Restraint as a Last Resort

Implement physical monitoring and observation of a patient who is restrained. 

The RN/LPN (licensed practical nurse) ensures monitoring and observation at a minimum, as follows: 

• Every 15 minutes for the first hour, then
• Every 30 minutes for one hour, then 
• Every hour until the restraint is discontinued 

Document restraint monitoring information in the patient's record (e.g. Restraint Monitoring Flowsheet).

If patient’s physical safety is a factor, increase the frequency of observation or provide 1:1 constant observation. Constant observation by an RN/LPN for 3-4 Point Restraints e.g. bilateral wrist and ankle restraints) may not be delegated to Unlicensed Health Care Providers (UHCP).

If less-restrictive restraints are unsuccessful, progress from least to most restraining, based on patient and assessment (e.g. patient’s physical and mental condition).

Every two hours:

• Perform skin circulation/assessment.
• Allow minimally 10 minutes restraint free.
• Encourage ambulation, toileting, exercises and other care. 

Assess intervention effectiveness or ineffectiveness, including if behaviour is unchanged, escalating, or de-escalating, or if the patient has settled or is sleeping.

When the patient is no longer a risk to themselves or others, and is able to tolerate discontinuation or reduction to a less restrictive restraint (e.g. from pelvic holder to Access Controlled Egress Door):

• The health care provider will collaborate with the patient and the Health Care Team to discontinue or reduce the restraint at the earliest opportunity. 

Continue regular 5P Purposeful Rounding with patient. 

Debrief with Health Care Team, patient, Circle of Support/SDM to begin to re-establish the therapeutic relationship. Review what did and did not work, as well as any complications or safety concerns. Debriefing with patients/families/SDMs and staff has also shown to be helpful in preventing future restraint episodes. Update the care plan accordingly.