Quality statement 3: Physical health during and after manual restraint

Quality statement

People with a mental health problem who are manually restrained have their physical health monitored during and after restraint.

Rationale

Restrictive interventions are most likely to be used in inpatient psychiatric settings and should only be used if other preventive strategies have failed. They should be used for no longer than necessary and de-escalation should continuously be attempted. Monitoring physical health during and after manual restraint is paramount for the person's safety. There is a risk of death from obstructing airways during manual restraint, but harm can also occur after the event. People with mental health problems are at increased risk of coronary heart disease, cerebrovascular disease, diabetes, epilepsy and respiratory disease; all of which can be exacerbated by the effects of manual restraint.

Quality measures

Structure

Evidence of local arrangements to ensure that people with a mental health problem who are manually restrained have their physical health monitored during and after manual restraint.

Data source: Local data collection, for example, service protocol on physical restraint.

Process

a) Proportion of incidents involving manual restraint of a person with a mental health problem in which physical health was monitored during the restraint.

Numerator – the number in the denominator in which physical health was monitored during the restraint.

Denominator – the number of incidents involving manual restraint of a person with a mental health problem.

Data source: Local data collection, for example, patient safety incident reports.

b) Proportion of incidents involving manual restraint of a person with a mental health problem in which physical health was monitored after manual restraint.

Numerator – the number in the denominator in which physical health was monitored after manual restraint.

Denominator – the number of incidents involving manual restraint of a person with a mental health problem.

Data source: Local data collection, such as patient safety incident reports.

Outcome

Proportion of incidents involving manual restraint of a person with a mental health problem where harm to the person occurred.

Data source: Local data collection, such as organisation patient safety incident reports.

What the quality statement means for different audiences

Service providers (such as mental health trusts, secondary care services, forensic mental healthcare services) ensure that systems are in place for people with a mental health problem who are manually restrained to have their physical health monitored during and after manual restraint until there are no further concerns. They should also ensure that the healthcare practitioners who may be required to physically restrain service users are trained in the safe application of physical interventions and monitoring the physical health of people during and after restraint.

Healthcare practitioners (such as mental health nurses and staff working in forensic mental healthcare services) use manual restraint only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive. Healthcare practitioners who may be required to physically restrain service users are trained in the safe application of physical interventions and monitoring of the physical health of people during and after restraint. If they do manually restrain a person, they monitor the person's physical health during and after restraint until there are no further concerns.

Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission keep the person safe by monitoring their physical health during and after manual restraint until there are no further concerns. They also ensure that they commission services in which manual restraint is used only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive.

People with a mental health problem who are being violent or aggressive are only manually restrained (physically held so that they can't hurt themselves or others) if all other attempts to stop the violence or aggression have failed. If manual restraint is used, the person has checks during and after the restraint to make sure that they stay safe and well.

Source guidance

Violence and aggression: short-term management in mental health, health and community settings (2015) NICE guideline NG10, recommendations 1.4.32 and 1.4.33

Definitions of terms used in this quality statement

Manually restrained

Use of a skilled, hands-on method of physical restraint by trained healthcare professionals to prevent service users from harming themselves, endangering others or compromising the therapeutic environment. Its purpose is to safely immobilise the service user.

[NICE's guideline on violence and aggression]

Physical health monitored during manual restraint

Monitoring of vital signs such as pulse (rate), respiration (respiratory rate), complexion (with special attention to pallor or discolouration) and level of consciousness.

[Expert consensus]

Physical health monitored after manual restraint

Monitoring physiological parameters could, as a minimum, be in line with the Royal College of Physicians' National Early Warning Score (NEWS), which measures:

  • respiratory rate

  • oxygen saturations

  • temperature

  • systolic blood pressure

  • pulse rate

  • level of consciousness.

[Expert consensus]