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Clinical Holding (Restraint) Policy, 5th^ Edition – June 2019 Page 1 of 29
Issue number: 5th^ Edition
CLINICAL HOLDING (RESTRAINT) POLICY
Author with contact details
Deborah Ward, Assistant Director – Safeguarding (Ext. 3534) David Gunn, Risk and Legal Services Manager (Ext. 3459) Tracy Greenwood, Assistant Director – Corporate Nursing (Ext. 2470) Executive Lead Diane Brown, Chief Nurse Original Issue date March 2008 Issue Date: June 2019 Review Date: June 2022 Level: Trust wide Location of Staff applicable to:
All staff across the Trust Staff groups applicable to
To all staff groups
To be read In conjunction with / Associated Documents:
Adults Safeguarding Policy Mental Capacity Act and Deprivation of Liberty Safeguarding Policy Using Bedrails Safely and Effectively Standard Operational Procedure Prevention and Management of Slips, Trips and Falls Policy Violence and Aggression Policy MEWS Procedure Rapid Tranquilisation Clinical Guidelines Infection Prevention Control Policy Enhanced Observation Policy
Information Classification Label
NHS Confidential NHS Protect Unclassified
Name of Approval Entity Safety and Risk Executive Led Group
Date Approved 8 th^ August 2019
Access to Information To access this document in another language or format please contact the policy author.
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Document Change History (changes from previous issues of policy (if appropriate) :
Issue Number Page Changes made with rationale and impact on practice
Date
5 Section 9 - Appendices Body Map added to the document (Appendix 6) June 2019
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1.0 SUMMARY PAGE
CLINICAL HOLDING FLOWCHART
Can clinical holding be avoided? Understand and respond to the patients behaviour Identify the underlying cause of the behaviour – illness, pyrexia, pain, anxiety, brain injury, drug dependency, mental illness or other Seek clinical/medical opinion Decide on strategies to manage the behaviour if appropriate
A patient at risk may be clinically held in some cases if they are: Putting themselves at risk of harm Putting others at risk of harm Requiring treatment by a legal order Requiring urgent life-saving treatment Lacking capacity under the Mental Capacity Act 20 05
Remember Clinical Holding is a last resort
Types of clinical holding: Physical – holding, moving, blocking movement, use of mitts Chemical restraint – using medication to restrain Psychological restraint – deprivation of something the patient wants or feels they need Technological Surveillance – closed circuit television to alert staff and restrict the patient’s movement
Management of clinical holding: Clear communication with patient/relative/carer in relation to the use of clinical holding MDT rationale for choosing clinical holding is documented in the patients’ medical records with evidence of a risk assessment and details of the clinical holding technique, e.g. Mitts Checklist Post incident review and reporting of any injuries Evaluate/ review the use of clinical holding as care plan/ complete daily risk assessment Ensure ethical considerations such as avoiding harm
Additional support available to staff: Senior nurse/ clinician Clinical Manager/ General Manager on Call Safeguarding Team extension 2590 Contact security staff when additional support is required on extension 2810 or 3333 for an immediate response (Section 4.14) There are violent and emergency situations where the Police would be contacted (Section 4.15)
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2.0 INTRODUCTION
Aintree University Hospitals NHS Foundation Trust (AUHT) is committed to delivering the highest standards of health,
safety and welfare to its patients, visitors, and employees.
Restraint includes the use, or threat of, force to do something that a person resists or any restriction of liberty whether or not a person resists. The inappropriate use of restraint is against the law. Restraint can constitute, assault, battery or false imprisonment and can lead to criminal prosecution and/ or penalties under civil law.
This policy seeks to ensure that staff at the Trust is aware of, and comply with, the requirements set out in law and best practice, in relation to the use of restraint. Staff are reminded that the use of restraint should be a last resort when other strategies (which do not involve the use of force) have been tried and found to be unsuccessful or, in an emergency, when the risks of not employing a restrictive intervention are outweighed by the risks of using force.
2.1. POLICY AIMS
This policy aims to assist staff working at the Trust to:
Understand what clinical holding is (Section 4.2) Provide person-centered care that minimizes the need for clinical holding Understand the legal and ethical frameworks Know what to do if they suspect inappropriate or abusive use of clinical holding Understand the circumstances in which clinical holding may be legally or ethically appropriate Understand how to minimize the risks if clinical holding is used
3.0 ROLES & RESPONSIBILITIES
Chief Executive As the accountable officer, the Chief Executive must ensure that responsibility for clinical holding is delegated to an appropriate Executive Lead.
Chief Nurse / Medical Director
As nominated Executive Leads, the Chief Nurse and Medical Director must ensure that robust systems and processes are in place regarding clinical holding.
Divisional Directors of Nursing and Service Management Leads
Assistant Directors of Nursing and Service Management Leads monitor systems and processes to ensure that any clinical holding is in line with the policy and that staff concerned has the necessary competence to carry this out safely.
Ward Managers
Ward Managers have a responsibility to complete a training needs analysis for their staff members. Managers must ensure that post incident reviews are carried out following incidents and that any necessary actions to address issues of aftercare of staff, patients or others involved in the incident are resolved.
Safeguarding Team
The Safeguarding Team will offer advice on safeguarding concerns: Where physical, psychological, institutional, discriminatory abuse is suspected or has occurred as a result of restraint Where clinical holding is used abusively in the Trust or in another care setting - see the Adults Safeguarding Policy (2018) on the intranet Regarding issues under the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS)
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As with all types of clinical intervention, it is important to consider a patient’s capacity when deciding whether the use of clinical holding is appropriate and the powers under which provide the necessary authority. Guidance on this can be found in the Trust Mental Capacity Act including Deprivation of Liberty Safeguards Policy (2018).
In all circumstances, it should be reasonably believed that the use of clinical holding is necessary in order to prevent harm and the restraint employed is reasonable and proportionate to the likelihood of harm occurring and seriousness of that harm.
The use of clinical holding of adults may be appropriate in the following circumstances:
Patients who Lack Capacity:
Where a patient lacks capacity, the use of clinical holding may be appropriate under the principle of best interest where the person:
Is displaying behaviour that is putting themselves at risk of harm Is displaying behaviour that is putting others at risk of harm Requires care or treatment, including in circumstances where such treatment is urgent and for the purpose of saving-life, and clinical holding is necessary for the purpose of providing such treatment
The use of clinical holding in these circumstances will typically be governed by the MCA 2005. However, in some circumstances, the use of the Mental Health Act 2007 (MHA 2007) may be more appropriate. In extremely limited circumstances, the common law powers set out in the section below may be relied upon.
Where a patient has capacity, the use of clinical holding may be appropriate where the person:
Is displaying behaviour that is putting themselves, others or property at risk of harm. However, it should be noted that clinical holding could not be used to impose treatment on a patient who has capacity and who is refusing that treatment, even where such a refusal could cause the patient harm, unless this was provided under the appropriate powers of the MHA 2007
4.4 Legal Powers under which Restraint may be Permitted
Consent
If a person has capacity in relation to a particular care or treatment intervention and provides valid consent, that care or treatment will be permitted. Therefore, if restraint forms part of a planned programme of care, to which the patient has provided valid consent and has capacity to do so, it will be lawful.
Restraint under the MCA 2005
If a person is assessed as lacking capacity, or there is reasonable belief that the person lacks capacity, then the power to restrain most typically relied upon in a clinical setting is that under section 5 of the MCA 2005. This confirms that a person will not incur any liability in relation to any act intending to restrain a patient, provided that the person:
Has taken reasonable steps to establish whether the patient lacks capacity in relation to the matter in question Reasonably believes that the patient lacks capacity and that it would be in the patient’s best interests for restraint to be used Reasonably believes it is necessary to restrain the patient in order to prevent harm to him or her Restraint is proportionate to the likelihood of the patient suffering harm and the seriousness of that harm
Further information is also contained in the Trust Mental Capacity Act including Deprivation of Liberty Safeguards Policy (2018).
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Restraint under the Mental Health Act 2007
The MHA 2007 has various powers under which a person can be restrained, even if they are considered to have capacity, if the person meets the relevant criteria and it is appropriate. Use of these powers at the Trust is anticipated to be rare. Further advice from clinicians with the relevant expertise should be sought when considering the use of these powers.
Restraint under Common Law Powers
If the MHA 2007 and MCA 2005 do not apply, there are certain common law powers which can be relied upon for the purposes of restraint. However, these are extremely limited and can only be relied upon for a short period. Common law powers include the power to restrain:
To prevent a breach of the peace. There is no breach of the peace unless an act is done or threatened to be done which (a) actually harms a person or, in his presence, his property; (b) is likely to cause such harm; or (c) puts a person in fear of such harm. For example, the power would enable the restraint of a patient whose words or behaviour are such that imminent violence is expected on a hospital ward. However, the use of such powers should be exercised with caution. There must be a ‘sufficiently real and present threat to the peace to justify the extreme step of depriving of his liberty a citizen who is not at the time acting unlawfully’ To prevent a crime (e.g. self-defence or defense of others) Under the doctrine of necessity (where steps to restrain can be taken where these are reasonably necessary to protect others from the immediate risk of significant harm)
4.5 Clinical Holding as a Last Resort
The use of clinical holding should always be a last resort when other strategies (which do not involve the use of force) have been tried and found to be unsuccessful or, in an emergency, when the risks of not employing a restrictive intervention are outweighed by the risks of using force. Clinical holding should be used only where it is considered in the best interests of a patient who lacks capacity or the individual gives valid consent, and it is considered necessary to ensure the safe and effective delivery of treatment and to reduce the risk of harm to the patient, members of staff and/ or visitors.
In most circumstances clinical holding can be avoided by positive changes to the provision of care and support for the patient. It should be noted that a person with capacity to consent might request items, such as bedrails, to enhance their feeling of safety and/ or security. The bedrail risk assessment must indicate that the nurse has discussed any potential risk of the use of bedrails and the rational for usage. Refer to the Trust Using Bedrails Safely and Effectively Standard Operational Procedure (2018) on the Trust Document Management System.
When a patient lacks the capacity to consent to an intervention staff should always seek to explain what they are doing, seeking their understanding and offering reassurance, whilst at all times ensuring that their actions are in the best interests of the patient and are the least restrictive on the patient’s rights and freedoms. This should be clearly documented in the patients’ clinical record.
4.6 Medication/ Chemical Sedation
There are certain, limited situations in which the use of chemical sedation may be appropriate. For example, in cases where the patient is suffering from extreme restlessness, aggression, agitation, or where other interventions have been unsuccessful or are considered to be inappropriate. The use of chemical sedation must be a short-term strategy to reduce immediate risk.
All staff prescribing or administering benzodiazepines or anti-psychotic drugs and other sedatives must be familiar with the properties of these drugs.
For some complex individuals this will need to be planned with the patient’s consultant who may seek further advice. Refer to the Trust Rapid Tranquilisation Clinical Guidelines (2019).
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Except in emergencies, decisions about clinical holding need to be made after discussion, wherever possible and appropriate, with the patient, their relatives and carers, and the multi-disciplinary team. A risk balancing exercise needs to be undertaken, where the risks of the behaviours are balanced against the risks associated with the types of clinical holding which may need to be employed to manage this behaviour.
Alternative forms of managing the behaviour, and the risks associated with those alternatives also need to be considered. It is important that the least restrictive option possible is identified. For example, often behaviour such as wandering is problematic for staff; however, this does not necessarily mean that preventing this behaviour is in the best interests of the patient concerned. The risk of falling must be assessed and weighed against the risks associated with any preventative action. These assessments should be integrated into a plan of care – refer to the Trust Prevention and Management of Patient Slips, Trips and Falls Policy (2018).
Any restraint must be the minimum intensity required for the shortest time possible. Care plans should specify what is to be done and include time limits and reviews. Staff must always judge whether restrictive interventions are acceptable and legitimate based on all presenting circumstances.
As part of care planning, staff should seek to understand the reason for a patient’s behaviour in order to inform the development of supporting environments and skills that can enhance a person’s quality of life, with a view to reducing the number of restrictive interventions that are required. Having identified the reason for the behaviour, staff should then decide on appropriate strategies for dealing with this in conjunction with other members of the multidisciplinary team and family (to include treatment of the underlying cause). This should be documented in the nursing/ medical notes. An individualised support plan should be developed which is person-centered, values-based and informed by skilled assessment of the probable reasons why a person presents behaviours of concern. Staff should record all plans and preventative strategies (such as de-escalation techniques, distraction or diversion). The plan should reflect any experiences and wishes of the patient which could impact on the use of restrictive interventions, such as a history of past abuse and trauma. It should describe any risks associated with their general health or with the care environment.
Where the patient lacks the mental capacity to consent to their plans, decisions about their care and treatment made on their behalf must be made in their best interests in accordance with the provisions of the MCA 2005. However, any actions taken should nonetheless be explained to the patient and staff should seek the patients understanding and, where possible, their agreement. Staff should refer to the Trust Mental Capacity Act including Deprivation of Liberty Safeguards Policy (2018).
These requirements apply to individuals being cared for by staff working in all types of settings, including clinical wards, clinical departments, acute care, continuing care and Accident and Emergency Department.
Concerns about the misuse of restrictive interventions should always be escalated through local safeguarding procedures. While abuse of restraint can occur in institutions, it may also happen in peoples own homes. Staff working in hospitals, care homes, or the community who suspect restraint is being used abusively in any setting should refer to Trust Adults Safeguarding Policy (2018).
4.10 Physical Intervention Techniques – Use of Restraint Mitts
The use of mitts is a form of restraint and the approach set out earlier in this policy should therefore be followed, as with all types of restraint. The use of hand mitts should only be used as a last resort following the MCA (Mental Capacity Act) process in which a Best Interest decision is made as the least restrictive option. This decision should be made where there is a known risk to the patient or others, or in order to prevent the confused, disoriented, cognitive impaired or combative patient from removing supportive and essential health care equipment, and all other alternative primary and secondary preventative approaches have been explored and exhausted.
If there are no carers/ family/ friends or person who holds a Lasting Power of Attorney/ Court Appointed Deputy to engage with regarding the use of this intervention, the decision maker must consider making a referral to the Independent Mental Capacity Advocate (IMCA) service, as the use of restrictive intervention may constitute ‘serious medical treatment’ requiring specific referral to an IMCA in consultation with Adult Safeguarding Lead Nurse. Although, staff need to be aware that essential treatment should not be delayed whilst awaiting response or review from IMCA.
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Examples of where the use of mitts may be appropriate include: Where the patient is intubated orally, nasally, or has a tracheostomy in situ and is in danger of unplanned extubation secondary to agitation Where the patient has essential drug therapy administered via a central line, peripheral line or naso-gastric tube and is at risk of displacing the line due to agitation Where the patient has essential feeding regime administered and is at risk of displacing the line due to agitation
Restraint mitts can only be used in the following circumstances: Where the patient presents with the conditions set out as per examples above As a last resort, where the patients safety could not be assured by other means If there has been consultation with others involved in the care of the patient, including carers as to what action they think is in the patients Best Interest Where a patient lacks mental capacity to consent and a decision is made in their Best Interest If the staff member reasonably believes that it is necessary to prevent harm to the patient Its use is proportionate both to the likelihood and seriousness of harm
Any decision to use mitts must be a multidisciplinary (MDT) decision. A risk assessment should be completed (Appendix
- and a clear rationale for the use of mitts must be recorded in the patient’s medical case notes. Any discussion that has taken place as regards the use of mitts with the patients and/ or those close to him/ her should be documented in the nursing/ multidisciplinary notes and an information leaflet provided (Appendix 3). Staff should note that, where a patient lacks capacity to consent to the use of mitts, staff must consult with those close to the patient, as this is required under the Best Interest decision making process set out under the MCA 2005. In all circumstances, the use of mitts should be risk assessed and authorized by the Consultant or Specialist Registrar responsible for the patient.
The mitts must be used for the shortest possible time. In cases where the patient lacks capacity to consent to mitts, if the need for the use of mitts is frequent, cumulative and ongoing then this information must be included within any application under DoLS.
A further risk assessment must be carried out on a daily basis by the patients Consultant or Specialist Registrar to decide whether the mitts need to be used. This must be recorded in patients nursing and medical notes, dated, timed and signed. Once it is safe to do so the mitts must be removed.
The mitts must be removed on each shift to allow the patient to move his/ her limbs freely to prevent complications from the restriction of movement. The patient’s limbs must be monitored regularly for any problems arising from the use of mitts, e.g. friction on the skin, and this must be documented during each shift in the nursing notes, dated, timed and signed, and a care plan completed (Appendix 4).
To ensure that patients are given time without the mitts frequent checks of the patient should be made and mitts removed to: Observe and monitor skin condition and colour Facilitate toileting Offer hand hygiene - perform passive exercises to prevent contractures Allow for Meal and drink provision Facilitate visiting if appropriate. (I.e. whenever anyone visits they can remove the mitts to hold the patient's hand)
Mitts must not be applied directly over intra venous (IV) sites as this can cause pain and lead to other complications. All patient care should be continued during the use of mitts, including regular repositioning of the patient. To ensure correct positioning of the hand and hand hygiene, ‘off-time’ should be clearly identified and followed; this allows for increased freedom and can help reduce the likelihood of secondary health problems developing, as well as being essential for psychological well-being.
Mitts are generally secured by Velcro straps at the wrist. Staff should ensure the application of mitts does not restrict wrist movement and wrist straps are not fastened too tightly. Where there are any injuries sustained or any untoward event, a risk event form should be completed using the Trust incident reporting procedures on the intranet. Such injuries should also be recorded in the patients’ medical case notes.
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Any injury to a patient, member of staff or visitor to the Trust premises, involving the use of clinical holding, should be considered a clinical accident/ incident and reported according to Trust Policy. Incidents should also be documented in the nursing/ multidisciplinary notes. If the injury is, or could be, a safeguarding concern, the Safeguarding Team, Ward Nurse Manager and Matron should all be informed as per the Adult Safeguarding Policy (2018) on the intranet.
A post incident review should take place where those directly involved meet for a debrief which includes a review of the patients care plan. The patient should not be compelled to take part in the debrief but should be told of their right to talk about the incident with appropriate support. A separate debrief should occur for witnesses not directly involved in the incident.
Reviews should be in a blame-free context and aim to help patients and staff identifies what led to the incident and what could have been done differently. Amendments to the behaviour support plan that are identified as being required as a result of this review should be made without delay.
4.14 Involvement of Security Staff in the Clinical Holding of Patients
Situations may arise when additional support is required (additional to that already available on the ward or department). In these cases security staff should be contacted (ext. 2810 or 3333 for immediate response). The aim of this service is to assist staff in maintaining the health and safety of patients, staff and visitors.
In most instances security staff will not know the patient or the circumstances surrounding their care and treatment. Staff who know the patient will therefore have a greater knowledge as to how to de-escalate the situation. Security staff should seek to make contact with the Nurse in Charge of the ward immediately on attendance for briefing prior to engaging with the patient where possible to do so (dependent on the presenting situation) - where not immediately possible the staff should receive briefing at the earliest opportunity. The Nurse in Charge must also seek to ensure (without putting own safety at risk) they observe the actions of security on attendance and provide a statement as required post incident where any physical restraint is required. Security staff cannot restrain a patient or prevent them from leaving where they have the capacity to make the decision, unless powers under the MHA 2007 or common law apply (see section 4.3 above). The usual issues in relation to patient confidentiality should be taken into consideration when sharing patient details with non-clinical staff – refer to the Adult Safeguarding Policy (2018).
Security staff are required to record detail on all such attendances in their security log and in the event that any physical restraint is required complete an incident report form.
In terms of infection control, all staff including porters and security staff should use universal precautions, as per the Trust Infection Prevention Control Policy, when intervening in a way that will or might involve contact with a patient.
4.15 When to Contact the Police
NHS Protect guidance indicates trigger points for the need for assistance from the police. The police will use techniques and act in accordance with their professional training while care and support staff have a continuing responsibility to alert police officers to any specific risks or health problems, and monitor the patients physical and emotional wellbeing. Prior to contacting the police staff should contact their Manager/ Site Manager or, if out of hours, the Clinical Manager or General Manager on Call. There are certain situations where the police may be able to provide help and support:
A violent situation where the safety of staff, patients or others is at risk – refer to the Trust Management of Violence and Aggression Policy (2017) If a patient has left the ward or hospital site, contrary to the advice of medical or nursing staff and is threatening to commit suicide. In these cases the police have powers under the MHA 2007 to take the person to a place of safety, which in most cases would mean bringing the person to the hospital, to be assessed If a patient has left the ward or hospital site, contrary to the advice of medical or nursing staff and you have serious concerns about the welfare or safety of that individual (e.g. the effect of not taking important medication) or others. In these circumstances the police may be able to check on the person by visiting them at home If a patient has left the ward and is subject to a Deprivation of Liberty Safeguards Authorisation. See the Trust Mental Capacity Act including Deprivation of Liberty Safeguards Policy (2018) for further information
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4.16. Deprivation of Liberty Safeguards (DoLS)
The Right to Liberty is a fundamental right in English Law. A person may only be deprived of their liberty in accordance with procedures set out in law. There is difference between a restriction of a person’s liberty and a deprivation of liberty.
The Supreme Court in the case of Cheshire West has confirmed that a deprivation of liberty exists if a person lacks mental capacity to consent to the admission, is (1) under continuous supervision and (2) is not free to leave. This test means that a large number of cases are likely to amount to a deprivation of liberty.
Where a deprivation of liberty is likely to occur, then appropriate authorisation should be sought without delay. If no authorisation is obtained under an appropriate legal provision, then the deprivation of liberty will be considered to be unlawful and can attract both civil and criminal penalties.
In view of the above, support and guidance should be sought from Trust Safeguarding and/or Legal Team at the earliest opportunity where it is believed that a patient’s care plan may result in a deprivation of liberty. Refer to the Trust Mental Capacity Act including Deprivation of Liberty Safeguards Policy (2018).
4.17 Staff Education and Training
The emphasis of training and education should be on dealing effectively with situations in order to remove the need for clinical holding/ restriction. Training should be provided for staff members that are regularly required to use physical methods of clinical holding. It is the responsibility of managers to identify if this training is required. Training is available in relation to Conflict Resolution which includes Breakaway technique.
5.0 MONITORING OF COMPLIANCE
Minimum requirement to be monitored
Process for monitoring e.g. audit/ review of incidents/ performan ce manageme nt
Job title of individual(s) responsible for monitoring and developing action plan
Minimum frequency of monitoring
Name of committee responsible for review of results and action plan
Job title of individual/ committee responsible for monitoring implementation of action plan
Security Staff Training Compliance
Training compliance report
Facilities Manager Annual Health and Safety Group Facilities Manager
Conflict Resolution Training/Breakawa y Technique Training Compliance
Training compliance report
Head of Learning and Development Annual^
Health and Safety Group
Head of Learning and Development
Review of incidents relating to use of mitts and any use of physical restraint
Incident reporting
Divisional Directors of Nursing Medicine, Surgery and Allied Health Professionals
Bi monthly Safeguarding Committee
Divisional Directors of Nursing Medicine, Surgery and Allied Health Professionals
6.0 EQUALITY, DIVERSITY AND HUMAN RIGHT STATEMENT
The Trust is committed to an environment that promotes equality and embraces diversity in its performance both as a service provider and employer. It will adhere to legal and performance requirements and will mainstream Equality, Diversity and Human Rights principles through its policies, procedures, service development and engagement processes. This policy should be implemented with due regard to this commitment.
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APPENDIX 1
RECORD LOG FOR AN UNPLANNED (EMERGENCY) RESTRICTIVE INTERVENTION
When a physical restriction intervention has taken place in an emergency, staff must record the actions and decisions taken. The recordings should be clear and consistent, completed as soon after the event as possible, and used to identify why the restriction took place.
Date: Time: Ward/ Department:
Patients Name: Date of Birth: NHS Number: Hospital Number: Who was involved in the incident: Name Designation Role in Restriction
Were there any witnesses to the incident: Yes No Name Designation Contact Number:
Duration of restrictive intervention (Please state length of time): Why did the restriction take place (Please state details below):
Where there any injuries sustained during the restrictive intervention: Yes No If yes, please state below:
Patient reviewed by Doctor: Yes No Doctors Name: Patient has Mental Capacity: Yes No
Mental Capacity Assessment completed: Yes No Patient has a DoLs application in place: Yes No
Referral to Safeguarding Team: Yes No Was the patient on a Section: Yes No (If yes, please state) Police contacted: Yes No Already on Site with Patient Detail below:
Datix Completed: Yes No WEB Number:
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Form completed by: Date: APPENDIX 2
RESTRAINT MITTS ASSESSMENT TOOL
Date of Assessment: Yes No Please Specify Supporting Information and Actions Does the patients behaviour have potential to endanger self, staff, others
(Restraint is inappropriate if response = ‘No’)
Has the patient removed essential tubes/ lines (Dates; how many occasions)
Is the patient presenting as acutely unwell/ disorientated/ agitated/ restless/ confused
(Brief presentation)
Have other methods been tried: (i.e. reorientation/ distraction techniques/ increased supervision/ consideration of basic needs – physical, social and environmental)
(Identify type(s) of technique tried)
Does the patient have capacity (Date of assessment)
Has the patient given informed consent (Do not use mittens if the patient demonstrates capacity and is refusing treatment)
If no, has an Mental Capacity Assessment been completed (Dates)
Is this decision a last resort where the patients safety could not be assured by other means
(I.e.: reasonable belief to prevent harm/ proportionate/ best interests/ least restrictive)
Has there been consultation with others involved in the care of the patient, including relatives/ carers
(Next of kin provides assent)
Has the use of mitts been explained to the patient/ relatives/ carers
(Leaflets/ verbal)
Has the patient/ relatives/ carers had the opportunity to see and try mitts before they are fitted
(reactions; observations)
Is there documented evidence that the clinical team agree that the use of mitts is in the patient’s best interests
(Date agreement reached and where MCA document held)
Has the care plan been:
- Discussed (patient, next of kin, team)
- Formulated
- Documented
(Date implemented and where document held)
Attach Patient Label: Surname: ……………………………….. Forenames: …………………………….. Date of Birth: …………………………... NHS No: ………………………………… Hospital No: ……………………………..
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APPENDIX 3
USE OF RESTRAINT MITTS INFORMATION LEAFLET FOR PATIENTS/ RELATIVES/ CARERS
Hand Mitts:
Hand control mitts have been designed in order to restrict the movement of one or both hands. The decision to apply mitts are only made as a last resort, in order to prevent the confused, restless, disoriented, or combative patient from removing supportive and essential health care equipment.
The reason why hand mitts are sometimes used:
Seeing a relative ill in hospital can be very frightening especially if they become disturbed or agitated. Patients sometimes seem to have many tubes attached which may be in place to provide fluid, blood, oxygen, medications or food to a patient during an acute episode of illness. The tubes can be fairly easy to dislodge and are often removed unintentionally by the patient. It can be highly upsetting for the patient to have the tubes repeatedly replaced and in turn this may exacerbate problems with receiving essential treatment and may prolong or even compromise recovery. Mitts are only considered for use as a therapeutic measure, when patients are unable to keep these tubes in.
Guidelines:
There are strict guidelines for staff to follow to ensure that the hand mitts are used appropriately including: Utilising alternative methods and approaches where appropriate Carrying out assessments, planning care, implementing and evaluating care plans Involving the patient/ family/ carers as far as practicably possible in the decision making process re best interest of the patient Careful monitoring and regular reviews to ensure patient safety Ongoing assessment and removal of mitts to ensure normal movement and function of the hands Discontinuing the use of mitts as soon as is practicably possible
Role of Staff:
Once a decision is made to use mitts in the best interest of the patient, then staff will follow appropriate guidelines mentioned above. Staff will also know the importance of and ensure the regular removal of the mitts in order to check the patient’s skin and to provide hand hygiene. It may be that this can also be timed around your visits so that the mitts can be removed when you are visiting.
Role of the Patient or Relative/ Carer:
It is not always possible but ideally you will have been shown the mitts before they are used. In order to alleviate further distress for the patient there will be an open and flexi visiting arrangement made to enable relatives/ carers to be present during the hospital stay or you may wish to involve other family members Communicate with staff, liaising with them to remove the mitts during visiting so that you can hold hands On occasion staff may have to put the mitts on before you visit in order to ensure your relative receives optimal care and the treatments needed to aid their recovery Ask any questions you may have surrounding the care and treatment offered
Concerns
If you have any anxieties or worries relating to the mitts being used and you would like to discuss it further, then in the first instance please speak to the nurse in charge of the ward. If you remain concerned and you do not feel that the concerns raised have been resolved then you can talk to the Trust Safeguarding Lead or contact PALS.
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APPENDIX 4
USE OF RESTRAINT MITTS RECORD
A check MUST be carried out at least once each shift. Any change to skin must be reported to the nurse in charge.
Date: Time: Confirm Mitts Removed:
(Yes/ No)
Confirm Skin Check Performed:
(Yes/ No)
Condition of Skin (e.g. Skin intact/ no redness/ evidence of circulation issues):
Designation: Signature:
Attach Patient Label: Surname: ………………………… Forenames: ……………………… Date of Birth: ……………………. NHS No: …………………………. Hospital No: ………………………
