Restraints
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.
- EVIDENCE-INFORMED BEST PRACTICESType of Evidence
- Implement a least restraint policyIV (Expert Opinion)
-
Staff Education: Provide tools and resources for on at-risk residents
and alternatives to restraintsIV (Expert Opinion) - Interprofessional collaborationIV (Expert Opinion)
- Use least restrictive restraints when requiredIV (Expert Opinion)
- Ongoing assessment during periods of restraintIV (Expert Opinion)
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.
Tools & Resources
Updated on December 14, 2015
Tools
Restraints Tools
- Failure Modes and Effects Analysis (FMEA) ToolHeartland Behavioral Health Services, Nevada, Missouri, 2008. This comprehensive tool helps healthcare teams reduce restraint use.
- Promoting Safety: Alternative Approaches to the Use of Restraints (Clinical Best Practice Guidelines) Registered Nurses' Association of Ontario (RNAO), February 2012. For a broad range of assessment and alternative treatment options to restraints tools.
QI Tools
- Communications Plan: Instructions , Tool
- Fishbone Template: Instructions , Tool
- Five Whys: Instructions , Tool
- Measurement Plan Template: Instructions , Tool
- Pareto Chart: Instructions , Tool
- PDSA Template
- Project Charter
- Tree Diagram Worksheet
For a more comprehensive list of tools and resources, visit HQO’s website:
Resources
- Möhler R, Meyer G. Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies.
Int J Nurs Stud. 2014 Feb;51(2):274-88 - Coming to grips with challenging behavior: a cluster randomized controlled trial on the effects of a multidisciplinary care program for challenging behavior in dementia Zwijsen SA, Smalbrugge M, Eefsting JA, Twisk JW, Gerritsen DL, Pot AM, Hertogh CM. J Am Med Dir Assoc. 2014 Jul;15(7):531.e1-10
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
- Patient Restraints Minimization Act, 2001 Ministry of Health and Long Term Care
- Long-Term Care Homes Act, 2007 Ministry of Health and Long-Term Care
QI Resources
-
Interpreting Run Charts
Health Quality Ontario -
Model for Improvement (Clip 1)
Institute for Healthcare Improvement -
Model for Improvement (Clip 2)
Institute for Healthcare Improvement -
PDSA Cycle Video (Part 1)
Institute for Healthcare Improvement -
PDSA Cycle Video (Part 2)
Institute for Healthcare Improvement -
The run chart: a simple analytical tool for learning from variation in healthcare processes
Perla RJ, Provost LP, Murray SK. BMJ Qual Saf. 2011 Jan;20(1):46-51.
Background
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.
