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 |
How To Implement |
Toolbox |
Implement a least restraint policy |
Ensure hospital teams understand the legislative and legal requirements of restraint policy and usage.
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Implement a least restraint policy
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Supporting Resources
Allen DE, de Nesnera A, Souther JW. Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation. J Am Psychiatr Nurses Assoc. 2009 Aug;15(4):260-64. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/21665812
Gelkopf M, Roffe Z, Behrbalk P, Melamed Y, Werbloff N, Bleich A. Attitudes, opinions,
behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs. 2009 Dec;30(12):758-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19916810
Köpke S, Mühlhauser I, Gerlach A, Haut A, Hastert B, Möhler R, Meyer G. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. A randomized control trial. JAMA. 2012 May 23/30: 307(20): 2177-2184. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618925
Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restratints in long-term geriatric care – a Cochrane review. Journal of Clinical Nursing 2012: 21: 3070-3081. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21328295
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
Registered Nurses’ Association of Ontario (RNAO). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto: Registered Nurses’ Association of Ontario; 2012 Feb. Available from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Staff Education: Provide tools and resources for at risk clients and alternatives to restraints |
Provide resources and tools to identify residents at-risk of needing restraint, as well as an environment that is supportive of alternatives to the use of restraints. (Practice Standard: Restraints, 2009, College of Nurses of Ontario). If restraints must be used, discuss with the patient or the caregiver the rationale for the need to use restraints, the expected outcome, and the type of restraint to be used:
Provide staff education about the assessment, planning, implementation, support and evaluation of least restraint practices and patient rights |
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Staff Education: Provide tools and resources on at-risk residents and alternatives to restraints
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Allen DE, de Nesnera A, Souther JW. Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation. J Am Psychiatr Nurses Assoc. 2009 Aug;15(4):260-64. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/21665812
Gelkopf M, Roffe Z, Behrbalk P, Melamed Y, Werbloff N, Bleich A. Attitudes, opinions,
behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs. 2009 Dec;30(12):758-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19916810
Köpke S, Mühlhauser I, Gerlach A, Haut A, Hastert B, Möhler R, Meyer G. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. A randomized control trial. JAMA. 2012 May 23/30: 307(20): 2177-2184. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618925
Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restratints in long-term geriatric care – a Cochrane review. Journal of Clinical Nursing 2012: 21: 3070-3081. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21328295
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
Registered Nurses’ Association of Ontario (RNAO). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto: Registered Nurses’ Association of Ontario; 2012 Feb. Available from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Interprofessional collaboration
Use interprofessional health care team collaboration in developing and implementing the plan of care. |
Examples of interprofessional collaboration include:
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Interprofessional collaboration
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Allen DE, de Nesnera A, Souther JW. Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation. J Am Psychiatr Nurses Assoc. 2009 Aug;15(4):260-64. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/21665812
Gelkopf M, Roffe Z, Behrbalk P, Melamed Y, Werbloff N, Bleich A. Attitudes, opinions,
behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs. 2009 Dec;30(12):758-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19916810
Köpke S, Mühlhauser I, Gerlach A, Haut A, Hastert B, Möhler R, Meyer G. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. A randomized control trial. JAMA. 2012 May 23/30: 307(20): 2177-2184. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618925
Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restratints in long-term geriatric care – a Cochrane review. Journal of Clinical Nursing 2012: 21: 3070-3081. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21328295
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
Registered Nurses’ Association of Ontario (RNAO). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto: Registered Nurses’ Association of Ontario; 2012 Feb. Available from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Use least restrictive restraints when required |
If attempts to modify or eliminate the risk factors have not been successful and a restraint is required, use the least restrictive restraint measure following consultation with the client or substitute decision maker. (Practice Standard: Restraints, 2009, College of Nurses of Ontario) Examples of least restrictive measures include:
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Use least restrictive restraints when required
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Allen DE, de Nesnera A, Souther JW. Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation. J Am Psychiatr Nurses Assoc. 2009 Aug;15(4):260-64. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/21665812
Gelkopf M, Roffe Z, Behrbalk P, Melamed Y, Werbloff N, Bleich A. Attitudes, opinions,
behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs. 2009 Dec;30(12):758-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19916810
Köpke S, Mühlhauser I, Gerlach A, Haut A, Hastert B, Möhler R, Meyer G. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. A randomized control trial. JAMA. 2012 May 23/30: 307(20): 2177-2184. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618925
Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restratints in long-term geriatric care – a Cochrane review. Journal of Clinical Nursing 2012: 21: 3070-3081. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21328295
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
Registered Nurses’ Association of Ontario (RNAO). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto: Registered Nurses’ Association of Ontario; 2012 Feb. Available from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Ongoing assessment during periods of restraint |
If a patient requires restraint, use ongoing assessment protocols to maximize outcomes by assessing:
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Ongoing assessment during periods of restraint
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Allen DE, de Nesnera A, Souther JW. Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation. J Am Psychiatr Nurses Assoc. 2009 Aug;15(4):260-64. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/21665812
Gelkopf M, Roffe Z, Behrbalk P, Melamed Y, Werbloff N, Bleich A. Attitudes, opinions,
behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs. 2009 Dec;30(12):758-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19916810
Köpke S, Mühlhauser I, Gerlach A, Haut A, Hastert B, Möhler R, Meyer G. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. A randomized control trial. JAMA. 2012 May 23/30: 307(20): 2177-2184. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618925
Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restratints in long-term geriatric care – a Cochrane review. Journal of Clinical Nursing 2012: 21: 3070-3081. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21328295
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
Registered Nurses’ Association of Ontario (RNAO). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto: Registered Nurses’ Association of Ontario; 2012 Feb. Available from: http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
Lancet. 2003 Oct 11;362(9391):1225-30.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747
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 |
Collected measures can be presented graphically by plugging the monthly results into run chart.
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#
For a more comprehensive list of tools and resources, visit HQO’s website:
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
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.
Toronto: College of Nurses of Ontario; 2009 Jun
Available from: http://www.cno.org/Global/docs/prac/41043_Restraints.pdf
J Clin Nurs. 2014 Nov;23(21-22):3012-24
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
Toronto: Queen’s Printer for Ontario; 2015.
Available from: http://www.hqontario.ca/Portals/0/documents/pr/measuring-up-2015-en.pdf