1.2.21 Procedure for physical restraint

Goal and purpose

Physical restraint of patients is not unavoidable in hospital. This includes all measures that restrict the patient's freedom of movement, such as

• Fitting belt systems with magnetic fasteners
• Raising bed rails
• Locking; the room, the ward, the exits of the facility
• Removal of walking aids and wheelchairs
• Fixed table top on the chair

The following rules are presented and explained in order to protect hospital staff against accusations of deprivation of liberty, coercion, bodily injury, negligent homicide or manslaughter and to give them the necessary security in carrying out their duties.

Area of application

Applies to all departments of the hospital

Fixation is only applied:

• if the patient or their legal representative has given their informed consent
• the restraint was ordered by the competent district court or criminal court
• In the event of danger to life or limb

Inclusion criteria/indication

• Fixation is indicated for mot. Restlessness, states of confusion with mot. restlessness and to protect the patient when feeding tubes, catheters and tubes are in place, if another measure that is less stressful for the patient is not possible.
• Restraint may also be considered if the life or limb of employees, patients, visitors, etc. or the patient to be restrained is at risk and no other measure is possible. visitors, etc. or the patient to be restrained are in danger and another measure that is less stressful for the patient is not possible.

Exclusion criteria / contraindication

Description of the process

Order from an attending physician

The attending physician may only order the restraint if the patient or the legal representative has given their written consent or if the local court or a criminal court has ordered the patient to be restrained.

Nursing staff may only restrain patients on the orders of the attending physician.

In the case of patients who are treated in a closed psychiatric ward in accordance with Psych KG, the medical order is deemed to have been given by the admission.

The attending physician must inform the patient and/or the legal representative about the nature, consequences and necessity of the measure and obtain written consent for the intervention. If consent is not given, the doctor must apply to the local court at the patient's place of residence for an order for physical restraint. If the local court cannot be contacted, the guardianship court in Cologne is responsible (Annex 1)

Phone 477-0, Fax 477-1918

If a care recipient consents to physical restraint and the restraint is permanent (24 hours) and regular (over seven days), a further court order is also required.

Imminent danger

In the event of danger to life or limb of persons or the patient to be restrained, the medical or nursing staff may immediately restrain a patient if no other measure is possible and the restraint is proportionate after weighing up all the circumstances. As soon as there is no longer a risk to life or limb, the restraint must be lifted. If the restraint has been imposed by the nursing staff, the attending physician must be informed immediately. If the restraint is to be maintained, the restraint must be ordered as in 3.1.

Carrying out the fixation using fixation belt systems

• Procurement of a fixation system customised to the patient (see appendix for list of materials)
• The patient is asked to remove any clothing that may be restrictive; if necessary, this is done by care staff
• Hazardous objects such as lighters, scarves, belts, etc. are removed, jewellery, glasses, prostheses, watches are taken off by the patient; if necessary, taken over by the carer.
• Personal belongings are locked up by the carer.
• Patients should be accommodated close to the ward room so that frequent visual contact is possible with short distances.
• The responsible doctor informs relatives/representatives/carers about the measure. In exceptional cases, this task can be delegated to a carer.
• When putting on belts (Segufix), observe the manufacturer's instructions (see appendix)
• Height-adjustable beds should be set as low as possible
• Unlocking magnet is kept within reach in the patient's room
• Documentation of the measure by the doctor and the carer
• Patient is given the opportunity to talk about the measure

Monitoring

• Patient can operate the bell system at any time to be released by the carer. (Revocation of consent is therefore possible at any time)
• Skin condition + restraint straps are checked by the nursing staff according to the patient's condition (fit, counter-tension, etc.), but at least every 2 hours.
• Medical rounds 3 times a day, at least every 10 hours
• The nursing staff inform the responsible doctor of any changes in the patient's condition
• The nursing staff immediately inform the responsible doctor about the possibility of ending the restraint
• The doctor orders the end of the restraint
• Special feature in psychiatric wards: Constant observation must be ensured during restraint.

Documentation

Information and declaration of consent

The attending physician must inform the patient or carer in accordance with the VA "Information and consent before medical interventions". The informed consent protocol and the declaration of consent signed by the patient or their legal representative must be attached to the medical file. Consent can be withdrawn at any time.

Contents of the medical documentation

• The attending physician must submit the application for a decision by the local court to order physical restraint (Annex 1) to the competent local court. A copy must be attached to the medical file.
• The court order must also be included in the medical file.
• The doctor's order must be in writing (Annex 2) and contain the following:
• Consent/order
• Reason for fixing
• Type of fixation
• Start and end of fixation
• Name of the ordering physician and the nursing staff involved in the restraint
• Type and frequency of the monitoring measure
• Type and frequency of accompanying care activities
• The doctor's order must be attached to the patient's temperature chart as a loose sheet. The order is referred to in the temperature chart by the word "Fixation".
• The order must be regularly renewed by the responsible doctor. After the patient is discharged, the care report remains in the patient's medical records.

Contents of nursing documentation

• Carrying out the maintenance measures
• Patient observation (problems/resources)
• Information to the doctor
• Fixation controls
• Carrying out the doctor's orders
• Special features

Report in the event of restraint to avert danger

A report must be drawn up on the restraint in the event of averting danger, stating the danger situation, the persons threatened with their names and addresses, the measures taken and the witnesses with their names and addresses.

Resources

Material

• Belt systems with magnetic fastener/Velcro fastener
• Bed rails
• Tables that cannot be unlocked or removed by the patient, e.g. on wheelchairs and care chairs

Time required

• Bureaucratic effort approx. 30 min.
• Medical and nursing care in difficult cases for up to 24 hours

Responsibility, qualification

Organisational unit	Responsibility
Medical staff	Determining the indication and requirements for fixation
	Information, obtaining consent
	Arrangement
	Indication of the time for reviewing the order
	Arrangement of the observation parameters and the observation frequencies during fixation
	Forwarding information to the local court and obtaining the court order
Nursing staff	Applying the fixation
	Responsibility for the proper implementation of the fixation
	Responsibility for the fulfilment of medical orders

Notes and comments

• Any type of restraint (even if it is only temporary) initially constitutes a deprivation of liberty and bodily harm, which can be penalised under criminal law.
• There is no deprivation of liberty if persons objectively lack the ability to move (unconscious persons, infants).
• It is only permissible if, after weighing up all the circumstances and alternatives, it is proportionate and does not exceed the absolutely necessary period of time.
• The correct and appropriate use of restraints, taking into account the legal framework and respect for human dignity, is the aim of every restraint that becomes necessary.
• Any additional risk to the patient through the use of restraint systems such as decubitus ulcers or strangulation must be avoided.
• If the patient is restrained using only the abdominal belt, a continuous side rail must be attached to the bed. (risk of strangulation)

Applicable documents

Literature, legislation

1 Myonghwa Park and Jane Hsiao-Chen Tang, "Changing the practice of physical restraint use in acute care," Journal of Gerontological Nursing 33, no. 2 (February 2007): 9-16.

Basic Law: Article 2 GG - Freedom of the person; Article 104 GG - Legal guarantees in the event of deprivation of liberty

Act on Assistance and Protective Measures for Mental Illness (Länder regulations) § 20 Special safety measures

German Civil Code (BGB)

§ Section 1906 Authorisation of the guardianship court for placement

Criminal Code

§ Section 32 StGB Self-defence

§ Section 34 StGB Justifiable state of emergency

§ 225 maltreatment of persons under protection, § 228 consent, § 239 deprivation of liberty, § 240 coercion

terms is the capacity to consent:

who can weigh up the risks of the intervention against the benefits.

from the age of 14. From then on, until the age of 18, the ability to give consent must be checked.

Legal representatives are

• Parents for minors
• Carer with the task of determining residence or accommodation measures
• Authorised representative, with a written power of attorney in which the accommodation and accommodation-like measures are expressly mentioned.

Attachments

Protocol of a fixation
Fixation material