restraint minimisation safe practice enabler.pdf

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ENABLERS (RESTRAINT MINIMISATION & SAFE
Protocol

PRACTICE)
CPM.E1.1
CLINICAL PRACTICE
MANUAL

STANDARDS
This  protocol  specifies  the  conditions  /  situations  in  which  enablers  (equipment,  devices  or
furniture,  voluntarily  used  by  a  patient  following  appropriate  assessment  that  limits  normal
freedom  of  movement,  with  the  intent  of  promoting  independence,  comfort  and  /  or  safety
RMSP  NZS  8134.0:2008)  are  used  and  ensures  compliance  with  the  Bay  of  Plenty  District
Health Board (BOPDHB) policy 1.2.4 Restraint Minimisation and Safe Practice.
Enablers  may  be  used  when  required  to  facilitate  treatment  delivery  /  investigations  where
movement  may  increase  the  risk  of  injury  to  the  patient  or  impede  the  recording  of
investigations  necessary  to  improve  health  state.  Verbal  agreement  by  the  patient  or
representative  is  required  and  any  risks  explained.  Use  of  enabler  should  be  documented
within the patient’s care plan and observations carried out as described for each enabler. If
required a Falls Risk Care Plan should be completed.
Examples:
1.  A patient voluntarily uses bed rails to assist their mobility in bed, to aid in the positioning
of pillows for comfort or to prevent them falling from bed (RMSP NZS 8134.0:2008)
2.  A patient voluntarily uses a fixed tray in front of their chair to assist them to have a meal
independently (RMSP NZS 8134.0:2008)
3.  Equipment,  devices  or  furniture  is  used,  following  appropriate  assessment,  to  assist  in
the physical positioning of a patient without limiting their normal freedom of movement.
These  interventions  are  not  considered  a  form  of  restraint,  but  rather  a  normal
component of the patient’s day to day life (RMSP NZS 8134.0:2008)

APPROVED ENABLERS IN BOPDHB – refer to Appendix 1
  Splints (Adult / Paediatric)
  Mittens / Boxing Glove bandaging
  Limb Enabler
  Specialist Chairs
  Bedrails / Cot Sides (Paediatrics)
  Personal Safe Hold (Adult)
  Personal Safe Hold (Child)
  Paediatric Pigg-0-stat Device
  Lap Belts

STANDARDS TO BE MET
1.  The  techniques  used  are  to  be  carried  out  in  a  safe  and  controlled  manner,  with
emphasis  on  maintaining  patient  safety  and  not  causing  any  additional  harm.    An
explanation of the personal hold will be given to the patient at the outset where possible.
2.  Assessment  should  be  completed  in  partnership  with  patient,  family  /  whānau,  and
significant others. This shall ensure cultural considerations,  respect for  dignity, patients
privacy  and  choices  are  met.  This  shall  also  assist  to  identify  triggers  and  alternative
options.
3.  Obtain  related  assessments  from  the  multidisciplinary  team  into  factors  such  as  pain,
which may be exacerbating the patient’s agitation or restlessness.
4.  Ensure  there  is  a  documented  comprehensive  Care  Plan  that  includes  rationale  and
monitoring to prevent injury or discomfort.
5.  Check  and  monitor  patient  for  any  negative  effects  such  as  increased  incontinence,
pressure areas, muscle atrophy, decreased muscle tone and strength, contractures, loss
of ability to walk and loss of autonomy.
6.  Psychological, cultural and spiritual factors also need to be considered.
7.  Any  signs  of  agitation,  stress  or  discomfort  must  be  reported  to  the  nurse  in  charge
immediately.
Issue Date:
May 2017
Page 1 of 5
NOTE: The electronic version of
Review Date:   May 2020
Version No:  10
this document is the most current.
Any printed copy cannot be
Document Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator

ENABLERS (RESTRAINT MINIMISATION & SAFE
Protocol

PRACTICE)
CPM.E1.1
CLINICAL PRACTICE
MANUAL

Appendix 1
Enabler Classification Tool

Type
Usage
Application
Observation and monitoring
Documentation
Bedrails / padded
  To prevent patient accidentally falling
  Transporting of patients.
  Minimum ½ hourly visual checks.
  Falls Risk
rails.
from bed.
  Anaesthetised or sedated
  Minimum 2 hourly check for food, fluids, toileting,
Care Plan
Cot sides
  Normal practice in Emergency
patients
and pressure areas.
  Generic Care
in paediatrics
Department, Paediatrics, ICU and
  Supporting pillows.
  Bed placed at its lowest position following any
Plan

Perioperative Care.
  Distorted body image
cares or interventions.
  Patient’s
  NB. Not to be used solely as the
  Check appropriateness if patient confused and
health record
means to prevent patient climbing
at risk of climbing out of bed.

out of bed.
  Assess if delirium present and if so refer to Delirium    CPM.D1.1
protocol
Lap belts
  For patients with poor trunk control to
  As part of a falls prevention
  Ensure no excess pressure on patient.
  Falls Risk
prevent accidental falling / slipping out
programme
  Minimum ½ hourly visual checks.
Care Plan
of chair or wheelchair.
  By prescription of
  Observe for physical discomfort and offer
  Generic Care
  Patients who need to be correctly
Occupational Therapist only
assistance with personal requirements.
Plan
positioned in wheelchairs
  Minimum 2 hourly checks for toileting, offering food,    Patient’s
fluids and pressure areas.
health record
Limb enablers:
  To prevent paediatric or confused
  Apply firmly without
  Minimum 1 hourly check for skin integrity.
  Generic Care
  Dressing-soft
patients from:
interfering with circulation.
  Remove when patient co-operative.
Plan
gamgee
-  Pulling at medical devices (IV, NG
  Ensure 2 fingers can be
  Patient’s
padding and
etc.)
inserted.
health record
soft bandaging
-  Pulling off dressings
  Allow as much limb
  Soft Velcro
-  Grabbing,
movement as possible.
padded limb
-  hitting or scratching
enabler
Issue Date:
May 2017
Page 3 of 5
NOTE: The electronic version of
Review Date:   May 2020
Version No:  10
this document is the most current.
Any printed copy cannot be
Document Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator

ENABLERS (RESTRAINT MINIMISATION & SAFE
Protocol

PRACTICE)
CPM.E1.1
CLINICAL PRACTICE
MANUAL

Type
Usage
Application
Observation and monitoring
Documentation
Mittens / boxing
  To prevent paediatric or confused
  Hands to be padded with
  Bandage should be removed at least 2 hourly
  Generic Care
glove bandaging:
patients from:
bulky gauze in “resting”
during the day or when awake for inspection of
Plan
  Tubigrip
-  Pulling at medical devices (IV, NG
position then firmly but not
warmth, colour, movement and sensation of hands
  Patient’s
  Gauze or
etc.)
tightly bandaged to form a
and to provide hygiene requirements. Finger
health record
cotton wool
-  Pulling off dressings
‘boxing glove’. Tape in place
movement should be encouraged at this time.
padding
-  Grabbing, hitting or
carefully to ensure it is not
  While patient is asleep boxing glove bandaging can
  Bandages
-  Scratching
too tight.
remain in place.
  Tape
  Remove during meal times if appropriate and while
under constant supervision (family or staff)
  Report any pain, swelling or impaired circulation to
medical staff and complete an Incident
Management form.
Paediatric
  To prevent injury to child during
  To keep patient still during
  Ensure no excess pressure on patient
  Care Plan
Personal Safe
procedures / diagnostic interventions
procedure.
  Ongoing communication
  Patient’s
Hold for treatment
and or examinations.
  Technical positioning using
  Monitor for bruising
health record
delivery
  Technical holding for lumbar
appropriate technique.
punctures or cervical spine
  Staff or parents (if
stabilisation.
appropriate) can hold child.
  Insertion of NG tubes, cannulae,
  Blanket may be used if
sutures or venepuncture
appropriate to wrap child.
  Administration of medications
Paediatric
  To allow chest x-ray of 0 - 2 year olds.
  Radiology only.
  Ensure careful explanation and support given to

Pigg-o-stat Device
parents along with information leaflet.
Issue Date:
May 2017
Page 4 of 5
NOTE: The electronic version of
Review Date:   May 2020
Version No:  10
this document is the most current.
Any printed copy cannot be
Document Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator

ENABLERS (RESTRAINT MINIMISATION & SAFE
Protocol

PRACTICE)
CPM.E1.1
CLINICAL PRACTICE
MANUAL

Type
Usage
Application
Observation and monitoring
Documentation
Personal Safe
  To prevent injury to patient during
  To keep patient still during
  Ensure no excess pressure on patient
  Patient’s
Hold Treatment
procedures / diagnostic interventions
procedure
  Ongoing communication
health record
delivery for Adults
and or examinations.
  Technical positioning using
  Monitor for bruising
  Technical holding for lumbar
appropriate technique
punctures or cervical spine
stabilisation.
  Insertion of NG tubes, cannulae,
sutures, venepuncture
  Administration of medications.
Specialist Chairs
  Used for patients with reduced
  As part of falls prevention
  Ensure no excess pressure on patient
  Falls Risk
Examples:
postural stability
  To prevent patient slipping
  Minimum ½ hourly visual checks
Care Plan
  Wheel chairs
down / out of chair
  Observe for physical discomfort and offer
  Generic Care
  Lazy-boys
assistance with personal requirements
Plan
  Chairs with a
  Minimum 2 hourly checks for toileting, offering food
  Patient’s
fixed table or
and fluids, mobilising / physiotherapy
health record
pushed under a
  Remove patient from specialist chair every 2 hours
table for meals
  Offer alternative activities while patient in chair
or activities
Splints (Adult or

  Care Plan
Paediatric)
  For prevention of interfering with lines
  Select appropriate
  Splints and limbs to be checked on a regular basis,    Patient’s health
  Velcro fastening
/ wounds
equipment.
according to the individual care plan and / or health
record
band
  To prevent limb shortening
  Application under the
record.
  Tubigrip or
  To be used in conjunction with existing
direction of a registered
  All checks should be performed 2 hourly minimum.
similar
treatment policies to facilitate the safe
health professional
  Wherever possible continue to work in partnership
  Padded wooden
delivery of clinical intervention and to
with patient, family / whānau, significant others.
splints / plastic
prevent injury during treatment.
splints

  Crepe / Elastic
Bandage

Issue Date:
May 2017
Page 5 of 5
NOTE: The electronic version of
Review Date:   May 2020
Version No:  10
this document is the most current.
Any printed copy cannot be
Document Steward:  Restraint
Authorised by:  Director of Nursing
assumed to be the current version.
Co-ordinator