Physical restraint is a high-risk intervention for health care workers and patients in terms of injuries and COVID-19 transmission. It should be avoided wherever possible and the principles in section 6 should need for restrictive practices.

Therapeutic alliance, meaningful engagement, careful listening and open communication are key to providing information and reassurance and will minimise the need for de-escalation and more restrictive practices.

Personal protective equipment during physical restraint

Mental Health staff should refer to the general health staff advice in Appendix 4A of the CEC Infection Prevention Control Manual:

Appendix 4A: COVID-19 risk assessment guide for PPE selection for direct care of patients

When caring for patient suspected, probable or confirmed COVID-19, physical restraint requires:

  • P2/N95 respirator
  • Protective eyewear/face shield
  • Gloves
  • Disposable fluid repellent gown

P2/N95 masks are more effective than a surgical mask only when fitted correctly and when a seal is maintained. See Respiratory Protection Program and education, training, posters and videos for advice on fit checking.

Considerations for managing PPE during physical restraint

  • If the patient does not have a mask on already, a staff member should assist them to apply a surgical mask as soon as it is safe to do so.
  • If there is scope not to engage in immediate close contact, including restraint and it is safe to do so, staff should apply full PPE before making contact with the patients.
  • If there is an immediate risk to the safety of staff and others and there is no time to apply PPE, staff should remove others from the immediate area and secure the scene whilst a team in PPE is assembled. Any initial respondents in such circumstances should don at minimum surgical mask and gloves.
  • Where a staff member's PPE is damaged, that staff member should be immediately relieved by staff in intact PPE.
  • In the case of a PPE breach or unprotected contact, any affected staff should shower and change clothes immediately. The local infection prevention and control and Public Health Units should be consulted to determine whether the staff is required to self-isolate (See Health Care Worker COVID-19 Exposure Risk Assessment Matrix and COVID-19 Advice for Healthcare Professionals)

General principles for risk mitigation and safety during physical restraint

  • Restrictive intervention, including restraint must be for the minimum time.
  • Prone restraint has been associated with sudden patient death, this risk is higher for patients with physical health (including respiratory issues) and increases with administration of parenteral medication.
  • The physical wellbeing of the patient must be closely and continuously monitored throughout any restrictive intervention, including restraint - document respiration rate, and level of consciousness (See also PD2020_018 Recognition and management of patients who are deteriorating).

Seclusion principles

  • Seclusion is a last resort where other attempts to manage ASBD have failed and must be used for the shortest amount of time possible (See PD2020_004 Seclusion and restraint in NSW Health Settings).
  • The seclusion room must be cleaned and disinfected post use.
  • Seclusion is not to be used for the sole purpose of isolating a patient with COVID-19.
  • Staff should consult with their local Public Health Unit for advice on the use of a public health order where isolation is required for a patient in a mental health facility.

If isolation is required due to COVID-19 risk:

  • Patients must be informed of:
    • why COVID-19 isolation is required
    • the nature and purpose of COVID-19 isolation
    • the health benefits, risks and consequences of COVID-19 isolation
    • their rights to appeal their detention under the Mental Health Act 2007 NSW.
  • staff must ensure that patients are given:
    • a reasonable period of time to discuss the decision with the treating team
    • support with adequate information regarding public health advice for COVID-19
    • access to timely advice and support from public health professionals if requested
    • opportunities to discuss this advice with their designated carers.

Level 1 constant observation (1:1 nursing)

The risk to the staff could potentially be twofold:

  • risk of exposure to COVID-19
  • risk of assault due to close proximity to patient.

Level 1 Observation for a patient with confirmed or suspected COVID-19 must be deemed absolutely necessary and the following considerations discussed with the NUM and/or On-call Executive in conjunction with nurse unit manager and/or on-call executive in conjunction with infection control:

  • Level 1 Observation (arm’s length) will require the staff providing observation to be wearing PPE for the period they are in the room including gown. It may be preferable to wear a face shield to a mask and goggles to improve communication and comfort. Gloves should be worn when touching the consumer or items in the room and good hand hygiene practises observed.
  • Level 1 Observation (visual) PPE as above. Where mental health clinical risk assessment indicates it is safe to do so:
    • door may remain open to allow for better airflow (unless negative pressure room)
    • the observing staff may sit either within or outside of the room, maintaining line of site of the patient
    • staff completing Level 1 observations must be relieved at regular intervals or no less than each hour.

Post incident management

  • Patient debrief.
  • Patient is offered support by peer worker where available.
  • Open disclosure principles, including with family as required
  • Immediate ‘hot debrief’ with staff post incident.
  • Plan for ‘cold debrief’ with staff.
  • Opportunity for ward debrief if required.
  • Auxiliary services conducts terminal clean of exposed environmental areas and equipment.
  • Replace and reorder PPE stock as required.
  • Post COVID-19 exposure management processes for staff. (Review HCW Exposure risk matrix)

Return to COVID‐19 Acute Severe Behavioural Disturbance Risk Formulation Framework.

Current as at: Wednesday 20 October 2021
Contact page owner: Health Protection NSW