Page 1 of 5
Restraint Minimisation and Safe Practice Policy
Policy: Restraint Minimisation and Safe Practice
Purpose
Counties Manukau Health (CM Health) is dedicated to serving our
patients and communities by ensuring quality focussed health care.
CM Health takes the health, safety and welfare of all patients and staff
extremely seriously.
Staff will ensure that patients receive and experience services in the
least restrictive manner whilst recognising that all staff have the right to
perform their duties without tolerating abuse or acts of aggression.
Note: This Policy must be read in conjunction with Procedure:
Restraint Minimisation and Safe Practice for Restraint and Enabler
Use. Or Procedure: Restraint Minimisation – Personal Restraint
Mental Health Inpatient Services and the Safe and Appropriate Use
of Bedrails Guideline.
Philosophy
It is the philosophy of CM Health, in line with the values of the
organisation, to support health professionals and support staff
to achieve the intent of the Health and Disability Services
(Restraint Minimisation) Standard NZS 8134. 2008: which is that
Restraint and/or Enablers should only be used in the context of
ensuring, maintaining, or enhancing the safety of the patient,
service providers, or others.
Scope
This policy is applicable to:
All CM Health employees and visiting health professionals working in
any CM Health Facility (note: students and contractors are excluded
from performing restraint).
Specific clinical areas must have procedures/guidelines, consistent
with this policy, that reflect the contextual issues in a particular
setting.
Approval of Restraints and Enablers
All Restraints and Enablers used at CM Health must be approved by
the Restraint Minimisation and Safe Practice Group (RMSPG).
Document ID:
A17357
Version:
3.1
Department:
Patient Safety
Last Updated:
20/06/2017
Document Owner: Restraint Minimisation Safe Practice Group
Next Review Date:
20/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
14/09/2010
Counties Manukau Health
Page 2 of 5
Restraint Minimisation and Safe Practice Policy
Policy
Restraint is a serious intervention that requires clinical rationale and
oversight. It is based on sound clinical judgement with clear
justification for use.
Restraint shall be perceived in the wider context of risk management;
it is not a treatment within itself but one of a number of strategies
used by service providers to limit or eliminate a clinical risk.
Restraint should only be used as a last resort after alternative less
restrictive interventions have been attempted. e.g. de-escalation,
interpreters, cultural support. It will be used for the shortest time
possible.
CM Health does not support the use of Chemical Restraint.
CM Health does not support the use of bed rails as a method of
Restraint.
Enablers can only be used voluntarily for positioning, mobility or
comfort.
Incidents resulting from Restraint/Enablers will be reported in the
Incident Reporting System (IRS).
Audits of restraint and enabler use will be tabled at the Restraint
Minimisation and Safe Practice Group quarterly meetings as well as
discussed within Services as appropriate.
Documentation
Restraint use must be recorded in the IRS. The exception to this is
the use of soft wrist restraints e.g. Critical Care Complex, however,
an auditable record of its use must be current and available.
An e-version of the information required in the folder is available on
SouthNet by clicking on this link:
http://southnet/RestraintMinimisation
Education
All CM Health employees with patient contact will receive
information/training related to Restraint Minimisation and Safe
Practice at a level that supports safe practice in their role, discipline
and service.
Definitions
Terms and abbreviations used or are relevant for this document are described below:
Term
Definition
Restraint
The use of any intervention by a service provider that
limits a patient’s normal freedom of movement.
Type of Restraint:
Where a service provider uses their own body to
intentionally limit the movement of a consumer e.g.
Document ID:
A17357
Version:
3.1
Department:
Patient Safety
Last Updated:
20/06/2017
Document Owner: Restraint Minimisation Safe Practice Group
Next Review Date:
20/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
14/09/2010
Counties Manukau Health
Page 3 of 5
Restraint Minimisation and Safe Practice Policy
Personal Restraint
holding a patient.
Type of Restraint:
Where a service provider uses equipment, devices or
furniture that limits a patients normal freedom of
Physical Restraint
movement e.g. fixed trays, lap belts or specialised
seating.
Type of Restraint:
Where a service provider intentionally restricts a patients
normal access to their environment. e.g. locking devices
Environmental
on doors, removing mobility aids e.g. wheelchair.
Seclusion
Where a patient is placed alone in a designated room or
area, at any time and for any duration, from which they
cannot freely exit. Seclusion only occurs in the inpatient
Mental Health Services at CM Health.
Enabler
Equipment, devices or furniture, voluntarily used by a
patient following appropriate assessment by a health
professional, that limits normal freedom of movement.
The least restrictive option is used with the intent of
promoting independence, comfort and or safety
(consented to by the patient or their legal
representative).
Chemical Restraint
CM Health does not support the use of Chemical
Restraint
NZS 8134: 2008 Health & Disability Standard.
“Al Medicines should be prescribed and used for valid
therapeutic indications. Appropriate health professional
advice is important to ensure that the relevant
intervention is appropriately used for therapeutic
purposes only.”
Chemical restraint is defined as the intentional use of
medication to control a person’s behaviour when no
medically identified condition is being treated,
or where the treatment is not necessary for the
identified condition
or amounts to excessive treatment for the identified
condition
or where the intended effect of the drug is to sedate the
person for convenience sake or purposes of
punishment
Use of medication as a form of ‘chemical restraint’ is in
breach of this standard.
Bed rails
CM Health does not support the use of bed rails as
a Restraint.
Bed rails can be used as an Enabler in specific
circumstances. The inappropriate use of bed rails is
associated with significant risks to the patient. Staff
must be familiar with the Safe and Appropriate Use of
Bed Rails Guideline before using this equipment as an
enabler.
Transportation of
The temporary use of bed rails or safety belts for patient
patients
safety when a patient is in transit from one place to
another is not considered restraint as long as a staff
member is present. When transporting a patient by
vehicle land transport requirements must be met e.g.
the wearing of seat belts.
Document ID:
A17357
Version:
3.1
Department:
Patient Safety
Last Updated:
20/06/2017
Document Owner: Restraint Minimisation Safe Practice Group
Next Review Date:
20/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
14/09/2010
Counties Manukau Health
Page 4 of 5
Restraint Minimisation and Safe Practice Policy
If the bed rail remains in use once on a ward, then an
assessment must be completed and documented in the
clinical record.
Technical positioning
Is not considered to be Restraint
and planned safe
Adults, children and young persons are often held or
holding
their ability to move is limited while an investigation or
procedure occurs. This is referred to as technical
positioning and planned safe holding. It is expected that
the need for this will be essential to the procedure,
included in the relevant procedure along with safety
requirements, education needed to ensure patient
safety and informed consent requirements will be met.
Family
Members of a patient’s close or extended family or
whaanau; partners; friends; health advocates; guardian
or other representatives nominated by the patient.
Non Clinical
Use of restraint recommended and applied by law
Intervention
enforcement officers i.e. police/prison officers, for
reasons other than clinical treatment, is not covered by
this policy. Police/prison officer have full responsibility
for safe law enforcement Restraint. These situations are
governed by Criminal Law including the Trespass Act
1980 and the NZ Crimes Act 1961.
Locked Units:
In a locked unit the locked exit is a permanent aspect of
service delivery to meet the safety needs of patients
who have been assessed as needing that level of
containment. Although by definition the locking of exits
constitutes Environmental Restraint the requirements of
NZS8134.2 are not intended to apply to designated
locked units that have entry and exit criteria and can
ensure any patient who does not meet the criteria has
the means to independently exit at any time.
SPEC
Safe Practice, Effective Communication (SPEC) is a four
day training course focusing on effective Communication
de-escalation and approved Restraint techniques.
CALM
Facilitated course in effective communications and de-
escalation principles.
Restraint Minimisation E-learning session accessed online by health
E-Learning Package
professionals.
Document ID:
A17357
Version:
3.1
Department:
Patient Safety
Last Updated:
20/06/2017
Document Owner: Restraint Minimisation Safe Practice Group
Next Review Date:
20/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
14/09/2010
Counties Manukau Health
Page 5 of 5
Restraint Minimisation and Safe Practice Policy
Associated Documents
NZ Legislation
NZ Crimes Act 1961
NZ Bill of Right Act , 1990
Health and Disability Act 2001
Code of Health and Disability Services Rights 1996
Protection of Personal and Property Right Act 1988
Mental Health (Compulsory Assessment and
Treatment) Act 1992.
Human Rights Acts 1993
Health and Safety in Employment Act 1992
CM Health Policies and Policy: Tikanga Best Practice
Procedures
Policy: Informed Consent
Policy: Management of aggressive behaviour in the
workplace
Policy: Visitors
Policy: Security
CM Health Vision and Values
Procedure: Restraint Minimisation and Safe Practice
for Restraint and Enabler Use
Procedure: Restraint Minimisation – Personal Restraint
Mental Health Inpatient Services
Policy: Incident Management and Reporting
Procedure: Incident Management and Reporting
Policy: Management of Consumer Complaints and
Feedback
Procedure: Management of Consumer Complaints and
Feedback
NZ Standards
Restraint Minimisation and Safe Practice Standard
NZS 8134.2 :2008
Health and Disability Services (general) Standard NZS
8134. 0: 2008.
Health and Disability Services (core) Standards NZS
8134.1: 2008.
Restraint of Children with Disabilities, or Medical
Conditions, in Motor Vehicles NZS 4370:2013
Organisational
Safe and Appropriate use of Bedrails Guideline
Procedures
Assessment and Care of Patients Presenting to EC at
risk of Suicide or in an Agitated State (Procedure)
Restraint Minimisation – Personal Restraint Mental
Health Inpatient Services
Other related
Management of Adults with Severe Behavioural
documents
Disturbance (Guideline)
Restraints - Critical Care Complex (Guideline)
Dealing with Violent and/or Abusive Patient (Guideline)
Management of Challenging Behaviour in Pukekohe
and Franklin Memorial Hospitals (Guideline)
Document ID:
A17357
Version:
3.1
Department:
Patient Safety
Last Updated:
20/06/2017
Document Owner: Restraint Minimisation Safe Practice Group
Next Review Date:
20/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
14/09/2010
Counties Manukau Health
Page 1 of 6
Procedure: RM&SP for Restraint and Enabler Use.
Procedure: Restraint Minimisation and Safe Practice for
Restraint and Enabler Use.
Definition/Description
The purpose of this procedure is to describe the process of Restraint
Minimisation and Safe Practice for Restraint and Enabler use within Counties
Manukau Health (CM Health).
This document is to be read in conjunction with CM Health Restraint
Minimisation and Safe Practice Policy.
Note: This Policy must be read in conjunction with Policy:
Restraint Minimisation and Safe Practice, and Safe and Appropriate
Use of Bedrails Guideline
People involved and Responsibilities
This applies to all CM Health employees with patient contact (full-time, part-time
and casual) including visiting health professionals working in any CM Health
facility (note: Students and contractors are excluded from performing restraint).
Security staff trained in the Safe Practice Effective Communication (SPEC)
course (with annual updates) can be called to assist for Personal and
Environmental Restraint under the Registered Health Professionals instructions.
The Restraint Minimisation and Safe Practice Group (RMSPG) authorises the
use of restraints and enablers in CM Health and meets regularly to review the
use of restraints and enablers to ensure their appropriate use and identify
improvement opportunities.
Note: Personal Restraint for Mental Health Inpatient Services
will refer to Procedure: Restraint Minimisation – Personal Restraint
Mental Health Inpatient Services.
Objectives
To ensure enablers are only used voluntarily and not for restraint.
To ensure restraint is used as a last resort after alternative less restrictive
interventions have been attempted.
Procedure Enabler Use
Initiation
When requested by patient, family/whaanau or registered health
professional for providing comfort, positioning or mobility. The assessment
Document ID:
Obtain from Objective
Version:
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Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 2 of 6
Procedure: RM&SP for Restraint and Enabler Use.
for the enabler use will be documented in the clinical record and state the
reason, type of enabler and intended benefit.
The correct equipment will be ordered through Task Manager or an
Occupational Therapist. A Physiotherapist will assist with correct
positioning.
Monitoring
Regular visual checks of the patient are to be maintained. The call bell
must be within the patient’s reach or in a supervised area.
Monitoring times will be documented in the care plan/daily intervention.
Documentation
The assessment supporting enabler use will be documented in the clinical
record and will include the name of the patient, family/whaanau who was
informed.
Evaluation
An evaluation of the effectiveness of the use of enablers will be undertaken
and documented in the patient clinical record.
Procedure Physical Restraint Use
Initiation
Restraint use will be initiated after assessment and discussion by the
clinical team.
The decision making process will be clearly documented in the clinical
notes and an individualised care plan developed to ensure all the patient’s
needs are met whilst restraint is being used.
A patient-centred goal will be developed in the patient’s plan of care
outlining the use, monitoring and evaluation of restraint use.
Wherever possible discussion and consent process will include the patient
and family/whaanau. Continuation of restraint will be discussed at any
family/whaanau meetings.
Restraint will be initiated only when the environment is safe and appropriate
for initiation and when adequate resources are in place.
Monitoring
Patient checks are to be maintained at a minimum of every 30 minutes
unless more or less frequent checks are clinically indicated (e.g. mental
health area).
The call bell must in reach of the patient or the patient must be in a
supervised area.
Monitoring requirements will be documented in the care plan/daily
intervention.
Documentation
Restraint to be logged in the Incident Reporting System (IRS).
Document ID:
Obtain from Objective
Version:
1.1 DRAFT
Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 3 of 6
Procedure: RM&SP for Restraint and Enabler Use.
Documentation in the patient clinical record or care plan/daily intervention is
required including monitoring times.
Monitoring form for physical restraint must be completed.
Evaluation
An evaluation of the effectiveness of the use of restraint will be undertaken
and documented in the patient’s clinical record.
Audits to assess the effectiveness and relevance of restraint use will be
undertaken regularly to facilitate professional development of practice and
appropriate use.
Procedure Personal and Environmental Restraint Use
Initiation
Restraint use will be initiated after assessment and discussion by the
clinical team.
Exceptional circumstances will require emergency restraint. This must be
initiated by a Registered Health Professional.
The decision making process will be clearly documented in the clinical
notes and an individualised care plan developed to ensure all the patient’s
needs are met whilst restraint is being used.
A patient-centred goal will be developed in the patient’s plan of care
outlining the use, monitoring and evaluation of restraint use.
Wherever possible discussion and consent process will include the patient
and family/whaanau.
Restraint will be initiated only when the environment is safe and appropriate
for initiation and when adequate resources are in place.
Monitoring
Staff will remain with the patient at all times.
Security Guards will follow the direction of a Registered Health
Professional.
Documentation
Personal and environmental restraints must be reported on the IRS
including the type and position of restraint.
The decision making process will be clearly documented in the patient
clinical notes or care plan/daily intervention is required including the
rationale, goal, process and evaluation of the restraint.
Evaluation
An evaluation of the effectiveness of the use of restraint will be undertaken
and documented in the patient’s clinical record.
Audits to assess the effectiveness and relevance of restraint use will be
undertaken regularly to facilitate professional development of practice and
appropriate use.
Resources
.
Document ID:
Obtain from Objective
Version:
1.1 DRAFT
Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 4 of 6
Procedure: RM&SP for Restraint and Enabler Use.
Definitions
Terms and abbreviations used or relevant for this document are described below:
Term
Definition
Restraint
The use of any intervention by a service provider that
limits a patient’s normal freedom of movement.
Type of Restraint:
Where a service provider uses their own body to
intentionally limit the movement of a consumer e.g.
Personal Restraint
holding a patient.
Type of Restraint:
Where a service provider uses equipment, devices or
furniture that limits a patients normal freedom of
Physical Restraint
movement e.g. fixed trays, lap belts or specialised
seating.
Type of Restraint:
Where a service provider intentionally restricts a patients
normal access to their environment. e.g. locking devices
Environmental
on doors, removing mobility aids e.g. wheelchair.
Seclusion
Where a patient is placed alone in a designated room or
area, at any time and for any duration, from which they
cannot freely exit. Seclusion only occurs in the inpatient
Mental Health Services at CM Health.
Enabler
Equipment, devices or furniture, voluntarily used by a
patient following appropriate assessment by a health
professional, that limits normal freedom of movement.
The least restrictive option is used with the intent of
promoting independence, comfort and or safety
(consented to by the patient or their legal
representative).
Chemical Restraint
CM Health does not support the use of Chemical
Restraint
NZS 8134: 2008 Health & Disability Standard.
“Al Medicines should be prescribed and used for valid
therapeutic indications. Appropriate health professional
advice is important to ensure that the relevant
intervention is appropriately used for therapeutic
purposes only.”
Chemical restraint is defined as the intentional use of
medication to control a person’s behaviour when no
medically identified condition is being treated,
or where the treatment is not necessary for the
identified condition
or amounts to excessive treatment for the identified
condition
or where the intended effect of the drug is to sedate the
person for convenience sake or purposes of
punishment
Use of medication as a form of ‘chemical restraint’ is in
breach of this standard.
Document ID:
Obtain from Objective
Version:
1.1 DRAFT
Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 5 of 6
Procedure: RM&SP for Restraint and Enabler Use.
Bed rails
CM Health does not support the use of bed rails as
a Restraint.
Bed rails can be used as an enabler in specific
circumstances. The inappropriate use of bed rails is
associated with significant risks to the patient. Staff
must be familiar with the Safe and Appropriate Use of
Bed Rail Guideline before using this equipment as an
enabler.
Transportation of
The temporary use of bed rails or safety belts for patient
patients
safety when a patient is in transit from one place to
another is not considered restraint as long as a staff
member is present. When transporting a patient by
vehicle land transport requirements must be met e.g.
the wearing of seat belts.
If the bed rail remains in when on the ward, then an
assessment must be completed and documented in the
clinical record.
Technical positioning
Is not considered to be Restraint
and planned safe
Adults, children and young persons are often held or
holding
their ability to move is limited while an investigation or
procedure occurs. This is referred to as technical
positioning and planned safe holding. It is expected that
the need for this will be essential to the procedure,
included in the relevant procedure along with safety
requirements, education needed to ensure patient
safety and informed consent requirements will be met.
Family
Members of a patient’s close or extended family or
whaanau; partners; friends; health advocates; guardian
or other representatives nominated by the patient.
Non Clinical
Use of restraint recommended and applied by law
Intervention
enforcement officers i.e. police/prison officers, for
reasons other than clinical treatment, is not covered by
this policy. Police/prison officer have full responsibility
for safe law enforcement Restraint. These situations are
governed by Criminal Law including the Trespass Act
1980 and the NZ Crimes Act 1961.
Locked Units:
In a locked unit the locked exit is a permanent aspect of
service delivery to meet the safety needs of patients
who have been assessed as needing that level of
containment. Although by definition the locking of exits
constitutes environmental Restraint the requirements of
NZS8134.2 are not intended to apply to designated
locked units that have entry and exit criteria and can
ensure any patient who does not meet the criteria has
the means to independently exit at any time.
SPEC
Safe Practice, Effective Communication (SPEC) is a four
day training course focusing on effective Communication
de-escalation and approved Restraint techniques.
Communicating
Facilitated course in effective communications
Effectively
Restraint Minimisation E-learning session accessed online by health
E-Learning Package
professionals.
Associated Documents
Document ID:
Obtain from Objective
Version:
1.1 DRAFT
Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 6 of 6
Procedure: RM&SP for Restraint and Enabler Use.
Other documents relevant to this policy are listed below:
NZ Legislation
NZ Crimes Act 1961
Mental Health (Compulsory Assessment and
Treatment) Act 1992
Human Rights Act 1993
Health and Safety in Employment Act 1992
Health and Disability Act 2001
CMDHB Clinical Board
Restraint Minimisation and Safe Practice (Policy)
Policies
Informed Consent (Policy)
Security Department (Policy)
NZ Standards
Restraint Minimisation and Safe Practice Standard
NZS 8134:2; 2008
Health and Disability Services (General) Standard NZS
8134, 0; 2008
Health and Disability Services (Corel) Standard NZS
8134, 1; 2008
Organisational
Safe and Appropriate Use of Bed Rails Guideline
Procedures
Assessment and Care of Patients Presenting to EC at
risk of Suicide or in a Agitated State (Procedure)
Restraint Minimisation – Personal Restraint Mental
Health Inpatient Services
Other related
Management of Adults with Severe Behavioural
documents
Disturbance (Guideline)
Restraints - Critical Care Complex (Guideline)
Dealing with Violent and/or Abusive Patient (Guideline)
Management of Challenging Behaviour in Pukekohe
and Franklin Memorial Hospitals (Guideline)
Document ID:
Obtain from Objective
Version:
1.1 DRAFT
Department:
Patient Safety
Last Updated:
11/06/2017
Document Owner: Clinical Director Patient Safety and Quality Assurance
Next Review Date:
11/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
11/12/2012
Counties Manukau Health
Page 1 of 4
Guideline: Safe and appropriate use of bedrails
Guideline: Safe and Appropriate Use of Bedrails
Purpose
The purpose of this guideline is to ensure bedrail use is appropriate. Following an
individual patient risk/benefit assessment, a bedrail may be used for the following
purposes:
-
To prevent the patient from rolling out of the bed where there is an
assessed risk of this occurring.
-
To assist the patient to mobilise more independently in the bed.
-
To promote patient comfort in bed by allowing the positioning of pillows.
Important:
-
Bedrails are not appropriate for a patient who is, or who is likely to
become:
- Mobile and confused
- Mobile and agitated
- Mobile and lacking insight
-
Bedrails are not to be used as a means of preventing or impeding a
patient from intentionally leaving the bed.
-
The use of bedrails is a clinical decision made in collaboration with the
patient and or whaanau, and requires ongoing assessment of the risks
and benefits as they apply individually to the patient.
-
The inappropriate use of bedrails poses a significant risk to a patient,
including the risk of falling from the bed, entrapment, postural asphyxiation
and psychological stress.
N
ote: This guideline must be read in conjunction with:
R estraint Minimisation and Safe Practice Policy
Scope of Use
This guideline is applicable to all CM Health employees, (full-time, part-time and
casual), visiting health professionals and students working in any CM Health facility.
Exclusions
This guideline does not apply to:
-
The use of bedrails or cot sides for young children as a normal response
to their developmental age.
-
The use of bedrails for a patient who is supervised and is:
-
in transit
-
on a narrow trolley (ED)
-
recovering from general anaesthesia
Document ID:
A143
CMH Revision No:
1.0
Service:
Patient Safety
Last Review Date :
Document Owner: Restraint Minimisation and Safe Practice Group
Next Review Date:
16/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
16/06/2017
Counties Manukau Health
Page 2 of 4
Guideline: Safe and appropriate use of bedrails
Responsibilities
Nursing:
Assessment
The use of bedrails is a clinical decision which is made in partnership with the
patients following an assessment of the risks and benefits as they apply
individually to the patient (refer bedrail decision guide, p.3).
Where a patient and/or their whaanau request the use of bedrails the decision
remains a clinical decision. The rationale for the decision should be discussed
with the patient and whaanau and documented in the clinical notes.
The bedrail decision guide focuses on the likelihood of the patient rolling out of
bed, the patient’s mobility and the patient’s mental state/likely behaviour. There
are however other elements that also need to be taken into account when
considering the safe and appropriate use of bedrails such as the patient’s
vulnerability to injury, visual and spatial awareness and the use of special
mattresses.
Monitoring
The monitoring of the patient during bedrail use is to be determined at
assessment and documented in the patient’s plan of care. Staff should be
directed to reassess the safety and appropriateness of the bedrail use at each
point of contact.
Documentation and Communication
Where bedrails are used the clinical rationale for use and the monitoring
requirements are to be documented in the patient’s clinical notes and
communicated at shift handovers. For ongoing assessment update the plan of
care document.
Service:
Assessment
Ensuring bed, mattress and bedrails are compatible so as to avoid gaps that
potentially could lead to entrapment.
Monitoring
Ensuring bedrails are correctly installed on the bed and maintained as per
standards to ensure equipment safety.
Damaged or faulty bedrails must be clearly labelled as faulty and removed from
circulation.
Document ID:
A143
CMH Revision No:
1.0
Service:
Patient Safety
Last Review Date :
Document Owner: Restraint Minimisation and Safe Practice Group
Next Review Date:
16/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
16/06/2017
Counties Manukau Health
Page 3 of 4
Guideline: Safe and appropriate use of bedrails
BEDRAIL DECISION GUIDE
Very Immobile
Neither
Mobilising
(bedrest or hoist
Independent nor
Independently
transfer)
Immobile
(requires staff
assistance)
Confused and
Bedrails NOT
Bedrails NOT
Bedrails NOT
disorientated (refer
recommended
recommended
recommended
CAM score)
Drowsy
Bedrails recommended
May use bedrails
May use bedrails
with care
with caution
Orientated and alert
Bedrails recommended
May use bedrails
May use bedrails if
with care
requested
Unconscious
Bedrails recommended
Not applicable
Not applicable
BEDRAIL INTERVENTION GUIDE
Assessment of bedrail
appropriateness from decision
guide
Bedrails recommended
May use bedrails with care/caution
Bedrails NOT recommended
The clinical decision is in partnership
The clinical decision is in partnership
Consider other interventions:
with the patient/whaanau
with the patient/whaanau
-
Bed at lowest position
Make
-
Floor bed
AND
AND
-
Whaanau support
-
Consider a watch
The patient is
NOT likely to become
The patient is
NOT likely to become
AND
mobile and confused, agitated, or
confused, agitated, or lack insight.
Streamline
Document rationale in notes
lacking insight
Consider the risk of the patient
admission
Streamline admission process
attempting to exit the bed unassisted
process
Action steps to follow:
Provide information brochure to patient/whaanau if bedrail is in use. The
Streamline
call bell must be in reach for patients.
admission
process Streamline
Document the clinical decision rationale for bedrail use and monitoring
admission
requirements/removal of bedsides in the patient’s clinical notes. For
process
ongoing assessment update the plan of care document.
Note: This should be updated and communicated at each shift handover.
*This is a guide only and a clinician may make a decision to use bedrails if it is clinically
appropriate. This guide has been adapted from the National Patient Safety Agency: Using
Bedrails safely and Effectively, London NPSA 2007.
Document ID:
A143
CMH Revision No:
1.0
Service:
Patient Safety
Last Review Date :
Document Owner: Restraint Minimisation and Safe Practice Group
Next Review Date:
16/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
16/06/2017
Counties Manukau Health
Page 4 of 4
Guideline: Safe and appropriate use of bedrails
References
National Patient Safety Agency (UK),
Bedrails – Reviewing the evidence, A
systematic literature review, March 2007
ww.nsa.nhs.uk
Thanks to ADHB and CDHB for sharing their bedrail resources.
Definitions/Description
Terms and abbreviations used in this document are described below:
Term/Abbreviation
Description
Bedrail (enabler)
Equipment that is
voluntarily used by a patient that
limits normal freedom of movement, with the intent
of promoting comfort and/or safety.
Family/whaanau
Family includes a patient’s extended whaanau, their
Partners, friends and advocates, guardian or other
representatives nominated by the patient.
Associated Documents
Other documents relevant to this guideline are listed below:
NZ Legislation /
Health and Disability Act 2001
Standards
Restraint Minimisation and Safe
Practice Standard NZS 8134.2 :2008
Health and Disability Services
(general) Standard NZS 8134. 0:
2008.
Health and Disability Services (core)
standards NZS 8134.1: 2008.
Code of Health and Disability
Services Rights 1996
Human Rights Acts 1993
CM Health Documents
Policy: Restraint Minimisation and Safe Practice
Procedure: Restraint Minimisation and Safe
Practice
Policy: Informed consent
Patient pamphlet: Bedrails
Other related documents None
Document ID:
A143
CMH Revision No:
1.0
Service:
Patient Safety
Last Review Date :
Document Owner: Restraint Minimisation and Safe Practice Group
Next Review Date:
16/06/2020
Approved by:
Clinical Governance Group
Date First Issued:
16/06/2017
Counties Manukau Health
Document Outline
