Restraint minimisation safe practice approval of practices.pdf

RESTRAINT MINIMISATION & SAFE PRACTICE –
Policy 1.2.4

APPROVAL OF PRACTICES
Protocol 1
RESTRAINT
PROTOCOL

STANDARD
The Clinical Governance Committee, as the identified restraint approval group, will approve
all forms of restraint minimisation used by the Bay of Plenty District Health Board (BOPDHB)
based on the recommendation of the Practice of Restraint Advisory Group (PRAG).
The  Mental  Health  &  Addictions  Service  (MH&AS)  Safe  Practice  and  Effective
Communication  (SPEC)  trainers  shall  endorse  restraint  minimisation  practices  for  their
specialty and submit these for approval to the Clinical Governance Committee.
Any individual, team or service may request approval for a restraint they wish to use or are
currently using.
All forms of restraint shall be submitted to the Practice of Restraint  Advisory Group (PRAG)
who will make a recommendation to the Clinical Governance Committee, excluding MH&AS.
The following information needs to be provided:
  Category of the restraint (as defined by NZS 8134.2:2008)
  Description of restraint
  Equipment needed
  Criteria for use
  Cultural requirements
  Risk assessment and management
  Delegated authority
  Education, competency and evaluation
  Procedure for use
  Process and frequency for monitoring and observation
  Evaluation and review frequency
  Documentation
  Maintenance frequency (for equipment)
  References and supporting evidence

PROCEDURE FOR APPROVAL

ACTION
RESPONSIBILITY
1
Identification

  Identify need for a form of restraint

  Contact Restraint Co-ordinator to discuss new restraint
  Unit  /  service  /  team  or

individual
  Contact  Controlled  Documents  to  initiate  controlled    Document Steward
document development process

  Document  the  procedure  for  the  identified  form  of
restraint  as  above;  liaise  with  Restraint  Co-ordinator  if
necessary

  Indicate  whether  the  restraint  is  currently  in  use.  Use
may be continued pending the outcome of this approval
process

  Forward  completed  documentation  to  PRAG  via  the    Document Steward
Restraint Co-ordinator
  Attendance  at  the  PRAG  meeting  may  be  required  as
part of the approval process
Issue Date:
May 2017
Page 1 of 3
NOTE:  The  electronic  version  of
Review Date:  May 2020
Version No:  7
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator

RESTRAINT MINIMISATION & SAFE PRACTICE –
Policy 1.2.4

APPROVAL OF PRACTICES
Protocol 1
RESTRAINT
PROTOCOL

ACTION
RESPONSIBILITY
2
PRAG Endorsement to Proceed

  Review the request at the next meeting:

  Appropriateness  of  request,  checking  accuracy  of    PRAG
detail

  Consider areas of application.

  If not endorsed:
  Restraint Co-ordinator
  Further  information  may  be  requested  from  the
document steward

  Detailed specialist information may be required

  The  request  may  be  declined  and  immediate
direction be given to all relevant departments not to
use the restraint method



  If  endorsed  Restraint  Co-ordinator  initiate  Action  3
  Restraint Co-ordinator
below.



  In all cases notify the requester of the outcome
  Restraint Co-ordinator
3
Approval by Clinical Governance Committee

  Restraint Co-ordinator initiates review of CPM.R2.9 (per    Restraint Co-ordinator
2.1.2 P6) for addition of approved restraint on table

  Amended  protocol  to  Clinical  Governance  Committee    Controlled Documents
for endorsement
4
Controlled Document Signoff

  Controlled Documents is notified that protocol has been    Restraint Co-ordinator
endorsed by Clinical Governance Committee for signoff.
  Version  control,  authorisation  and  publishing  is    Controlled Documents
completed.
5
Registration of Approved Restraint

  Register  approved  restraint  on  the  BOPDHB  Restraint    Restraint Co-ordinator
Database
  Database  will  include  approved  restraints;  the
individuals  and  /  or  services  approved  to  use  them;
indications  for  their  use;  monitoring  requirements;
frequency  of  review  and  audit;  training  and  education
requirements; and issues related to restraint use.

ASSOCIATED DOCUMENTS
  Bay  of  Plenty  District  Health  Board  Restraint  Minimisation  &  Safe  Practice  controlled
documents
  Bay of Plenty District Health Board policy 0.0 Glossary of Terms / Definitions
  Bay of Plenty District Health Board policy 1.1.1 Informed Consent
  Bay of Plenty District Health Board policy 2.1.1 Risk Management
  Bay  of  Plenty  District  Health  Board  policy  2.1.2  protocol  2  Controlled  Document
Development Standards
  Bay of Plenty District Health Board policy 2.1.2 protocol 6 Controlled Document Review
Standards
  Bay of Plenty District Health Board policy 2.1.3 Hazard Management
  Bay of Plenty District Health Board policy 2.1.4 Incident Management
Issue Date:
May 2017
Page 2 of 3
NOTE:  The  electronic  version  of
Review Date:  May 2020
Version No:  7
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator

RESTRAINT MINIMISATION & SAFE PRACTICE –
Policy 1.2.4

APPROVAL OF PRACTICES
Protocol 1
RESTRAINT
PROTOCOL

  Bay  of  Plenty  District  Health  Board  policy  5.4.7  Threatening  Behaviour,  Bullying,
Harassment and Violence in the Workplace - Management
  Bay of Plenty District Health Board policy 7.104.1 protocol 3 Care Delivery – Observing
Patients
  Bay of Plenty District Health Board Practice of Restraint Advisory Group (PRAG) Terms
of Reference
  Bay of Plenty District Health Board Incident Management Form

Issue Date:
May 2017
Page 3 of 3
NOTE:  The  electronic  version  of
Review Date:  May 2020
Version No:  7
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator