use of mechanical restraints

see also:

• managing violence or the aggressive patient in the ED
• rapid sedation of the agitated or aggressive patient in the ED
• Mental Health Act 2014 Victoria
• Vic. Chief Psychiatrist's Guideline. Mechanical Restraint. 2006.
• Australian Society for Geriatric Medicine. Position Statement No. 2: Mechanical Restraint Use in Older People. Revised September 2012
• Department of Health & Ageing, Australian Government. Decision making tool – Responding to issues of Restraint in Aged Care. 2010

• restrictive interventions include:
  • seclusion
  • mechanical restraint
  • physical restraint
• mechanical restraint is the use of mechanical devices in the restriction of movement against the patient's will to allow safer care of a patient when this is the least restrictive option available at that time to achieve safety, it includes:
  • type 1 mechanical restraints:
    • padded limb control bracelets used to secure a person’s hands and/or feet to a bed or trolley
    • 2 point restraint is generally defined as wrists only
  • type 2 mechanical restraints:
    • Beds with both rails raised, prohibiting free movement, excluding:
      • Rails on trolleys during transport.
      • For up to 4 hours post sedation.
      • Patients in the Intensive Care Unit when documented as clinically necessary.
      • Patients with suspected spinal injury
    • Chairs with table inserts
    • Over bed tables placed in front of the patient with the intent of restricting patient movement
    • Tilting and tub chairs or chairs that are difficult to get out of (e.g. bean bags, water chairs and deep chairs)
    • Commercially available mittens
• for the purposes of this discussion, mechanical restraint excludes:
  • the wrapping of a child for a necessary medical procedure where it is deemed necessary
  • utilisation of a splint and tubigrip over a child’s hand to prevent interference with a IV line or nasogastric tube
• in Victoria, mechanical restraints may be utilized either under:
  • the Mental Health Act 2014 Victoria which has very specific processes and documentation requirements, or,
  • as a Duty of Care if the patient is not under the MH Act, and for this, most hospitals will also require appropriate documentation to justify its use
• the general principles of using mechanical restraint are:
  • to minimize its use, used as a last resort and in the least restrictive manner and alternative strategies MUST be attempted and/or considered prior to making a decision to mechanically restrain a patient,
  • to maintain patient dignity which should be respected and promoted at all times,
  • to comply with legal and ethical standards,
  • to ensure risks of restraint are minimized (this also generally requires that specifically trained “security” officers apply Type 1 restraints),
  • to ensure regular nursing and medical review (nursing obs every 15 minutes and 1:1 nursing if Type 1 restraints),
  • to terminate use of restraints as early as possible (this also generally requires that specifically trained “security” officers remove Type 1 restraints)
  • Prisoners in Manacles/Metal Shackles or detainees from a Detention Centre in handcuffs – must not be removed and substituted with hospital Type 1 Mechanical Restraints unless required for a medical procedure.

• Use of mechanical restraint interventions are governed by legislation and common law, and in Victoria, the relevant laws include:
  • The Aged Care Act 1997 (Cth)
  • Charter of Human Rights and Responsibilities Act 2006 (Vic)
  • Disability Act 2006 (Vic)
  • Guardianship and Administration Act 1986 (Vic)
  • Medical Treatment Act 1988 (Vic)
  • Mental Health Act 2014 (Vic)
  • Medical Treatment Planning and Decisions Act 2016 (Vic)
    • see also: https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/advance-care-planning/medical-treatment-planning-and-decisions-act
  • Occupational Health and Safety Act 2004 (Vic)
  • Nolan v Clifford (1904) 1 CLR 429

• As with any other medical treatment, consent must be obtained prior to use of mechanical restraints.
• The exceptions to this are:
  • When mechanical restraint is required to administer emergency treatment or in an emergency situation as a Duty of Care
  • Vic. Mental Health Act 2014 - medical treatment and consent
  • For Compulsory Patients as defined under the Mental Health Act

• these should be considered as options where applicable:
  • de-escalation, reassurance and communication
  • determine and address underlying cause (eg. pain, urinary retention, etc)
  • review any medical devices and remove any that are unnecessary
  • modify environment to reduce stimulation and improve orientation if delirium is the issue
  • diversional activities
  • increased supervision - use of a “special” 1:1 carer, or moving closer to nursing station
  • other strategies to reduce falls risk
  • pharmacologic strategies
    • see rapid sedation of the agitated or aggressive patient in the ED