GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
PURPOSE BC Children’s Hospital and Sunny Hill Health Centre seek to create an environment that minimizes the use of restraint and maximizes the patient’s health and safety when restraint is used. POLICY STATEMENTS Restraint is used when there is an imminent risk of an individual physically harming self or others (including staff), or for medical/surgical necessity to avoid the risk of injury or re-injury. The use of chemical restraint requires clear indications for use, safe administration, consideration of alternative methods, monitoring and reassessment guidelines. Informed consent must be obtained prior to use of chemical restraint unless in emergency situations when there is no parent/family/substitute decision maker (SDM) in attendance, in which case the patient will require certification under the Mental Health Act. All Mental Health Act Consent to Treatment Forms (Form 2 and Form 5) must include a statement that restraint may only be used when the safety of self or others is at immediate risk. A patient safety check must be conducted on patients assessed to be a danger to self or others and who require restraint to ensure safety of patient, staff members and/or others who may come in contact with potentially unsafe items. Restraints should never be used as a form of punishment or consequence for behaviour or as a substitute for observation or direct care. DEFINITIONS Chemical restraint: Refers to the use of a medication to control behaviours or restrict the patient’s freedom of movement that is not a standard treatment for the patient’s medical or psychiatric condition. This definition does not apply to patients receiving sedation or muscle relaxants for procedures or medical treatments. De-escalation techniques: are used to reduce the level and intensity of a difficult situation. De-escalation means making a risk assessment of the situation and using both verbal and non-verbal communication skills in combination to reduce problems. Alternatives Methods to restraint use: refers to a method that imposes less control on the patient than restraining or confining them. Restraints may be avoided by adequate preparation of the patient and collaborative problem solving, disengaging, limit setting, continuous supervision of the patient, use of acceptable physical outlets, etc. Assess developmental stage, cognitive functioning and/or patient safety to determine most appropriate alternative intervention(s), such as: Increase supervision of child (eg. by family, volunteer or child & youth counselor) Refer to child’s careplan and note his/her triggers-respond proactively to de-escalate behaviour Create plan with child Prepare child for what is expected, consult with child life Provide therapeutic touch Provide active listening Provide adequate protection to site “make a deal” with child Provide physical contact Reduce environmental stimulation (decrease sounds, lights, people) Provide place to easily observe child Utilize distraction techniques Exercise/ambulate/physical outlets Provide less restrictive device Utilize clothing to camouflage site Toilet the child frequently (e.g. toileting schedule) CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 1 of 6
GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
Evaluate pain management Evaluate drug regimes for relationship between medications and restraints Use creative positioning Provide outlet for anxious behaviour Offer choices Decrease noise/visual stimuli Require transitional items from home Frequent reorientation Require parent at bedside Place mattress on floor GUIDELINES Rationale 1. DETERMINE need for restraint. See Least The use of psychoactive medication used, not to treat Restraint, Last Resort Decision Tree. Chemical illness, but to intentionally inhibit a particular behaviour restraint is indicated when a patient remains or movement is considered a medical decision based agitated when physically restrained or when patient on a team assessment of the need to provide safety for behaviour needs to be controlled rapidly. all patients, staff and visitors in the area. 2. ATTEMPT to use de-escalation techniques and De-escalation strategies, including anger management Alternative Methods to chemical restraint. and stress reduction techniques, are part of crisis management and prevention strategies that may obviate the need for seclusion or restraints. 3. CONSIDER cause of behaviour and treat When a patient is exhibiting irritable behaviours, staff underlying cause. must consider possible causes. Such behaviours may be related to: Cognitive or sensory deficit Neurological condition Pain Hypoxia Hypoglycemia Dehydration Hunger or thirst Alcohol/drug abuse Medications Electrolyte imbalance Full bladder Constipation Fatigue/sleep disturbance Infection or fever Lack of muscle tone Depression Need for control or independence Age Medical condition Environmental issues: lighting, furniture placement, access to/ability to use nurse call bell, room temperature, noise, equipment. 4. REVIEW with family/caregivers, if possible, history Family members must be included in the discussion to of prior aggressive behavior including warning ensure a complete assessment is done, that all signs, triggers, repetitive behavior, prior response alternatives are explored and to ensure their to therapy, previous seclusion, and/or restraint. engagement in the planning process. Initial assessment should also identify any
CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 2 of 6
GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
cognitive deficits, learning disabilities, and neurological limitations/deficits as well as any factors that may necessitate changes in restraint procedures. 5. OBTAIN certification under the Mental Health Act if If the patient is deemed by the physician to be patient has been brought in involuntarily and no "incompetent" according to the Infant Act, then the substitute decision maker (SDM) is present. parent/guardian may sign consent for treatment. o Form 4- Medical Certificate (Involuntary Form 2 “Consent for Voluntary Treatment” is signed by Admission) (generally completed in the either the “capable youth” or parent of an “incapable Emergency Department). youth” if the need for chemical restraint is deemed 6. EXPLAIN to patient/family that the use of chemical necessary for safety reasons. restraint may be necessary to ensure safety. ENGAGE patient/family in the informed consent In urgent situations, Form 4 is essential, but it is not process. REFER to PHSA Consent to necessary to wait for Form 5. Treatment/Procedures Policy. Form 5 is signed by the patient (if over 16 years of age NOTE: for Mental Health admissions, the following and deemed competent) or by the Director or delegate consent documents are used: (if patient is deemed incompetent to consent). o Form 2-Consent for Treatment (Voluntary It is important that the patient/family receive an Patient) explanation as to why restraint is necessary and they o Form 5-Consent for Treatment (Involuntary should be given the opportunity to respond to Patient) alternative methods when appropriate and safe. NOTE: In non-emergency situations, verbal consent from the patient/family/SDM is required. In emergency situations, if patient/family/SDM is not able/available to give consent, an explanation with rationale should be provided as soon as possible after the event. 7. ASSESS patient and obtain history to ensure that Prevents possible adverse events. chemical restraint is not medically contraindicated. Contraindications include: a. Prior history of dystonic reactions b. Allergy to drugs used c. Potential unknown poly-substance use 8. CHECK chart for physicians order for chemical Required elements of safe prescribing practices to restraint/sedation. The order must specify: reduce medication related adverse events. a. Date/time b. Drug name c. Dose d. Dose formula e. Route f. Rationale in relation to patient’s condition and/or plan of care. 9. MEASURE baseline vital signs (VS) including Baseline measurements allows for comparison of respiratory rate and depth, blood pressure, pulse readings following sedation. and temperature, oxygen saturation (SpO2) and arousal score, if possible, and DOCUMENT on nursing record. 10. CONDUCT safety check and ENSURE patient Ensures safety of patient, staff and others who may remains in his/her street clothes unless a come in contact with unsafe items.
CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 3 of 6
GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
physical exam is required. If not safe to conduct Maintains patient dignity and promotes self-care. safety check at this point, conduct it once the patient is chemically restrained. 11. IDENTIFY patient, EXPLAIN procedure and If required, the patient may be held briefly in a recovery ADMINISTER sedation as ordered. position in order for staff members to provide IM medication and to safely leave the room. Prone restraints must never be used. Literature shows that sudden death during prone restraint, particularly for those in a state of agitation, is not an uncommon phenomenon. The mechanism of death is thought to be a sudden fatal cardiac arrhythmia or respiratory arrest due to a combination of factors causing decreased oxygen delivery at a time of increased oxygen demand.
12. MONITOR SpO2 continuously while Arousal Score Complications of chemical restraint may include over- is above 2. Patient must have constant 1:1 sedation leading to respiratory depression and loss of supervision by qualified staff member if arousal gag reflex, thereby compromising the patient’s ability to score is above 2 and/or if physically restrained. protect the airway, and increased risk of choking and
13. MEASURE and RECORD VS, SpO2, and arousal aspiration for the patient who vomits while in a score every 5 minutes while arousal score is above restraint. 2; every 15 minutes for 1 hour when arousal score Allows for early recognition of effectiveness or is 1 or 2; then hourly for 4 hours if stable. complications and prompt initiation of interventions. 14. POSITION patient on side or in recovery position while arousal score is above 2. 15. MONITOR patient for desired effect and need for further medication. 16. If more medication is needed or if medication was not effective, the physician must follow up in person and evaluate patient. If the medication was effective, the physician must see and evaluate the patient within one hour. 17. CONDUCT a staff debriefing session if possible. All staff where possible who were involved in the incident with at least one of the following: Medical Director, Program Manager, CNC, Charge Nurse or Nurse Educator should discuss how the situation went, what was done well and what could be improved on the next time.
DOCUMENTATION DOCUMENT on appropriate records: o Date and time o Antecedent behaviours o Alternative interventions attempted o Rationale for decision to use chemical restraint (specific reasons: actual violent behaviour, threat, etc such as “threatened to hit nurse, tried to hit physician” rather than general indication such as “was violent”) o Medication administered (drug, dose, route, patient response) o Staff involved o Record of monitoring patient while sedated and post event with times noted o Debriefing with patient
CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 4 of 6
GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
o Post event sequence such as return to room, changes to care plan, response of patient, etc. o Any other pertinent actions or observations REFERENCES American Academy of Child & Adolescent Psychiatry. (2002). Practice parameter for the prevention and management of aggressive behaviour in child and adolescent psychiatric institutions, With Special Reference to Seclusion and Restraint. Journal American Academy of .Child and Adolescent Psychiatry (Supplement), 41:2, 4S-25S. Baren, J.M., Mace, S.E., Hendry, P.L., Dietrich, A.M., Goldman, R.D. & Warden, C.R. (2008). Children’s Mental Health Emergencies – Part 2, Emergency Department Evaluation and Treatment of Children with Mental Health Disorders. Pediatric Emergency Care. 24(&), 485-498. Bezchlibnyk-Butler, K.Z. & Virani, A.S. (Eds). (2004) Clinical Handbook of Psychotropic Drugs for Children and Adolescents. Hogrefe & Huber: Toronto, Ontario. Brenner, M. (2007). Child Restraint in the Acute Setting of Pediatric Nursing: An Extraordinarily Stressful Event. Issues in Comprehensive Pediatric Nursing, 30(1-2):29-37. Brenner, M., Parahoo, K. & Taggart, L. (2007). Restraint in Children’s Nursing: Addressing the distress. Journal of Children’s and Young People’s Nursing, 1(4):159-162. British Columbia Ministry of Health. Guide to the Mental Health Act, 2005 Edition. April 4, 2005. Retrieved from http://www.health.gov.bc.ca/library/publications/year/2005/MentalHealthGuide.pdf. British Columbia Ministry of Health. Mental Health Act [RSBC 1996] CHAPTER 288. Current to November 24, 2011. Queen's Printer, Victoria, British Columbia, Canada. Brown, R.L., Genel, M. & Riggs, J.A. (2000). Use of Seclusion and Restraint in Children and Adolescents. Archives of Pediatric and Adolescent Medicine. 154(7): 653-656. Brown University Child & Adolescent Phychopharmacology Update. (2005). Using pediatric chemical restraints in the ER: Protocol and safety concerns. 7(5):1, 5-7. College of Nurses of Ontario. (2009). Practice Standard: Restraints. Retrieved December 22, 2011 from http://www.cno.org/docs/prac/41043_Restraints.pdf. Crisis Prevention Institute, Inc. (2005). Risks of Restraints: Understanding Restraint-Related Positional Asphyxia. Wisconsin: Crisis Prevention Institute, Inc. Darby, C. & Cardwell, P. (2011). Restraint in the Care of Children. Emergency Nurse, 19(7):14-17. Dorfman, D.H. and Mehta, S.D. (2006). Restraint Use for Psychiatric Patients in the Pediatric Emergency Department. Pediatric Emergency Care. 22(1):7-12. Government of Ontario, Patient Restraints Minimization Act, 2001 chapter 16. Retrieved December 23, 2011 from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_01p16_e.htm. Huckshorn, K. (2004). Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing, 42(9), 22-33. Joint Commission Standards on Restraint and Seclusion/Non-violent Crisis Intervention Training Program. (2010). Wisconsin: Crisis Prevention Institute (CPI), Inc. Miller, C.D. (2004). Silent Killer: Death by Restraint. PA Newz Page. Retrieved September 14, 2009 from http://www.charlydmiller.com/RA/restrasphyx01.html. Nunno, M. & Holden, M, & Tollar, A. (2006). Learning from tragedy: A survey of child and adolescent restraint fatalities. Child Abuse & Neglect, 30: 1333-1342.
CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 5 of 6
GUIDELINES FOR USE OF CHEMICAL RESTRAINTS
Sorrentino, A. (2004). Chemical Restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: controversies and recommendations. Current Opinions in Pediatrics. 16(2):201- 205. Wong, D.L. & Perry, S.E. (1998). Maternal Child Nursing Care. Mosby-Year Book, Inc: St Louis, Missouri. Hospital Review: BENCHmarking Effort for Networking Children’s Hospitals. Conference Call: Behaviour Management as an Alternative to Restraints. May 12, 2009. Participants: Children’s Hospital of Alabama, Birmingham; Connecticut Children’s Medical Center, Hartford, CT; Cardinal Glennon Children’s Medical Center, St. Louis; Children’s Memorial Hospital, Chicago, IL; Children’s Hospital Medical Center, Cincinnati, OH; DuPont Hospital for Children, Wilmington DE; East Tennessee Children’s Hospital, Knoxville, TN; Kosair Children’s Hospital, Louisville KY; Methodist Children’s Hospital of South Texas; Children's Hospital and Regional Medical Center, Seattle, WA. Calgary Health Region. Child Health Policies and Procedures: Restraints – Physical. Established 04/98. Calgary, Alberta. Children’s Hospital of Eastern Ontario. Interdisciplinary Clinical Manual. Least Restraint. Effective October 6, 2008. Ottawa, Ontario. IWK Health Centre. Children’s Health Program Clinical Policy Manual. Least Restraint Policy. Effective November 2006. Halifax, Nova Scotia. Seattle Children’s Hospital. Clinical Policy/Procedure: Restraint or Seclusion. Revised 01/27/09. Seattle, Washington. Toronto Sick Children’s Hospital. Policy, Procedure & Guideline: Least Restraint. Last modified 03/05/08. Toronto, Ontario.
CC.07.16 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Page 6 of 6