Provincial/Territorial Professional Standards of Practice
To enhance national consistency in the use of physical restraints for medical purposes, thereby contributing to patient safety
Applies to nurses, psychiatrists, physicians, Correctional Officers and other Correctional Service of Canada staff members who contribute to efforts to ensure the safety of inmates who are inpatients at a Regional Hospital or Regional Treatment Centre
Physical restraint is a measure used to control the physical activity of a person or a portion of his/her body. Physical restraints limit a person’s movement and can include a table fixed to a chair (like a geri chair) or a bed rail that cannot be opened by the person (College of Nurses of Ontario, 2009). Due to a temporary or chronic medical condition in which a patient is at risk of unintentional injury, physical restraint may be required as a last resort, after all other alternatives have proven ineffective.
Nurses and physicians are required to follow provincial legislation and professional standards of practice developed by the provincial regulatory body related to the use of restraints.
In order to use restraints for medical purposes, all of the criteria outlined in this policy document must be met.
CRITERIA FOR RESTRAINTS FOR MEDICAL PURPOSES
Restraints for medical purposes can only be applied to inmates who have been diagnosed by a physician or psychiatrist with a medical condition, such as dementia, Alzheimer’s, delirium, or acute or chronic brain injury, symptoms of which place the inmate at an elevated risk for unintentional injury. For example, inmates with these diagnoses may wander or climb out of bed and be at an elevated risk for injury due to falling. Inmates with an acute brain injury may require temporary physical restraint to prevent them from pulling out intravenous, central lines, catheters, or breathing tubes. This policy document does not apply to intentional self-injurious behaviour. Direction related to intentional self injurious behaviour can be found in Commissioner's Directive (CD) 843 – Management of Inmate Self-Injurious and Suicidal Behaviour.
If an inmate has a medical condition, a symptom of which is periodic violent psychotic behaviour, how this behaviour will be managed should be part of the Treatment Plan. The decision as to whether or not the equipment for physical restraint for medical purposes is needed or appropriate will be based on the individual circumstances of the inmate.
Inmates who require physical restraints for medical purposes must be inpatients in a Regional Hospital or Regional Treatment Centre, as they require 24-hour nursing care.
Physical restraints for medical purposes can be used only if ordered by a physician or psychiatrist. The order must include the type(s) of physical restraint included, under what circumstances they can be applied, and the monitoring required while the restraint is in use and must be congruent with CD 803 – Consent to Health Services Assessment, Treatment and Release of Information.
Physical restraints for medical purposes must be included in the inmate’s Treatment Plan, which must include all details of the physician’s order. Inmates who are inpatients in a Regional Treatment Centre have an interdisciplinary Treatment Plan available to all members of the interdisciplinary team. If Correctional Officers working directly with the inmate are not part of the interdisciplinary team (in a Regional Hospital, for example), they have a need-to-know about the physician’s/psychiatrist’s order for physical restraints for medical purposes.
Availability of Appropriate Restraint Equipment
The equipment used for restraint for medical purposes is different from that contained in the Security Manual. The following are examples of equipment used for physical restraint for medical purposes:
Geri-chairs (medical recliners)
Guard rails on hospital beds
Torso supports/wrap around belts.
The Pinel Restraint SystemFootnote
1 should not be used as a restraint for medical purposes.
Regional Director, Health Services, Informed
The Regional Director, Health Services, must be informed of all physician orders for restraints for medical purposes. The Regional Director, Health Services, is responsible for ensuring that appropriate monitoring is conducted when an inmate is in a restraint for medical purposes and for tracking the number of inmates with orders for restraints for medical purposes.
APPLICATION OF RESTRAINTS FOR MEDICAL PURPOSES
Application by Nursing Personnel
Similar to hospital and long-term care settings, nurses apply physical restraints for medical purposes. As for all medical equipment purchased, Regional Hospitals and Regional Treatment Centres will need to ensure that nurses are aware of the proper use of the medical restraint equipment that is purchased for the institution.
Assistance from Correctional Staff
If during the application of restraints for medical purposes the inmate becomes non-compliant or combative, nurses will request assistance from Correctional Officers. Health care staff are in charge of the application of restraints for medical purposes conducted within the parameters of the Treatment Plan, even if assistance from Correctional Officers is required.
Nurses are not required to consult with correctional staff before applying restraint equipment for medical purposes, as the authorization has been provided by the institutional physician or psychiatrist and the application is part of the inmate’s Treatment Plan.
USE OF FORCE
Application of physical restraints for medical purposes within the parameters of the Treatment Plan and ordered by the physician/psychiatrist, regardless of who assists the nurse in the application, is not a reportable incident and therefore is not reportable as a “use of force.” Similarly, assisting or guiding an inmate to walk, when no resistance is provided by the inmate, is not a use of force.
Application of medical restraints becomes a reportable incident and/or reportable use of force only if the application of the restraints progressed beyond the parameters of the Treatment Plan and any level of force, security restraint equipment and/or physical handling was used. If the situation becomes a use of force incident, videotaping will then occur pursuant to CD 567-1 – Use of Force. In collaboration, the health care professionals involved will advise when interventions are beyond the parameters of the Treatment Plan, and the Correctional Officer(s) will advise when a level of force has been used.