CLINICAL GUIDELINE

FOR THE USE OF HAND CONTROL MITTENS IN ADULT PATIENTS

Version / 1
Name of responsible (ratifying) committee / Nursing and Midwifery Committee
Date ratified / 02 March 2016
Document Manager (job title) / Consultant Nurse, Stroke Service
Date issued / 22 July 2016
Review date / 21 July 2018
Electronic location / Clinical Guidelines
Related Procedural Documents / Mental Capacity Act 2005: Practice and Procedures Policy
Enteral Feeding guideline
Restriction and Restraint policy
Key Words (to aid with searching) / Hand Control, Mittens, Preventing harm

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
1 / 02/03/16 / New guideline to replace policy of the same name (version 1 issued 27.11.2008) / L Field

CONTENTS

1. QUICK REFERENCE GUIDE 3

2 PURPOSE 4

3. SCOPE 4

4. DEFINITIONS 4

5. DUTIES AND RESPONSIBILITIES 4

6. DECISION MAKING PROCESS 5

7. TRAINING REQUIREMENTS 6

8. REFERENCES 6

9. EQUALITY IMPACT STATEMENT 7

10. APPENDIX 1- ASSESSMENT TOOL 8

11. APPENDIX 2- CARE PLAN 9

12. APPENDIX 3- INFORMATION SHEET ON USE OF HAND MITTENS 10

13. APPENDIX 4- INFORMATION FOR RELATIVES 12

14. APPENDIX 5- PROCUREMENT INFORMATION 13

QUICK REFERENCE GUIDE

This guideline must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this guideline.

  • The main purposes of hand control mittens are to facilitate the provision of essential treatments to patient who remove tubes/lines.
  • The recommended mittens ONLY are to be used. Alternatives such as bandaging MUST NOT be used.
  • The mittens are supplied with restraint straps that are designed to fix the hand to a bed rail. THESE MUST BE DISCARDED AS SOON AS THE PACKET IS OPENED AND UNDER NO CIRCUMSTANCES ARE THEY TO BE USED
  • Hand control mittens are used following careful assessment with patients who have removed essential tubes/lines, outlined in appendix 1.

INTRODUCTION
Patients in the acute phase of their illness frequently become restless and inadvertently remove feeding tubes and other essential access lines. There are various treatment options which include forms of restraint (see NG retaining device guideline) and, as such, are ethically sensitive and fraught with emotion for the patient, their family and for staff. Such tensions have to be managed alongside the need to provide optimal treatment.
The use of hand control mittens is recognised as a form of restraint. This policy and supporting guideline have been written to enable practitioners to follow an agreed decision-making, assessment and procedure process.MDT involvement in decision-making is key.
Staff are required to consider the patient’s capacity to be involved in the decision-making process and where at all possible gain the patient’s consent or alternatively, the assent of the nominated next of kin.
Consideration of an individual patient’s physical condition, cognitive ability, personal preference and family’s views should be undertaken to ensure all possible avenues are fully explored when deciding if mittens are in the patient’s best interests or if less restrictive options would be more appropriate.

1.PURPOSE

This clinical guideline describes how Portsmouth Hospitals NHS Trust (PHT) will manage the use of hand control mittens in adult patients

2.SCOPE

This guideline applies to all health care practitioners involved in the prescription and/or use of hand control mittens.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

3.DEFINITIONS

Hand control mittens are a specific product (appendix 1) designed to restrict the movement of one or both hands and used with patients who have removed essential lines/tubes. The Trust does NOT condone the use of bandaging to restrict hand movement in patients who remove tubes/lines.

4.DUTIES AND RESPONSIBILITIES

  • Portsmouth Hospitals NHS Trust board is responsible for providing optimal treatment for patients and ensuring appropriate training is available to those involved in the selection, fitting and use of hand control mittens.
  • PHT Hand control mittens project team in partnership with the Nursing and Midwifery Advisory Council is responsible for the production, maintenance and review of policies and guidelines related to the use hand control mittens
  • Clinical managers are responsible for ensuring the implementation of this policy and associated guideline and monitoring compliance.
  • The decision for use of hand control mittens will only be undertaken by a person able to demonstrate an understanding of the risks and benefits associated with their use.

For advice and support consider liaising with- Clinical Nutrition Nurse Specialists, Infection Prevention and Control, Tissue Viability, Chaplaincy, Safeguarding Adults, Linen Room.

Policy to be read in conjunction with;

  • Mental Capacity Act 2005 Practice and Procedures Policy
  • DOH April 2004 Positive and Proactive Care reducing the need for restrictive interventions. Restriction and Restraint Policy in Adult Care

5.DECISION MAKING PROCESS FOR APPLYING HAND MITTENS

Action / Rationale
Hand control mittens are only considered if patients have removed essential lines or tubes. There is no definitive number of incidences which will trigger assessment and the decision about need for assessment should be based upon clinical judgment and best interests of the patient. / This is an ethically sensitive decision and has to be undertaken following a clinical assessment process (see appendix 1)
Where Enteral tubes are required, consider for referral to Nutrition Team for Nasal Bridle should also be given. / Nasal bridle, in some circumstances may be considered the least restrictive option
Patients and their families or carers should be involved in the decision making process and provided with information as appropriate / The provision of advice and support for individuals and families is an essential step in the decision-making process.
A review of use of mittens must be undertaken if:
a) the patient’s condition changes or
b) within 24 hours of initial assessment and
c) daily there after / To ensure use remains appropriate and documented – use of care plan Appendix 2.
An individual care plan and timetable for mittens use will be written in consultation with the multi-professional team / To ensure correct positioning of the hand, hand hygiene and ‘off-time’ is clearly identified and followed.
Demonstrate clear decision making process and clear documentation of use, evaluation, continuation or discontinuation.
Frequent checks of the patient will be made, mittens removed to facilitate toileting, meal and drink provision and during visiting if appropriate. / To ensure patients are given time without the mittens.

6. TRAINING REQUIREMENTS

Staff must be able to demonstrate competence prior to use of hand control mittens as well as full understanding of the issues of using least restrictive options to ensure patient dignity at all times.

Clinical managers/ward sisters/charge nurses are responsible for ensuring assessment tool and care plans are used for every occasion that patients require hand control mittens.

Work based training will be facilitated by each specialty with support from specialty based practice development teams.

7. REFERENCES AND ASSOCIATED DOCUMENTATION

Procedural documents must be evidence-based and referenced, wherever possible. References could include any associated national policies, standards, guidelines, Acts of Parliaments.

References and associated documents must be checked when reviewing an existing procedural document, to ensure they are still current and relevant.

The following referencing format must be used:

An Organisation-Wide Policy for the Development and Management of Procedural Documents: NHSLA, May 2007.

1. Norton B. et al. 1996. A randomised prospective comparison of percutaneousendoscopic gastrostomy and nasogastric tube feeding after acute dysphagicstroke

British Medical Journal; 312:13-16.

2. Eisenberg P, Spies M, Metheny N., 1987. Characteristics of patients who remove their nasal feeding tubes. Clinical Nurse Specialist; 1(3):94-98.

3. Meer J., 1987. Inadvertent dislodgement of nasoenteral feeding tubes: incidence and prevention. Journal of Parenteral and Enteral Nutrition; 11(2):187-189.

4. Ciocon J.O. et al., 1988. Tube feeding elderly patients: Indications, benefits and

complications. Archives of Internal Medicine; 148:429-433.

5. National Collaborating Centre for Acute Care, 2006. Nutrition Support in Adults, oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre forAcute Care, London

6. Kee K et al, 2006. Evaluating the use of hand control mittens in post stroke patients

who do not tolerate naso-gastric feeding. Poster presentation UK Stroke Forum

Conference, Harrogate.

7. Mahoney C. et al 2006. The acceptability of interventions used to maintain naso-gastric feeding in acute stroke patients. Poster presentation UK Stroke Forum Conference, Harrogate

8. Bray K. et al, 2004. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nursing in Critical care;9(5):199-212

9. Royal College of Nursing, 2004. Restraint revisited –rights, risks and responsibilities. RCN, London

10. Royal College of Nursing, 2008. “Let’s talk about restraint” Rights, risks and responsibility. RCN, London

11. A thesis by C Mahoney (2009) An Investigation into Maintaining Naso-gastric Feeding for Stroke Patients: A Mixed Methods Design

12. Positive & Proactive Care: reducing the need for restrictive interventions. DoH. April 2014.

13. Mahoney C. et al 2015. Nasogastric feeding for stroke patients: practice and education. British Journal of Nursing,26 March 2015, vol./is24/6(319-325)

14. Horsburgh D. et al 2008. A necessary evil? Interventions to prevent nasogastric tube-tugging after stroke. British Journal of Neuroscience Nursing,01 May 2008,vol./is.4/5(230-234)

15. Beavan J.R,; Wells R. 2013. Views of health professionals on methods to reduce removal of nasogastric tubes after acute stroke. Cerebrovascular Diseases, May 2013, vol,/is.35/(706), 1015-9770.

8. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This guideline has been assessed accordingly.

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

Efficiency

This guideline should be read and implemented with the Trust Values in mind at all times.

APPENDIX 1: HAND CONTROL MITTENS ASSESSMENT TOOL/RECORD

Name / Date of Birth
Hospital Number / Ward
PATIENT / YES / NO / Please Specify
Supporting Information and Actions
1. Has the patient removed essential tubes/lines?
2. Have other methods been tried?
(I.e. distraction techniques, Have all underlying causes of agitation e.g. constipation, urinary retention, pain, been addressed? Has the patient any cultural, dietary or religious objection to either the use of mittens or the proposed enteral feeds? Chaplaincy support may help reassure patients and families who have concerns about the proposed use of enteral feeding and the use of mittens. All feeds are Halal and Kosher / Identify type(s) of technique to be used:
3. Does the patient have capacity to consent to the use of mittens?
4. Has the patient given informed consent?
5. If no to 3. Patient should have mental capacity assessment documented in the notes. Does the patient have a nominated next of kin who can provide assent?
6. Has the nominated next of kin had reasons for the use of mittens explained and had the opportunity to see and try mittens before they are fitted?
7. If the patient has no next of kin, is there documented evidence that the clinical team agree that the use of mittens is in the patient’s best interests? This must be reassessed at least daily and fully documented on care plan
Completed by / Date / Name/ Signature/ Designation

APPENDIX 2: HAND CONTROL MITTENS CARE PLAN

CARE PLAN FOR USE OF HAND CONTROL MITTENS

  1. Assessment form for use of mittens completed and mittens recommended Date Sign

  1. Communication with patient and/or NOK Date Sign

Date
Every shift / E / L / N / E / L / N / E / L / N / E / L / N / E / L / N / E / L / N / E / L / N
Check mittens for contamination and replace as required
Remove mittens to check skin integrity.
The patient has had some “off time” during visiting/meals/personal hygiene as appropriate.
The hand has been washed and dried daily.
Mittens must be discontinued if-
1. The patient becomes more agitated or distressed with mittens on.
2. Consent is withdrawn by patient or use of mittens is no longer in patient’s best interest.
3. Skin deterioration is noted
4. The patient’s condition changes and mittens are no longer required

APPENDIX 3: CLINICAL GUIDELINES FOR THE USE OF HAND CONTROL MITTENS

1. What are hand control mittens?

  • The main purposes of hand control mittens are to facilitate the provision of essential treatments to patient who remove tubes/lines.
  • The recommended mittens ONLY are to be used. Alternatives such as bandaging MUST NOT be used.
  • The mittens are supplied with restraint straps that are designed to fix the hand to a bed rail. THESE MUST BE DISCARDED AS SOON AS THE PACKET IS OPENED AND UNDER NO CIRCUMSTANCES ARE THEY TO BE USED

2. When are they used?

  • Hand control mittens are used following careful assessment with patients who have removed essential tubes/lines, outlined in appendix 2

The following people may be considered for the use of hand control mittens:

  • Acutely ill patients
  • Disorientated patients
  • Restless and agitated patients
  • Confused patients for clinical or functional reasons

3. Guidance for wearing and monitoring of mittens use

  • Mittens are supplied to fit either hand If the patient has neurological or musculo-skeletal impairments of the hand or wrist their use must be discussed with the medical and therapy teams to ensure appropriateness of use and agree timetable for wearing of mittens
  • Mittens must be used with extra care if a cannula is sited in the hand or wrist
  • Times when mittens are taken off are timetabled, for example around visiting times, meal times etc.
  • The hand(s) must be washed, dried carefully and mittens reapplied at least three times per day to ensure skin is visualised and any changes, potential problem areas recorded, treated appropriately and handed over.
  • Mitten use may be discontinued at anytime by any practitioner if:-

The patient becomes more agitated distressed when wearing the mittens

Consent/assent is withdrawn

Deterioration is skin condition is noted

Patient’s condition changes and mittens are no longer required

4. Control of Infection

  • Mittens must be checked frequently and at least daily for contamination
  • Clean mittens are supplied if contamination is found
  • The mittens must be laundered between patient uses following manufacturer’s guidelines and according to infection control guidelines
  • Each unit/area is responsible for purchasing (see appendix 5 for procurement information) , and sending to the laundry service in a brown plastic bag supplied by the linen Queen Alexandra Hospitals.
  • It is recommended that a record of number and date mitten laundry triplicate tickets must be completed and top 2 copies sent with mittens for tracking purposes.
  • Mittens are checked for damage after laundering for tears, damaged stitching etc. and taken out of use and replaced if found to be faulty.

APPENDIX 4: INFORMATION SHEET FOR RELATIVES

Information sheet for relatives on the use of hand control mittens

Seeing a relative in hospital can be very frightening. Patients sometimes seem to have many tubes and attachments, which may not always make sense to you. This leaflet has been written to explain why hand control mittens are sometimes used.

Tubes may be placed to provide fluid, medications or feed to a patient. Hand control mittens are only considered for use when patients are unable to keep in these tubes. This can be because of restlessness or confusion and the patient may not be aware that they need to keep these tubes in. They are often removed unintentionally and can be fairly easy to dislodge.

The nursing staff will have tried other methods to try and keep these tubes in place, but sometimes we have to use hand mittens for a short period of time to ensure that patients receive the treatment they need.

These mittens are only used on these occasions and the need for them has to be reviewed daily. There is a guideline for staff to follow to ensure that they are used appropriately.

Sometimes the team caring for your relative will have to make a clinical decision to use the mittens in the best interests of the patient. Where possible, we will always involve the patient in that decision, but sometimes they are not able to give their consent. Ideally you will have been shown the mittens before they are used, but on occasion we may have to put them on before you visit in order to ensure your relative receives the treatments needed to aid their recovery. It is also distressing for patients’ to have tubes put in over and over again and using the mittens can reduce this.

If the mittens are used, it is important that they are removed regularly to check their skin and to give hand hygiene. This may be timed around your visits so that they can be removed when you are visiting.

If you have any concerns about the mittens being used or would like to discuss it, then please speak to the nurse in charge of the ward.

Thank you.

APPENDIX 5: PROCUREMENT INFORMATION

Available for order on the i-proc catalogue under the description section 'Upper Arm Appliances Lower Arm Appliances Full Arm Appliances Slings Splints & Harnesses'