2.3.
3.4
The following criteria need to be met for restraint usage to be implemented on a client
without their informed consent:
3.4.1 Involuntary status under Section 24 of the SK Mental Health Services Act (2004);
and/or
3.4.2 Under Section 16 of the Health Care Directives and Substitute Health Care decision
makers Act (2004); and/or
3.4.3 In the case of a client who has a Personal Guardian legally appointed under the
Adult Guardianship and Co-decision-making Act (2011); consent may be sought
from the guardian; and/or
3.4.4 The family/SDM/proxy shall be contacted by the health care team to inform them of
the need for restraint use in order to maintain the safety of the client/coclients/staff/visitors.
3.4.5 Environmentally restrained to a locked room in the ER while awaiting appropriate
psychiatric assessment and disposition under Sections 18 and 19 of the MHSA.
3.5
Restraints may be used in an emergent situation when there is inadequate time to complete
the least restraint use procedure (see Procedure 2.1.3 - Emergent Situations).
3.6
Documentation will include the assessment, decision to use and the rationale to restrain,
type of restraint used, ongoing monitoring and evaluation and the outcome of restraining.
3.7
Debriefing with the team will occur in a timely manner when a restraint has been applied
and discontinued, and/or as soon as possible following application of restraints in an
emergent event.
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4.
3.8
Initial and ongoing education regarding alternatives to least restraints and the appropriate
use of restraints will be provided to the team.
3.9
Restraints will be applied following manufacturer’s instructions and will be maintained as per
manufacturer’s recommendations.
3.10
The least restraint procedure does not apply for safety measures used only for the duration of
a procedure or test and shall be discussed with the client/family/SDM/proxy beforehand.
3.10.1 During transportation and completion of medical/surgical/diagnostic procedures.
Examples such as:
 Medical - a pediatric swaddle wrap is necessary for suturing
 Medical – side rails on a stretcher in the emergency room following medical
treatments as part of approved practice (i.e. sedation in conjunction with the
other required nursing interventions including close observation and SaO2
observation)
 Surgical – limb least restraints are needed to maintain a sterile field while
performing surgery
 Diagnostics – a least restraint may be required to ensure an accurate result of the
diagnostic test for proper diagnostics
 Nursing -- Side rails used on stretchers or beds during transport of a client following
surgery or between ER and diagnostics or on transfer from one unit/room to
another
3.10.2 During motor vehicle transportation, clients must wear seatbelts and pediatric clients
must be properly restrained in a car seat with shoulder harness.
3.11
Given the developmental and cognitive stages that must be considered when working with
children and adults, temporarily restricting their activities to ensure their safety during their
care may be both necessary and appropriate: i.e. following surgery, an elderly client with
dementia makes attempts to remove his bandages, IV tubing, oxygen mask, and attempts
to get out of bed, which may result in increased pain, fear and risk of falls.
3.11.1 Age or developmentally appropriate protective interventions (i.e. stroller safety belts,
swing safety belts, high chair lap belts, raised crib rails and crib covers) that a safety
conscious child care provider outside a healthcare setting would utilize to protect an
infant, toddler, or preschool aged child would not be considered a restraint.
ROLES AND RESPONSIBILITIES
4.1
Most Responsible Physician (MRP), Nurse Practitioner RN(NP) or Resident
4.1.1 Collaborate and communicate with team members in relation to assessment and
decision to restrain.
4.1.2 Complete the Least Restraint Use Consent/Physician Order Form # 103694.
4.1.3 Collaborate with team members in the review and ongoing evaluation of the
restraint. Refer to Appendix A ‘Least Restraint Use Algorithm’.
4.2
Team
4.2.1 In collaboration with the client/family/SDM/proxy, any licensed team member can
obtain consent for the use of restraints.
4.2.1.1 Client/family/SDM/proxy work as part of the team to make appropriate and
informed choices and decisions related to least restraint use.
4.2.2 According to skills, knowledge and ability ensure that restraint usage is appropriate
and all other alternatives have been tried prior to the implementation of the least
restraint.
4.2.3 Perform ongoing monitoring and evaluation of the client.
4.3
Registered Nurse (RN), Registered Psychiatric Nurse (RPN), and Licensed Practical Nurse
(LPN) (in collaboration with the RN/RPN)
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4.3.1
4.3.2
Collaboratively perform a comprehensive assessment of the client with the team
(including a description of behavior and the risks involved), identify alternative
interventions tried and the outcome, and document the decision to restrain.
Application of mechanical restraints: Other team members may apply or remove as
appropriate, if educated.
4.4
Security Services (where available)
4.4.1 Respond to a ‘Code White’.
4.4.2 Apply restraints at the direction of a physician or psychiatrist.
4.5
All staff
4.5.1 Maintain an awareness of the potential risks associated with the use of restraints. It is
the responsibility of all staff to familiarize themselves and comply with this policy and
procedure.
5.
POLICY MANAGEMENT
The management of this policy including policy education, monitoring, implementation and
amendment is the responsibility of Director, Professional Nursing Practice and Education.
6.
NON-COMPLIANCE/BREACH
Non-compliance with this policy will result in, at a minimum, a review of the incident. Noncompliance may also result in disciplinary actions up to and including termination of employment
and/or privileges with SHR.
7.
REFERENCES
Alberta Health Services. (2012). Restraint Policy Draft V-04. Alzheimer Society of Canada. (2007).
Restraints. Retrieved from http://www.alzheimer.ca/en/About-dementia/For-health-careprofessionals/Tough-issues
Capital Health. (2012). Policy CC65-031 Use of Rapid Physical Restraint on Acute Care Mental Health
In client Units. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Capital health (2007). Appendix C Learning Supplement for Least Restraint. Retrieved from
http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Capital Health. (2007). Interdisciplinary. Interdisciplinary Clinical Manual Policy & Procedure #CC-05030 Least Restraint. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Division of Developmental Disabilities. (2012). Policy 5.11-Restraints. Washington State Department of
Social &Health Services
Government of Saskatchewan. (2013). Regional Health Services Policy & Procedure manual 15.10
Restraints. Community Care Branch
Heartland Health Region. (2011). Policy # C01-39.01 Least Restraint. Heartland Health Region
Regina Qu’Appelle Health Region. (2008). Policy #1001-Adult Least Mechanical Restraint. Regina
Qu’Appelle Health Region
Registered Nurses Association of Ontario. (2012). Clinical best practice guidelines-Promoting safety:
alternative approaches to the use of restraints. Retrieved October 19, 2012 from
http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Page 6 of 29
Saskatchewan Registered Nurses’Association. (2010). SRNA position Statement use of restraints in
client care. Saskatchewan Registered Nurses’ Association
The Hospital for Sick Children. (2008). Policy, Procedure & Guideline Least Restraint. The H
ospital for Sick Children
The Health Care Directives and Substitute Health Care Decision Makers Act, SK., 1997
The Adult Guardianship and Co-decision-making Act, 2011
Page 7 of 29
PROCEDURE
Number: 7311-60-012
Title:
Least Restraint – Mechanical and Environmental
Authorization
[ ] President and CEO
[X] Vice President, Finance and Corporate
Services
Source: Director, Nursing Professional Practice and
Education
Cross Index: 7311-30-007; 7311-50-002
Date Approved: October 19, 2009
Date Revised: June 12, 20141
Date Effective: July 18, 2014
Date Reaffirmed:
Scope: SHR & Affiliates
1.
PURPOSE
The purpose of this procedure is to establish the process to facilitate safe and appropriate use of
least restraints.
2.
PROCEDURE FOR MECHANICAL AND ENVIRONMENTAL LEAST RESTRAINTS
2.1
1
Assessment
2.1.1 Clients should be assessed by RN, RPN, or LPN (in collaboration with the RN/RPN) on
admission for the potential and/or the presence of predisposing and precipitating
factors that put the client at risk for the use of least restraints.
2.1.2 If the client/family/SDM/proxy requests a restraint and the client has been assessed
and the use of a restraint is not clinically indicated, the restraint will not be applied if
the risks outweigh the benefits.
2.1.3
Non Emergent Situations
2.1.3.1 The RN, RPN or LPN (in collaboration with the RN/RPN) performs a
comprehensive assessment of the client and their environment, including a
description of the behavior(s) and the risk(s) involved, alternative interventions
and the decision whether to restrain or not. Decisions will be based on this
assessment resulting in an individualized plan of care. Refer to:
 Appendix A ‘Least Restraint Use Algorithm’
 Appendix B ‘Alternatives to Restraint Use’
 Appendix C ‘Algorithm for Use of a Client Attendant’ (where available)
2.1.3.2 Select the most appropriate least restraint based on the assessment. Refer to:
 Appendix D ‘Approved Least Restraints’
 Appendix E ‘Side Rail Pathway’ – for LTC only
2.1.3.3 Indications to restrain may include:
 Alternative interventions not effective or not available.
 Individual is at risk of harm to self or others
 Plan of care to which client/family/SDM/proxy have consented
2.1.4
Emergent Situations:
2.1.4.1 Attempt to de-escalate the behavior if appropriate using violence
management training. (Refer to SHR Violence Management Policy).
2.1.4.2 A “Code White” will be called for extra support. Refer to site specific
Emergency Preparedness Plans.
Editorial updates only Jan 2015
Page 8 of 29
2.1.4.3 The consent and physician order for the use of restraints must be obtained
within 12 hours.
2.1.4.4 The restraint should be used for the least amount of time.
2.1.4.5 Provide ongoing care, monitoring (2.8) and documentation (2.12) as outlined
in the sections mentioned.
2.1.4.6 Least restraint use will be reviewed/reordered at minimum every 24 hours or
sooner in emergency situations.
2.2
Obtain Informed and Written Consent (Refer to Appendix F)
2.2.1
Licensed staff, in collaboration with the client/family/SDM/proxy will obtain
consent.
2.2.2
Discuss the following with the client/family/SDM/proxy:
2.2.2.1 The reason for the restraint
2.3.2.2 Potential risks if restraint not used
2.3.2.3 Potential risks of restraint use
2.3.2.4 The intended outcome of using restraints
2.3.2.5 The type of restraint recommended
2.3.2.6 The duration of time the restraint will be used
2.3
Refusal of Consent
2.3.1 If the client/family/SDM/proxy does not consent to the use of restraints and the other
team members have determined that restraints are required for the client safety or
safety of others, the following will occur:
2.3.1.1 Document the refusal on the consent form
2.3.1.2 In an emergent situation apply appropriate least restraint as stated within the
procedure 2.14.
2.3.1.3 Provide ongoing monitoring of the client as per 2.8 below.
2.3.1.4 Continue to collaborate with the client/family/SDM/proxy for alternatives to
restraints, providing information to facilitate their understanding regarding the
rationale for and the types of restraints used.
2.4
Obtain Written Practitioner Orders
2.4.1
From the MRP, RN(NP) or Resident.
2.4.2
Pro re nata (PRN) orders for restraints will not be accepted.
2.4.3
A new order must be written every 24 hours for the first 7 days and at each review
point with extended use (refer to appendix H ‘Extended Restraint Use Algorithm’)
 For those LTC homeswhere a MRP or RN(NP) is not physically present or available
to write a new order, a telephone or faxed order can be received from the MRP
or RN(NP).
2.4.4
A separate order must be written for mechanical and environmental restraint(s).
2.4.5
The written orders should specify:
 The type(s) of restraint device
 The duration of the restraint application
 The reason for the restraint
2.5
Application of the Mechanical Restraint
2.5.1 The type of restraint used is based on the client assessment and physician order.
2.5.2 Refer to Appendix D ‘Approved Least Restraints’ for a list of SHR approved restraints
and manufacturers’ websites regarding correct application of the restraint. Apply
mechanical restraints according to manufacturer’s instructions and follow the Health
Canada and SHR safety alerts regarding restraint usage.
2.5.3 Restraints shall be used according to approved instruction and/or guidelines and
shall not be modified independently.
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2.5.4
2.5.5
2.5.6
2.5.7
2.5.8
Restraints shall be applied so that the client is comfortable and can breathe easily
but yet be snug. Mechanical restraints shall be applied in a manner that allows
comfort, safety, movement and good alignment.
A client who is at risk for seizures or aspiration shall be placed in a side lying position
when restrained in bed.
Use knots which can be easily released and/or ensure shears/scissors/magnet or
other tools needed to facilitate restraint removal in an emergency are present.
Secure the restraint to the bed frame, never to the side rails. When securing a
restraint to a bed, ensure that when the head of the bed is elevated, the restraint
allows the client to move with the bed.
The following will not to be used as a restraint. If it is not designed and sold or
marketed as a restraint device, it should not be used as a restraint. Please note, that
this is not an exhaustive list:
 bed sheets, draw sheets or other linens
 clothing
 bandaging materials (i.e. Kling®, Kerlix®)
 jackets or vests
 transfer belts
2.6
Use of Environmental Restraints
2.6.1 The type of restraint used is based on the client assessment and physician order.
Client and/or family/SDM/proxy should be included in the decision making process.
2.6.1.1 In long term care, consultation with the Behavioural Support Team should
occur where possible prior to use.
2.6.2 Refer to Appendix D ‘Approved Least Restraints’ for a list of SHR approved restraints
and manufacturers’ websites regarding correct use of the restraint. Environmental
restraints must have appropriate safety measures in place and must meet fire,
building and provincial/city/town codes and/or regulations with applicable permits
obtained. Environmental restraints will be used according to manufacturer’s
instructions and follow the Health Canada and SHR safety alerts regarding restraint
usage.
2.7
Maintenance of Mechanical and Environmental Restraints
2.7.1 Each facility/unit is responsible to ensure the restraints are in good condition and will
be inspected after each client use and maintained as per manufacturer’s guidelines.
Refer to Appendix D for specific manufacturer’s recommendations as to repair or
replacement.
2.8
Monitoring of Client while Restraint in Use
2.8.1 On-going care, observation, and documentation of the client must occur each time
a restraint is applied. Refer to Appendix G ‘Least Restraint Observation Record’ for
documentation.
Note: Documentation of respirations is required only if the restraint has the potential
to affect normal breathing.
Note: Monitoring and documentation can be completed by the individual team
member (RN, RPN, LPN, CCA) or a combination of team members involved in
the ongoing care of the client.
Note: Monitoring and documenting guidelines will be provided to the CCAs by the
licensed RN, RPN and LPN.
2.8.2 If monitoring/documentation requirements cannot be met then the restraint should
not be used. Consider alternatives.
2.8.3 Frequency of observation/documentation
 With initial application of a restraint, a team member will check the client after 15
minutes
 Following this every 30 minutes until the restraint is removed. May be more
frequent as indicated by the client’s condition.
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With each reapplication of the restraint, the team member will check the client
after 15 minutes followed by every 30 minutes until the restraint is removed.
Based on individual assessment and care plan, clients who are restrained will have at
minimum:
 Circulation/extremity/skin checks every 30 minutes
 Limb release/reposition/range of motion every 1 hour while awake
 Offered assistance to the toilet every 2 hours while awake
 Fluids offered/mouth care every 2 hours while awake
 Ambulation every 8 hours while awake

2.8.4
2.9
Extended Use of Least Restraint
2.9.1
Follow Appendix H ‘Extended Least Restraint Use Algorithm’.
2.9.2
Review points/re-evaluation are 1 week, 2 weeks, 1 month, 3 months as well as each
time a significant/adverse event has occurred and/or there has been a change in
the client’s condition.
2.9.3
With each review point/re-evaluation complete the procedure for least restraint use
including an assessment, practitioner orders and appropriate documentation.
Documentation of the review must be completed including the reason for continued
use or discontinuation.
2.9.3.1 If after thorough reassessment and with:
 no significant adverse events or
 no changes in the client condition and
 the restraint use is still appropriate and
 the most appropriate least restraint is still being used and
 the desired outcome is being achieved, proceed to the next review point
for re-evaluation
2.9.3.2 If there has been a change in any of the above or a different type of least
restraint has been used the next reassessment will occur within 7 days.
2.9.4
The extended use of a least restraint should never be for a period of greater than 3
months without thorough assessment being completed.
2.9.5
If a restraint has been discontinued, refer to de-restraining process outlined below.
2.10
De-restraining/Discontinuing
2.10.1 The RN, RPN and LPN in collaboration with the team, assess whether to continue with
least restraints or begin the process of de-restraining.
2.10.2 Collaborate and plan with the client/family/SDM/proxy the de-restraining process.
2.10.3 Consider a trial period to assess the client’s ability to manage behavior without a
restraint. The trial period should be at least a two hour period or longer.
2.10.4 Following restraint removal, assess the client’s behavior at least every thirty minutes
for one hour.
2.10.5 The RN, RPN and LPN and /or the MRP, RN(NP) or Resident will determine the level of
client monitoring required after restraints are discontinued.
2.10.6 Upon discontinuation clean and disinfect the restraints.
2.11
Debriefing Huddles for Emergent Situations
2.11.1 Following an emergent situation as soon as time permits, the Manager or designate
will conduct a debriefing huddle with the team including the client/family/SDM/proxy
(as appropriate and available).
2.11.1.1 The manager/rural site leader or designate will provide support to
other clients and debrief as necessary and appropriate while
maintaining confidentiality.
2.11.1.2 The manager/rural site leader will provide reassurance of unit safety
and security.
2.11.2 Debriefing huddles will be held:
2.11.2.1 Following an emergent situation where restraints were used
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2.11.2.2 Following an adverse/significant event with use of a restraint (i.e. fall,
client or staff injury).
2.11.2.3 At time of review.
2.11.2.4 During the huddle review and the most appropriate team member
documents:
 How the situation was handled
 The reasons for the use of restraints
 If the use of restraints achieved effective outcome
 Other alternatives that were considered and tried
 Were there any adverse/significant events
 What went well
 Action that could have improved or prevented the outcome
 What impact did the incident have on other clients, the unit and facility
 The perspective of the client/family/SDM/proxy of the situation
3.
2.12
Documentation
2.12.1 Documentation in the Progress Notes will include:
 Circumstances which precipitated the least restraint use
 Client assessment and alternatives tried and their effectiveness
 Client/family/SDM/proxy understanding related to least restraint use
 Time restraints applied and type of restraints used
 Time restraints discontinued
 Client’s response to the restraint
 Outcome
2.12.2 The most appropriate team member should initiate an adverse event report/safety
alert as indicated.
2.12.3 The clients care plan will be completed including:
 Alternatives to least restraints being used
 Type of restraint used and when it is to be used
 Any changes to care plan from previous and ongoing assessments
2.12.4 The nursing staff will complete Appendix G ‘Least Restraint Observation Record’ as
indicated in Procedure 2.7
2.12.5 On removal or discontinuation of restraints the following will be documented:
 The change in client’s behavior since the application of the restraint
 Any alternative interventions currently effective
 On-going reassessments of the client’s condition to ensure safety
2.12.6 If Security Services is involved, Security Services staff document in the Security
Information Management System (SIMS).
2.13
Education
2.13.1 Provide the client/family/SDM/proxy education regarding the alternatives,
complications/potential risks and outcomes from the use of least restraints and
expectations for ensuring safety from harm to client and staff. Refer to Appendix I
‘Least Restraint Information for Families’.
2.13.2 Provide staff education regarding the processes, principles, policy and procedure to
promote the practice of least restraint and prevent or reduce the use of restraints.
2.13.3 Provide staff with education on the proper application of restraints.
PROCEDURE MANAGEMENT
The management of this procedure including procedures education, monitoring, implementation
and amendment is the responsibility of Director, Professional Nursing Practice and Education.
Page 12 of 29
4.
NON-COMPLIANCE/BREACH
Non-compliance with this procedure will result in, at a minimum, a review of the incident. Noncompliance may also result in disciplinary actions up to and including termination of employment
and/or privileges with SHR.
5.
REFERENCES
Alzheimer Society of Canada. (2007). Least restraints. Retrieved from
http://www.alzheimer.ca/en/About-dementia/For-health-care-professionals/Tough-issues
Capital Health. (2012). Policy CC65-031 Use of Rapid Physical Least restraint on Acute Care Mental
Health In client Units. Retrieved from
http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Capital Health (2007). Appendix C Learning Supplement for Least Restraint. Retrieved from
http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Capital Health. (2007). Interdisciplinary Clinical Manual Policy & Procedure #CC-05-030 Least
restraint. Retrieved from http://policy.nshealth.ca/Site_Published/dha9/dha9_home.aspx
Division of Developmental Disabilities. (2012). Policy 5.11-Least restraints. Washington State
Department of Social &Health Services
Government of Saskatchewan. (2013). Regional Health Services Policy & Procedure manual 15.10
Restraints. Community Care Branch
Heartland Health Region. (2011). Policy # C01-39.01 Least restraint. Heartland Health Region
Regina Qu’Appelle Health Region. (2008). Policy #1001-Adult Least Mechanical Least restraint.
Regina Qu’Appelle Health Region
Registered Nurses’ Association of Ontario. (2012). Clinical best practice guidelines-Promoting safety:
alternative approaches to the use of least restraints. Retrieved October 19, 2012 from
http://rnao.ca/sites/rnao-ca/files/Promoting_Safety__Alternative_Approaches_to_the_Use_of_Least
restraints_0.pdf
Saskatchewan Registered Nurses’Association. (2010). SRNA position Statement use of least restraints
in client care. Saskatchewan Registered Nurses’ Association
The Hospital for Sick Children. (2008). Policy, Procedure & Guideline Least restraint. The Hospital for
Sick Children
Page 13 of 29
Least Restraint Use Algorithm
Appendix A
Client Assessment – “Describe the Behavior”
Identify the specific behavior (e.g. striking out at staff, spitting at staff, etc.) Explore the reasons for the
behaviour:
What issue is the behaviour communicating?
•
What is the unmet need?
•
What are the triggers for the behaviour?
Assessment should include:
•
Client's age
•
Mental status (oriented, confused, agitated) Acute changes? Fluctuates?
•
Level of cognitive impairment (moderate-severe dementia , trauma)
• Assess for triggers of delirium (medications, metabolic imbalance, infection, pain, exacerbations
of chronic illnesses)
• Alcohol/drug withdrawal
• Responsive behaviours (aggression, risk of injury to self or others , anxiety, challenging/disruptive
behaviours, restlessness/wandering)
• Decreased or inability to communicate (sensory impairment, aphasia)
• Unmet physical needs (toileting, hunger, thirst, fear)
• History of falls/fear of falls
• Increasing dependence (decline in mobility, increasing dependence for activities of daily living)
• Interference with life support equipment
• Environmental triggers (noise, music, temperature, unfamiliar environment)
• Consult with client's family, physician and other health care tea m members
• Activities and interests
• Availability of family or client attendant
Reflect on the following criteria :
• What is the potential harm and to whom?
• What are the detrimental risks of using the restraint on the client?
• Does the potential benefit of using a restraint outweigh the risk of harm?
What steps can we take to eliminate or change the behaviour so as to avoid the use of restraints?
Consider the use of a recommended assessment tool
Are Alternatives to Restraints Possible?
Are Alternatives to Restraints Possible?
Review the Alternatives to Restraints (see Appendix B)
What has been done in the past?
What need to change?
yes
•
•
•
•
no
Initiate alternatives in collaboration with
client/family/health care tea m
Assess needs of the client (e.g. pain, nutrition,
etc.)
Communicate and collaborate with tea m
Ongoing assessment, documentation and
monitoring of effectiveness of alternative
interventions as per policy
Alternative
Not Effective
•
•
•
•
•
•
•
•
Attempt de-escalating strategies through the use of
violence management training (e.g.
Workplace Assessment Violence Education (WAVE),
Gentle Persuasive Approach (GPA) , Professional Assault
Response Training (PART))
Use of Code White as required
Consider the type of restraint required ( environmental,
mechanical or physical)
Continue to implement alternatives
Assess need for Client Attendant where available
(see Appendix C)
Communicate and collaborate with team ASAP
Initiate restraint as per policy
Ongoing assessment, evaluation
Page 14 of 29
Appendix A
Ongoing Reassessment of the Need for
Least Restraint
Reassess every 24 hours for the first 7 days
then at each review point or when a
significant change in client (e.g. client
attempted to climb over side rails)
Extended Restraint Use: Refer to Appendix H
No
Yes
•
•
•
•
•
•
•
Code White as required
Consult health care team
Trial new alternative
Re-evaluate least restraint
Re-order restraint as per policy
Ongoing assessment, documentation and
monitoring as per policy
Communicate and collaborate with team
Discontinue restraint
Ongoing assessment of client’s behaviour
• Document decision and monitor
• Communicate and collaborate with team
•
•
Adapted from:
Alzheimer Society of Canada. (2007) Restraints. Retrieved from
http://www.alzheimer.ca/en/About-dementia/For-health-care-professionals/Tough-issues
Capital Health. (2007). Least Restraint, interdisciplinary Clinical Manual.
The Hospital for Sick Children. (2008). Least Restraint, Hospital – wide Client Care Policy, Procedure
and Guideline.
Registered Nurses’ Association of Ontario. (2012). Promoting Safety; Alternative Approached to the
Use of Restraints. Toronto, ON: Registered Nurses’ Association.
Page 15 of 29
Page 16 of 29
Page 17 of 29
Page 18 of 29
Appendix C
SASKATOON HEALTH REGION
Saskatoon, Saskatchewan
 RUH
 SCH
 SPH Other _____________
ALGORITHM FOR
USE OF A CLIENT ATTENDANT (SITTER, COMPANION)
Page 1 of 2
Assessment of Risk Behaviours
 Elopement
 Wandering
 Confusion or Dementia
 Agitation
 Agression
 Suicidal Ideation
Check off
identified
behaviours
Interventions
 Moved patient to more visible location
 Bed adjustment (lowest position, side-rails)
 Programming for elderly
 Contributing physiological factors (i.e. infection,
dehydration, electrolyte imbalances, medications)
 Regular toileting / commodes at bedside
 Vision / hearing aids
 Remove disruptive stimuli
 Medication review / Psychiatric consult
 Minimum restraint (i.e. Broda chair with table)
Check off
interventions used
Low Risk
 Risks minimized
Document impacts/responses to interventions on reverse
Medium Risk
 Request family
assistance
 Utilize volunteers
 Increase daytime programming
 Determine client attendant needs
for certain hours (document on
reverse
High Risk
 Assess client
attendant
requirements
(constant,
Security, etc.)
(document on reverse)
 Request family assistance
 Assess for mechanical restraints
Re-Assessment
 Re-evaluate client attendant
requirements Q 24 hours
(document on reverse)
Word
Form # 102892
08/07
Category: Care Plans/Outcomes
Page 19 of 29
ALGORITHM FOR
USE OF A CLIENT ATTENDANT (SITTER, COMPANION)
Page 2 of 2
Patient Name: ________________________________
HSN: ____________________ DOB: ______________
Intervention Assessment Documentation
If patient remains at medium or high risk, document the interventions used (and/or why they are not
applicable) and the impact(s) / response(s) to those interventions.
Review of Client Attendant Requirements
If patient (at medium or high risk) requires a client attendant for certain hours of the day, this requirement
must be reviewed and documented every 24 hours.
Day/Time:
Assessment Review:
Day/Time:
Assessment Review:
Day/Time:
Assessment Review:
Day/Time:
Assessment Review:
Day/Time:
Assessment Review:
Day/Time:
Assessment Review:
Page 20 of 29
Appendix D
APPROVED LEAST RESTRAINT
Note:
The intent of the device defines whether is a restraint or not
Not all restraints are available or applicable for all areas.
Please check with your supervisor before using.
Mechanical Restraints
•
Disposable soft least restraints
•
Pinel least restraint applied to bed or chair
•
Pinel gap covers
•
Broda Chair with table belt or thigh restraint belts
•
Wheelchair seatbelts
•
Soft cloth T-seat least restraint
•
Lap belt (secure across the client’s thighs and attaches to the bed or chair)
•
Body point belt
•
Tray tables
•
Wheelchair table
•
Vail bed
•
Posey foam pelvic holder
Environmental Restraints
•
Half doors, locked doors
Websites for Least Restraint
Pinel Least Restraint System:
http://www.pinelmedical.com/sef/page/id/14.html
Vail Bed:
http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotiuces/PublicHealthNotifications/UC
M062046.pdf
Broda Chair:
http://www.brodaseating.com/
Disposable Limb Holder:
Instructions for application come in the package from www.DJOglobal.com (Procare),
http://www.djoglobal.com/search/apachsoir_search/limb%20holders
Page 21 of 29
Appendix E
Side Rail Pathway
Page 22 of 29
Appendix F
Addressograph / Label
 RUH
 SCH
 SPH
 Other ________________
NAME: _________________________
HSN: __________________________
LEAST RESTRAINT USE CONSENT/PHYSICIAN ORDERD.O.B.:
FORM
Page 1 of 2
_______________________
___________
A) CONSENT FOR RESTRAINT DEVICES (each category needs a separate consent form)
Type of Restraint: Mechanical
Environmental
Specify each type to be used:
_______________________________________________________________________________________________
Purpose of Restraint:
Frequency and duration of restraint application: ________________________________________________
I have read the definitions, potential benefits and potential risks of restraint use, understanding
the potential benefits and risks of restraint use and the healthcare professionals’ evaluation:
I DO consent to the use of restraints as outlined above.
I understand that I have the right to refuse the use of restraints or can revoke this consent at any time.
I DO NOT consent to the use of restraints as outlined above and understand the related risks.
ADDITIONAL CONSIDERATIONS
__________________________________________________________________________________________
_________________________________________________________________________________________________

Date
Client Signature
OR

Proxy Personal Guardian Substitute Decision Maker
Other
2 Physician Signatures(if no proxy)


Signature
Date
Signature of Witness
Date
B) PHYSICIAN’S ORDER (required every 24hr x 7 days, then in 2 weeks, then in 1 month, then quarterly
from date of application)
Date & Physician Signature
Day 1
Date
Signature
Day 2
Date
Signature
Day 3
Date
Signature
Day 4
Date
Signature
Day 5
Date
Signature
Day 6
Date
Signature
Day 7
Date
Signature
2 weeks post application: Date due______________Signature _____________________________________
1 month post application: Date due______________Signature_____________________________________
Quarterly: Date due ______________Signature ___________________________________________
Date due ______________Signature ___________________________________________
Word
Form #
103694
01/14
Category: Consent/Release/Transport
Addressograph / Label
LEAST RESTRAINT USE CONSENT/ PHYSICIAN’S ORDER FORM
Page 2 of 2
NAME: _________________________
Appendix F
HSN: __________________________
RESTRAINT DEFINITIONS
D.O.B.:
_______________________
Mechanical:
___________
 Any device, material or equipment attached to or near a client which
cannot be easily removed
by the patient and involuntarily restricts the client’s freedom of movement or normal access to his
or her body (references: AHS, HHR, MDS)
Environmental:
 Any barrier or device that limits or controls the locomotion of an individual and thereby confines
an individual to a specific geographical area or location.
POTENTIAL BENEFITS


Managing agitation and aggression
Managing the safety of client and others
 Provision of necessary medical treatment
Other:
POTENTIAL RISKS






Behavior Alterations
Death
Hydration & Nutritional Status Alterations
Injury or Entrapment
Pain
Psychological






Cardiovascular System Alterations
Decreased Functional Status
Infection
Musculoskeletal Alterations
Perceptions of Self
Skin Integrity Alterations
PRINCIPLES
SHR staff will provide a collaborative and supportive atmosphere for clients who require restraints. An
environment will be created that adheres to informed decision making in regards to restraint use. All
staff will be respectful of the choices that clients make about restraint use and alternatives to
restraints.
SHR adheres to the practice of “least restraint”. The establishment of a therapeutic relationship
between the care team and client and family/SDM is beneficial for minimizing restraint use;
maximizing client independence; improving quality of life; minimizing risk of injury; and preserving
patient self-worth.
Page 24 of 29
Appendix G
Addressograph / Label
 RUH  SCH  SPH
NAME:
 Other
_
HSN:
LEAST RESTRAINT OBSERVATION
RECORD
DATE:
TYPE OF RESTRAINT(S):
REASON FOR RESTRAINT
TIME
D.O.B.:
Resp
_
 Risk of self-injury  Physical threat to others  Other:
Circulation
Care Given
Behavioral
Response
0730
0800
0830
0900
0930
1000
1030
1100
1130
1200
1230
1300
1330
1400
1430
1500
1530
1600
1630
1700
1730
1800
1830
1900
COMMENTS
INITIALS
(i.e. restraint applied, restraint removed)
(i.e. 15min check after application)
Note: Each time the restraint is applied, monitoring must be completed in 15 minutes, followed by q30 min monitoring
until the restraint is removed. With each application the same monitoring must occur. The 15 minute check can be
noted in the comments section
Documentation of respirations is required only if the restraint has the potential to affect normal breathing.
MINIMUM CARE
REQUIRED
Range of motion/limb
release q1h
Toileting q2h
Fluids/mouth care
q2h
Ambulation q8h
Word
Form # 102213
KEY:
CIRCULATION
Poor = p
Fair = f
Good = g
01/14
RESPIRATIONS
L = low (<12)
N = Normal (12-20)
H = High (>20)
Category: Flow Sheets
Page 25 of 29
CARE GIVEN
No Care = nc
Repositioned = rp
Repositioned self =
self
Skin Care = sc
Ambulated = amb
Range of Motion =
rom
Toileting = t
Fluids given = fl
BEHAVIORAL
RESPONSE
Sleeping = s
Calm = c
Agitated = a
Confused = cd
Combative = com
Resistive = res
Restless = r
Impulsive = imp
Memory problems =
mem
Addressograph / Label
 RUH  SCH  SPH
NAME:
 Other
HSN:
_
D.O.B.:
LEAST RESTRAINT OBSERVATION
RECORD
DATE:
TYPE OF RESTRAINT(S):
REASON FOR RESTRAINT
TIME
Resp
_
 Risk of self-injury  Physical threat to others  Other:
Circulation
Care Given
Behavioral
Response
COMMENTS
INITIALS
(i.e. restraint applied, restraint removed)
1930
2000
2030
2100
2130
2200
2230
2300
2330
2400
0030
0100
0130
0200
0230
0300
0330
0400
0430
0500
0530
0600
0630
0700
Note: Each time the restraint is applied, monitoring must be completed in 15 minutes, followed by q30 min
monitoring until the restraint is removed. With each application the same monitoring must occur. The 15
minute check can be noted in the comments section
Documentation of respirations is required only if the restraint has the potential to affect normal breathing.
MINIMUM CARE
REQUIRED
Range of motion/limb
release q1h
Toileting q2h
Fluids/mouth care q2h
Ambulation q8h
Word
KEY:
CIRCULATION
Poor = p
Fair = f
Good = g
Form # 102213
01/14
RESPIRATIONS
L = low (<12)
N = Normal (12-20)
H = High (>20)
Category: Flow Sheets
Page 26 of 29
CARE GIVEN
No Care = nc
Repositioned = rp
Repositioned self = self
Skin Care = sc
Ambulated = amb
Range of Motion = rom
Toileting = t
Fluids given = fl
BEHAVIORAL
RESPONSE
Sleeping = s
Calm = c
Agitated = a
Confused = cd
Combative = com
Resistive = res
Restless = r
Impulsive = imp
Memory problems = mem
Appendix H
Appendix I
Least Restraint Information for Families
Page 28 of 29
Page 29 of 29