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Restraint must be the final and only option

A blog article by Kenny Gibson, Future NHS collaboration platform

Restraint must be the last option

We all want safe, compassionate care for those we care about, and those we care for. Sometimes safety requires limiting a person’s activity or behaviour. Restraining a person is a last resort in an emergency or when other things haven’t worked.

We have an opportunity now, while still in the early stages of the outbreak of COVID-19, to put in place the basic principles and procedures for how we engage with and manage our patients, whether in community or inpatient settings. Patient engagement is simply recognising the needs of patients and how best to reach them and meet their needs if they or their families and carers are self-isolated.

We also encourage you to do what works best for your organisation and patient groups, so this is intended to be guidance, rather than prescriptive instructions.

Identification of vulnerable patients

We encourage you to start identifying vulnerable patients now. NHS England and NHS Improvement are currently working on developing clinical guidance to identify the most vulnerable patient groups. Until that guidance is ready, you can think in terms of three broad groups:

  • People whose vulnerability stems from a susceptibility to the virus, perhaps because of age or a chronic respiratory condition.
  • People whose vulnerability stems from their mental health, such as people with an eating disorder, people with underlying conditions and frail older people, or people with a learning disability, autism or both who are dependent on carers.
  • People whose vulnerability stems from both of the above.

For example, a young person with an eating disorder could be vulnerable because of their mental health and physical frailty. Patients who take clozapine are also potentially vulnerable because they need frequent blood tests, access to which may be compromised if patients are self-isolated or unable to access the usual setting where tests are undertaken, with consequences for their mental and physical health. People with a learning disability may also be vulnerable due to having a higher risk of respiratory issues.

You can think about how your services could be configured under different scenarios to meet patient needs, acknowledging the best local solutions for your patients could include working with primary care, community health and acute trusts.

There are 4 types of restraint:

  • Physical restraint is hands-on holding of arms, legs, or body
  • Medicine is a restraint when given to control behaviour or activity
  • Mechanical restraint, such as a lap belt, limits movement
  • Environmental restraint limits a person to a room or area by using a barrier such as a door the person can’t open

Restraint is a last resort because of many risks and safety concerns. Risks include:

  • emotional trauma, fear, mistrust of health care providers
  • medicine side effects such as confusion, falls, not being able to sleep at night
  • loss of muscle strength, falls
  • stress, delirium
  • frustration, hopelessness, agitation, anger

Patients and their care partners can give ideas to lower or avoid the use of restraint. If the use of restraint is likely to continue, the patient or guardian needs to consent to this care plan, unless it becomes an emergency such as a physical safety risk.

The goals during a behavioural emergency are to:

  • keep the person safe while helping them keep their dignity
  • help the person regain composure and return to their daily routine

The goals after a behavioural emergency are to:

  • explore how the situation could have been handled differently to have a better outcome
  • help the person develop skills to manage their emotions themselves
  • lower or avoid the need to use of restraint in the future

What can be done to use restraint as a last resort?

  • Reassure and welcome: You’ve come to the right place, I’m glad you’re here.
  • Listen to their concerns, even if the words don’t make sense.
  • Keep questions simple and in a calm tone – they may not be able to hear you properly or focus on what you’re saying. Give them time to answer.
  • Recognise that their perception is their reality, and it may be very frightening for them: ‘That must be scary’ instead of ‘That’s not real’. Don’t argue.
  • Be present, be genuine, and develop rapport. Try to limit the number of care givers to reduce confusion and to prevent the person having to repeat their experience several times.
  • Discuss needs and wants. Provide quiet time, meaningful activities, music and medicine as needed. Offer limited choices to give the person some sense of control.
  • Don’t isolate them – check in often to see if they’re okay, offer food and water.
  • Allow dignity: let them wear their own clothes, cover self-injury wounds, and help them to the bathroom regularly.

Helpful questions to ask

  • Is there someone you’d like to be with you?
  • What are some things that upset you?
  • What are some things that help you feel safe?
  • Has this happened before? What helped?
  • How can I help you to feel safe while we talk about what’s happened?
  • Helpful conversations for staff, family, and care partners
  • How are you feeling? Are you dealing with other challenges other than this situation? Who is supporting you?
  • Are you willing or available to help support this person emotionally right now?
  • Has this happened before? What helped?
  • What upsets the person? What are some early signs to recognize when they’re getting upset?
  • What helps them feel calm and relaxed?

When people are at risk of falling the goal is to prevent falls and fall injuries. At the same time it’s important to help them be as independent as they can be. The best way to do this is to find and remove the reasons for falls. Common reasons include medicine side effects, vision problems, and muscle weakness from not being active enough. Falling can lead to injury but using restraint also has many risks.

Use of restraint can cause:

  • loss of muscle strength and ability to walk alone (deconditioning)
  • loss of independence like not being able to get to the bathroom without help
  • feelings of being upset and embarrassed
  • trouble sleeping because of not being active enough
  • bruising or skin breakdown
  • a serious or life-threatening injury (climbing over bed rails and falling, getting stuck between rails, sliding down in a chair with a lap belt and not being able to breathe)
  • other serious medical issues such as heart stress, slower blood circulation, infection and delirium (a sudden increase in confusion that can be life-threatening)

What can be done to use restraint as a last resort?

  • Review all prescriptions, supplements and over the counter medicines. Stop any unnecessary medicines and use the lowest dose possible for all others. Being on 3 or more medicines makes it more likely a person will fall.
  • Wear glasses. It’s important to have an up-to-date prescription. Consider a separate pair of reading glasses instead of bi or tri-focal lenses.
  • Improve lighting and reduce clutter.
  • Walk often, with help, until stronger.
  • Wear non-slip shoes, socks or slippers.
  • Use aides such as a cane, 2 or 4 wheeled walker, or walker with a seat.
  • Get involved in group therapy and social activities during the day. But remember physical distancing.
  • Make sure the bed is in the lowest position, or place the mattress on the floor.
  • Helpful conversations for staff, family, and care partners
  • Special things to know to help with walking and exercise.
  • How to release a temporary restraint to help the person walk or change position.
  • Challenges such as back pain, mobility or strength that make it difficult to help.
  • Services, help and supports that are available in the community

When a confused person is at risk of becoming lost or leaving the building the goal is to protect them while allowing as much freedom and dignity as possible. Restraint to limit or stop wandering and getting lost may include codes to unlock doors and elevators. Sometimes changes are made to disguise doors, like painting doors the same colour as the wall, or painting murals (pictures) on doors.

What can be done to use restraint as a last resort?

  • Respond to the feelings instead of only what they’re saying (“you must be lonely”, instead of “you can’t go home”).
  • Redirect in a positive way (“come with me” instead of “don’t go out or there”).
  • Offer positive choices (“would you like a cup of tea, or a glass of water?”).
  • Put photos, signs, names, or familiar objects by the door of the person’s room
  • Put a picture of a toilet on the bathroom door.
  • Have familiar objects in the room (bedspread, quilt, or other items – keep in mind that space may be limited).
  • Provide enjoyable activities. Remember their choices.
  • Walk and talk with the person often, provide places to go and things to see and discover.

How Families and Care Partners Can Help

  • Bring in familiar items, and activities the person enjoys.
  • Think about why the person might be wandering (boredom, looking for something familiar). Suggest activities that could help like music, art, gardening, cards, fiddle boards and mats.
  • Walk with the person.
  • Eat and drink with the person.
  • Look at and talk about photos together. Avoid asking the person to remember things. (“This looks like someone’s birthday. You look very happy! I wonder what kind of cake this was.”).
  • Take the person outdoors or away from their room if it’s safe to do so. This helps them to get a break from the surroundings.
  • Helpful conversations for staff, family, and care partners – what about using tech during COVID isolation? 
  • Look for ways to work together if the person gets upset when they say goodbye to their loved one 
  • What helps the person feel calm and relaxed?
  • What type of music do they enjoy listening to?

Many things are stressful and upsetting for people with dementia. It can be embarrassing to get personal care from a care provider. It’s stressful to have trouble understanding or trying to explain things. The goal is to keep the person comfortable, help them to stay as independent as they can, and protect them and others from getting hurt.

Restraint used for agitation associated with dementia includes medicines, and temporarily keeping the person in a room, area, or chair to provide quiet and prevent injury to others. Sometimes gentle physical restraint of arms and legs is needed during care.

Restraint includes many risks:

  • In some people and at some stages in the disease, antipsychotic medicines can make symptoms worse. Sometimes small doses of these medicines may help some people for a limited time. Side-effects can include more confusion, higher risk of falls and pneumonia.
  • More distress and agitation from being kept in a room, area or chair. Being hurt while trying to free themselves.
  • Physical restraint during care can frighten the person and make it difficult for them to trust care providers.

What can be done to use restraint as a last resort?

  • Review and stop unnecessary medicines. Use the lowest dose possible for those that are necessary. Medicine side effects can cause more confusion and add to symptoms such as pain, falls, trouble sleeping, and nausea.
  • Help the person to walk and go to the bathroom, regularly during the day.
  • Look for what physical and social needs they may have like hunger, thirst, or loneliness.
  • Support sleep at night.
  • Help the person to be as independent as possible; involve them in their care.
  • Come back later if the person refuses care; try a different approach, or a different person.
  • Use gentle restraint if needed (holding a hand) and distraction (singing, talking about something the person is interested in).

How Families and Care Partners Can Help

  • Help staff get to know the person, their likes and dislikes.
  • Bring in favourite comfort items or activities.
  • Tell staff if you notice something that upsets the person such as noises, smells, or times of day.
  • Be involved in care activities if helpful for the person, and possible for you.
  • Helpful conversations for staff, family, and care partners
  • What are the person’s habits, likes, and dislikes?
  • Did they have hobbies, jobs or achievements they like to talk about?
  • What is the best answer to questions they ask often?
  • What helps the person feel calm and relaxed?
  • What type of music do they enjoy listening to?

When alcohol and drug withdrawal causes confusion or agitation, the goal is to prevent dangerous symptoms, like seizures, and to keep the person safe. The medicine given for symptoms of alcohol withdrawal is a treatment and not a restraint. Examples of restraint used during alcohol withdrawal include wrist restraint and lap belts.

Risks of mechanical restraint include:

  • more agitation
  • discomfort or not being able to change position
  • skin breakdown, infection
  • need to use more medicines

How Can Families and Care Partners Help?

You can:

  • sit or walk with the person
  • reassure
  • Helpful conversations for staff, family, and care partners – remember to use tech during COVID 

Has the person gone through alcohol withdrawal before? If so, what were the symptoms?

Do you know if the person wants to quit drinking alcohol after discharge? If not, consider harm reduction strategies.

Contingency plans

It is imperative for trusts and care homes to model their contingency plans on the local context. Please share any learning from modelling, table-top exercises, etc with the response cell to help shape guidance and identify good practice.

National clinical guidance published by the government and the national IMT, including this response cell, should be used to inform the development of your COVID-19 patient management plans.

This guidance is still under development, but your plans need to include:

  • transport and isolation solutions for patients suspected of being infected
  • person-centred care planning to support patients with the virus to adhere to the
  • isolation pathway and ensure use of the least restrictive option
  • ensuring each patient has a current safety and crisis plan which considers COVID- 19 and access to care
  • testing and sampling arrangements
  • inpatient estate that will support the care of inpatients with the virus (mild cases)
  • maintenance of medication supplies to patients, eg prescription and administration
  • of clozapine and lithium monitoring
  • lines of reporting and communication, including testing phone numbers and
  • increasing capacity of 24/7 response lines
  • training for mental health and learning disability staff on PPE, physical health care,
  • use of National Early Warning Signs, access to and administration of oxygen, vital
  • signs and when to escalate
  • digital technologies to support patients and staff in isolation.

Patient engagement

Please use the materials provided in the Campaign Resource Centre to display information in your premises, especially in your reception and waiting areas. Public Health England (PHE) is leading on clinical advice on COVID-19, and regularly publishes new advice for clinicians on management of potential cases, patient information and advice. You can find links to this on our coronavirus website: www.england.nhs.uk/coronavirus/

Please make sure patients, families and carers receive up-to-date information on COVID-19 and know what to do in case of suspected infection. We also encourage you to include information on COVID-19 in discharge plans and patient crisis or safety plans. Please keep following the Accessible Information Standard to ensure your messages to patients are clear and easy to understand.

In discussion with patients, families and carers, make sure they have:

  • up-to-date details of emergency contacts and key care co-ordinators
  • access to information on coronavirus and advice on how to avoid catching or
  • spreading the virus
  • information on what to do in case of suspected infection: use the NHS 111 online coronavirus service. Only call 111 if you cannot get help online.

It is a good idea to ask patients and families now if they have a preference for how you reach them, especially if later guidance enables you to use other channels like social media. Make it clear this isn’t a commitment to use any particular app or tool, but simply finding out what our options are.

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