Standards › Standard 1 › Policies
Policy · CLN-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.4
At a glance
- Restraint and seclusion are used only under this protocol and only as a last resort.
- Each use is time-limited, monitored and documented.
- A less restrictive option is tried first and recorded.
- No restraint is used for staff convenience.
- Stop and get help straight away if: restraint or seclusion is used with no order, no monitoring or past its time limit.
1. Purpose
To protect the patient from harm from restraint and seclusion, and to keep their use to the minimum (1.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Restraint and seclusion can cause injury, distress and death, and they are often used for the convenience of staff. A protocol that treats them as a last resort, time-limited and monitored, protects the patient.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Owns the protocol and reviews each use each month | Management |
| Responsible clinician | Orders and reviews each use | Doctor |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Last resort.
- Record the less restrictive options tried first.
- Use restraint only when the risk of harm is immediate.
Key point: Last resort, recorded.
Step 2. Order and time-limit.
- The clinician orders the restraint for a set time.
- Record the start and the review time (CLN-FRM-004).
Key point: Every use has a time limit.
Step 3. Monitor.
- Check the patient at the set interval, and release as soon as the risk passes.
Key point: Monitored and released.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Uses with order and time limit recorded | 100% | Monthly | Clinical director | Escalate to chief executive |
| Uses reviewed within the set time | 100% | Monthly | Clinical director | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| CLN-FRM-004 | Restraint and seclusion record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Slip, Trip & Fall Prevention (FALL-01)
- Patient Identification, Informed Consent and Patient Rights (T-07)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
Planned course: Hospital falls prevention, based on the falls guideline. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)