Postural Supports and Restraints

Health care in Canada is a provincial responsibility as set out in the Canada Health Act (1985); therefore, each province will have its own laws and regulations that are relevant to various aspects of health care. For therapists working in seating and mobility, it is important to understand the laws and regulations that may affect the prescription of wheelchairs, seating, and postural supports for clients in various clinical settings. How are postural supports, such as pelvic positioning belts prescribed for individuals? Are secondary postural supports considered restraints and under what circumstances?

Secondary postural support devices provide postural and positioning support for individuals seated in wheelchairs and can enhance function for individuals by providing postural stability. Such devices include pelvic positioning belts, head supports, chest supports, and medial or lateral thigh supports. Understanding the clinical rationale for a prescription and the laws and regulations which govern the clinical setting can help a therapist to make a determination if a piece of equipment is appropriate for a particular client.

In Ontario, for example, relevant laws include:

• Long-Term Care Homes Act, 2007
• Patient Restraints Minimization Act, 2001
• Health Care Consent Act, 1996
• Substitute Decisions Act, 1992

If you live outside of Ontario, check the provincial laws in the province in which you live for similar laws and regulations.

The Patient Restraints Minimization Act, 2001, which applies to hospitals in Ontario, defines "restrain" as "with respect to a person, to place the person under control by the minimal use of such force, mechanical means or chemicals as is reasonable having regard to the person's physical and mental condition, and "restraint" has a corresponding meaning." A restraint limits movement. (This Act does not apply in psychiatric facilities, where the Mental Health Act applies.)

The Act states that a hospital or facility may not restrain or confine a patient, or use a monitoring device on a patient, unless authorized under certain criteria. These criteria include, amongst others: when it is necessary to prevent serious bodily harm to the patient or another person; when it provides greater freedom or enjoyment of life to the patient; and when the patient or substitute decision-maker has consented to it as part of a treatment plan. There are several duties of hospitals and facilities related to restraints, which include establishing policies, ensuring staff training, monitoring patients and re-assessing in accordance with the regulations, record-keeping and reporting.

Similarly, in long-term care in Ontario, the Long-Term Care Homes Act calls for restraint minimization, with restraints being chemical or physical. A Guide to the Long-Term Care Homes Act, 2007 and Regulation 79/10 states that "A 'physical device' refers to any device that is used to limit or inhibit a resident's movement. 'Limit or inhibit' means that the person or the person's body movement is significantly impeded or his or her freedom of movement has been restricted in a significant way." (Queen's Printer for Ontario, 2011, p. 2-85)

The Act states that if a resident in a long-term care facility is both physically and cognitively able to release him or herself from a physical device, it is not considered restraining the resident. If the resident struggles to remove the device or takes a long time to do it, the device is considered a restraint for that resident.

Ontario's Long-Term Care Homes Act outlines the criteria under which a resident may have a plan of care that includes confinement. All of these conditions must be satisfied:

1. There is a significant risk that the resident or another person would suffer serious bodily harm if the resident were not confined.
2. Alternatives to confining the resident have been considered, and tried where appropriate, but would not be, or have not been, effective to address the risk referred to in paragraph 1.
3. The method and degree of confining are reasonable, in light of the resident's physical and mental condition and personal history, and the method and degree are the least restrictive of the reasonable methods and degrees that would be effective to address the risk referred to in paragraph 1.
4. A physician, registered nurse or other person provided for in the regulations has recommended the confining.
5. The confining of the resident has been consented to by the resident or, if the resident is incapable, by a substitute decision-maker of the resident with authority to give that consent.

If a resident is confined, the resident's condition must be reassessed and the effectiveness of the restraint reevaluated. The confinement must be only for as long as required to address the risk of injury. The least restrictive means of confinement must be used.

The Long-Term Care Homes Act adds another element to consider – the use of a personal assistance services device (PASD). A PASD is a device used to assist a person with a routine activity of living. A PASD may, in fact, limit a person's movement; however, it is the intent for which the device is used that determines whether it is considered a PASD or a restraint, if the resident is unable to release the device independently.

Again, there are criteria under which a PASD may be used and considered as such. The PASD must be included on the resident's plan of care to assist a resident with a routine activity of living. A PASD is not to be used or employed unless alternative means have been trialed or considered and found to be ineffective to assist with routine activity of living. The PASD must be reasonable given the resident's personal history, and be least restrictive. The use of the PASD must be approved by the physician, RN, RPN, registered occupational therapist or registered physiotherapist. The resident, or the resident's substitute decision-maker, must provide consent for the use of the PASD. A PASD should never be used with the intent to restrain an individual.

Let's look at an example; take for instance, a wheelchair tray. If the intent of placing a tray on a wheelchair is to limit movement and prevent an individual from arising from the wheelchair to prevent injury, the tray is considered a restraint. If the same individual is unable to remove the tray independently, however, the intended use of the tray is to provide a surface to assist with routine activity of living, such as facilitating eating a meal placed on the tray – and as long as the tray is removed following the activity of living – the tray is considered a PASD. (Queen's Printer for Ontario, 2011.)

Summary

The issue of restraints versus function versus postural supports is a large one! This month, Clinical Corner began to address the issue of restraints versus postural supports and personal assistance services devices. Future Clinical Corner articles will address issues such as how to minimize the use of devices that could be considered restraints on wheelchairs and when do we consider the effect of the device on an individual.

References

1. Canada Health Act, Revised Statutes of Canada (1985, c. C-6). Retrieved from http://laws-lois.justice.gc.ca/eng/acts/c-6/
2. Health Care Consent Act, 1996, Statutes of Ontario (1996, c. 2, Sched. A). Retrieved from https://www.ontario.ca
3. Long-Term Care Homes Act, Statutes of Ontario (2007, c. 8). Retrieved from https://www.ontario.ca/laws/statute/07l08#BK38
4. Patient Restraints Minimization Act, 2001, Statutes of Ontario (2001, c. 16). Retrieved from https://www.ontario.ca/laws/statute/01p16
5. Queen’s Printer for Ontario, 2011. A Guide to the Long-Term Care Homes Act, 2007 and Regulation 79/10. Retrieved from http://health.gov.on.ca
6. RESNA. (2013). RESNA Position on the Application of Wheelchairs, Seating Systems, and Secondary Supports for Positioning vs. Restraint. Retrieved from https://www.resna.org
7. Substitute Decisions Act, 1992, Statues of Ontario (1992, c. 30). Retrieved from https://www.ontario.ca