This document is a summarised version of OP-SE1.3.1 Mechanical Restraint, Assessment and Application (Patients). The summary has been created to be Emergency Department (ED) specific, and has been endorsed by the ED Leadership Team. Staff should review the Procedure listed above if they require further information.
This guideline provides a quick reference guide for the use of Type 1 Mechanical Restraints in Western Health Emergency Departments.
This guide applies to all ED staff involved in the care of patients where the application of Type 1 Mechanical Restraints is being considered.
It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG and associated PPG.
Operations Managers are responsible for ensuring relevant staff are familiar with and comply with restraint procedures.
The diagrams provided are guides only. All Western Health mechanical restraint must be in accordance with the Procedure listed above.
|Type 1 Mechanical Restraint
|Padded limb restraints used to secure a person’s wrists, ankles and/or biceps (where applicable) to a bed or trolley. This includes the padded restraint belt that can be applied to the knees.
Bicep restraints can only be used in the Sunshine and Footscray Emergency Departments.
This Type 1 mechanical restraint system can be used up to a 7 point restraint.
2 point restraint is defined as wrists only.
Ask yourself these questions when considering whether mechanical restraints are necessary.
Where the patient is escalating in behaviour and difficult to contain, is posing an acute risk of aggression, violence or destructive behaviour, and a Code Grey has been called:
Mechanical restraints are only to be used in exceptional circumstances when all other less restrictive alternatives have been exhausted.
Alternative strategies that may be effective include:
- Investigation and treatment of underlying cause (see relevant guidelines e.g. Delirium Management)
- Adjusting your communication (also consider use of an interpreter)
- Review medical devices that might be causing distress or discomfort
- Adjust the patient environment or move the patient
- Consider if family or carer involvement can offer reassurance
- Consider increased staff supervision
- Promote orientation to time and place
- Consider falls risk
- Diversional activities
- Review medications
A table of strategies is included in Appendix C.
Roles and Responsibilities
The decision to use mechanical restraints must be based on thorough nursing and medical assessment.
- Patient assessment and clinical justification are the responsibility of the Medical Officer (MO).
- In an acute emergency situation the Nurse in change or senior RN can initiate use of mechanical restraints before an MO is present.
- In this instance it is good practice for the NIC or RN to document the nature of the acute emergency situation giving rise to their decision.
- Nursing observations and care are provided at regular intervals for restrained patients. The Registered Nurse must clinically review a person subject to a Type 1 restrictive intervention as often as is appropriate having regard to the person’s condition, but not less frequently than every 15 minutes.
- Medical reviews are conducted at regular intervals.
- Restraints should be terminated at the earliest possible time, having regard to whether the patient’s risk profile has reduced / it is clinically safe.
- Debrief is to be offered and provided to patients post-use of mechanical restraints.
See Appendix A and Appendix B (process flowcharts) for more information.
|1. Applies restraints.
2. Conducts restraint release as requested by clinical staff (i.e. at 2 hourly offer of toileting/repositioning).
3. Maintains a log of mechanical restraints issued*.
|1. Completion of Order Forms:
a) AD351.1 Order Form for duty of care episodes; or
b) Part A of MHA140 Order Form for Mental Health Act episodes when requesting authority from the psychiatrist/on call (EMH/ECATT can assist with contact details).
Note only whoever speaks directly to the psychiatrist should sign Part A.
2. Consent process commenced – Pt/NoK/MTDM/Guardian/Public Advocate.
3. Documents medical and patient assessment and rationale for use of restraints including assessment of patient’s capacity for decision-making and judgement.
4. Notifies Registrar/Consultant of use of restraints (as applicable).
5. Conducts and records 4 hourly medical reviews and re-assessment of need to continue or cease restraints.
6. Conducts and records 24 hourly consultant review and re-assessment of need to continue or cease restraints.
|1. 15/60 records conscious state/behaviour/ circulation/skin/vital signs.
2. 60/60 Restraint site check/offer hydration (documents if patient declines or if not offered – includes rationale).
3. 2 hourly offer toileting/ offer repositioning – restraint release by security (documents if not offered – with rationale, or if patient declines toileting).
4. Documents in patient’s notes any clinical decision making concerning mechanical restraints use not recorded elsewhere (includes rationale).
Note an EMH/ECATT clinician whose discipline is nursing can complete Part A of MHA140 Order Form where they request authority from the psychiatrist/on call.
*Type 1 mechanical restraints will be kept in three locations only: Security Offices, Emergency Departments and Intensive Care Unit.
Documentation is a legal requirement and supports best patient care where restrictive interventions apply.
For the use of Type 1 Mechanical Restraints:
- The medical assessment, rationale, reviews and decision to remove restraints is documented in the patient’s electronic notes along with any rationale to explain clinical decisions.
- Nursing observations are documented in:
- The Mechanical Restraint Initial Order and Review Form (Form 1) where Duty of Care applies; or
- Form MHA140 Authority for Use of Restrictive Interventions, and Restrictive Interventions Observations form MHA142 where the restraints are applied to a patient who is under a compulsory order under the Mental Health Act 2014 (VIC).
- These patients are also referred to as persons receiving treatment in a Designated Mental Health Service on a Voluntary Basis (see Appendix B).
The principles of informed medical consent apply to the application of mechanical restraints with patients.
Consent is sought either from the patient (where they have the capacity to consent) or from a Medical Treatment Decision Maker (MTDM; where the patient does not have the capacity to consent).
- When mechanical restraint is required to administer emergency treatment or in an emergency situation.
- For Compulsory Patients as defined under the Mental Health Act.
The MTDM must be contacted within four hours or as soon as is practicable for consent for ongoing use of the mechanical restraints. Document if unable to contact and continue to attempt to contact.
See the Western Health policy for more information: P-CM3 Medical Consent.
Appendix 3 – Alternative Strategies
|Investigation and treatment of underlying causes
- Delirium – see Delirium Management Guidelines
- Behavioural and psychological symptoms of dementia – consider exacerbating factors (e.g. infection, electrolyte disturbance, constipation, urinary retention)
- Psychiatric illness
- Medication changes
- Drug or alcohol withdrawal
- Pain and discomfort
- Introduce yourself and others
- Maintain eye contact
- Talk in a calm and unhurried manner
- Use short, simple sentences – explaining one concept at a time
- Repeat yourself where necessary
- Give time for responses
- Consider use of an interpreter
|Review medical devices
- Remove unnecessary lines: IDC, IVC etc.
- Change position of IV site
- Re-tape artificial airway
- Abdominal binder to cover tubes/drains
- Stimulus reduction – noise, light
- Single room
- Lighting appropriate to time of day (curtains open during the day, minimal lighting at night.
- Would the presence of family or carers help?
- Consider continuity of carers/nursing staff
- Encourage family/carer to bring in personal and familiar objects
- Relocate patient closer to nursing station
- Frequent or constant observation (1:1 nursing)
|Orientation – time and place
- Re-orientation to surroundings
- Environmental cues: e.g. clocks, calendars
- Promotion of day/night sleep pattern
- Lo-lo or floor-line beds
- Toileting regime: 2 hourly toileting
- Bed and chair exit alarms, wandering alarms
|Consider medications to reduce agitation
- Music, TV, activities
- Mobilisation and physical activity.
- See Delirium Management Guidelines.
|For further support also consider the following referrals if necessary:
- Consultant Liaison Psychiatry
- Drug and Alcohol