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Overview

Updated on December 14, 2015

Issue

Physical restraints including belts, vests, bedrails, laptop trays, and acute control medications are all used to restrict or prevent movement in patients. Restraints are intended to be a method of last resort in Ontario care facilities and are used in the belief that they will protect a patient from harm.1 However, research shows that the use of restraints can lead to agitation, depression, confusion, weaker muscles and bones, and an increased risk of falling, strangulation, and pressure ulcers.2

In 2001, the Ontario government passed Bill 85, the Patient Restraints Minimization Act.3 Many facilities in Ontario use a least restraint philosophy. This philosophy acknowledges that the quality of life and the preservation of diginity are values guiding the practice of health care practitioners towards each resident.1

Call to Action

Physical restraints are sometimes used in long-term care homes to protect residents from hurting themselves or others, or to ensure a treatment is completed.4 The percentage of residents in Ontario long-term care homes who were physically restrainted on a daily basis has decreased substantially, from 16.1% in 2010/11 to 7.4% in 2014/15 (Figure 1).4 The Ontario Long-Term Care Homes Act (2007) requires homes to have minimal restraint policies as well as regular re-evaluations to determine the need for restraints.5 Restraints can cause patients to lose physical function which ultimately can contribute to infections, pressure ulcers, agitation, and increased risk of injury.2 The goal for all long-term care homes is to use restraints as little as possible.

  1. College of Nurses of Ontario. Practice Standard: Restraints.

    Toronto: College of Nurses of Ontario; 2009 Jun
    Available from: http://www.cno.org/Global/docs/prac/41043_Restraints.pdf

  2. Hofmann H, Hahn S. Characteristics of nursing home residents and physical restraint: a systematic literature review.

    J Clin Nurs. 2014 Nov;23(21-22):3012-24

  3. Government of Ontario. Chapter 16: An Act to minimize the use of restraints on patients in hospitals and on patients of facilities (Bill 85 Patient Restraints Minimization Act).

    Legislative Assembly of Ontario; 2001 Jun 29.
    Available from: http://www.e-laws.gov.on.ca/html/source/statutes/english/2001/elaws_src_s01016_e.htm

  4. Health Quality Ontario. Measuring Up 2015: A yearly report on how Ontario’s health system is performing.

    Toronto: Queen’s Printer for Ontario; 2015.
    Available from: http://www.hqontario.ca/Portals/0/documents/pr/measuring-up-2015-en.pdf

Best Practices

Updated on December 14, 2015

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.9 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.

To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach. 

Change ideas are specific and practical changes by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

  1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care.

    Lancet. 2003 Oct 11;362(9391):1225-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747

Measurement

Updated on December 14, 2015

“Some is not a number, soon is not a time.”
Don Berwick December 2004, at launch of the 100,000 Lives Campaign

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:

numerator
__________

denominator
Targets/ Benchmarks How is This Indicator Used?
Outcome Percentage of residents in daily physical restraints Residents who were physically restrained daily on their target assessments
Residents with valid assessments
Targets: As low as possible (set by individual homes)

Provincial benchmarks:
3%
Quality improvement

QIP indicator

Publicly reported by HQO


Run Charts

Collected measures can be presented graphically by plugging the monthly results into run chart.

  1. Canadian Institute for Health Information. Ontario Mental Health Reporting System (OMHRS): Q4 FY 2009/10, Q3 FY 2010/11 [Internet].

    Toronto: Canadian Institute for Health Information.
    Available from: http://www.cihi.ca/CIHI-ext-portal/internet/en/document/types+of+care/specialized+services/mental+health+and+addictions/omhrs_metadata#

Tools & Resources

Updated on December 14, 2015

Tools

Restraints Tools
QI Tools


For a more comprehensive list of tools and resources, visit HQO’s website:



Resources

Practice Standard
  • Restraints
    College of Nurses of Ontario, 2009. This practice standard helps nurses understand their responsibilities and make informed decisions about the use of restraints.
Links
QI Resources