Reducing Risks of Restraints

Although physical intervention is considered by most in healthcare security to be the method of last resort, sometimes hospital employees are left with no alternative but to use this approach on someone who becomes a danger to themselves or others. This last part of our series on managing abusive individuals discusses how hospital personnel can appropriately use restraints.

by Judith Schubert  

Parts I and II of this three-part series dealt with the importance of staff training in strategies for preventing, de-escalating and safely responding to disruptive behavior or assaults. Data clearly demonstrate there is a decrease in the use of physical restraints when facilities implement such training programs. In most healthcare and mental health facilities, however, there will still be times when people lose control to such a degree that the use of restraints is deemed necessary.
 

To protect the health and safety of both staff and patients, various accrediting and regulatory agencies have established standards relating to the use of restraints in healthcare and mental health settings. It is also important to be familiar with state regulations related to restraints, as these vary from state to state. Some states ban certain types of interventions altogether. Others have time limits governing use of restraint.
 

One key element that virtually all regulatory, statutory and accrediting bodies have in common is the emphasis on staff training in de-escalation techniques that can prevent the need for physical interventions. Equally important is staff training in the appropriate use of restraints.
 

Know Which Interventions to Use and When
Several key points should be included in all staff training on the topic of physical techniques: When to restrain; when not to restrain; how to use safer restraint techniques; and how to minimize risks associated with the use of restraints. Awareness of restraint-related positional asphyxia and how to avoid positioning that could restrict breathing is of critical importance as this can cause death.
 

Through both policy and training, staff members should know there are limited circumstances in which physical interventions are an appropriate response to acting-out. The following criteria should always be met:

• The person is an immediate danger to self or others
• Other ways to manage the person's dangerous behavior have failed
• Staff members are trained in the proper use of restraints
   

Physical restraints should never be used as a form of punishment, for the convenience of staff, or as a means to inflict pain. Instead, they should be seen as a temporary, emergency measure to take control of another person only until that person has regained control of his own behavior and is no longer a danger to others.
 

Because all physical intervention carries some risk of injury — to staff and to the person being restrained — such interventions should be used only when it is more dangerous not to intervene. Furthermore, there are several key steps facilities and staff can take to reduce the risks of restraint:
 

1. Train staff members in safer ways of restraining, and provide opportunities to practice those skills on a regular basis: Physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are well-versed in any applicable regulations, laws or policies pertaining to restraint use in their facilities.
   
   Furthermore, physical restraint should be recognized as an emergency response procedure — not so different from CPR or first aid. As with any emergency response procedure, staff members need to rehearse these skills on a regular basis.
    
2. Choose safer restraint techniques: Some restraints are more dangerous than others. In 1998, the Hartford Courant published a Pulitzer Prize-winning series of articles detailing 142 restraint-related deaths throughout the United States. Many of these deaths were the result of positional asphyxia, which occurs when a person being restrained is placed in a position in which he cannot breathe properly and is unable to take in enough oxygen.
   
   Especially dangerous positions include facedown floor restraints or any position in which a person is bent over and held in a way that makes breathing difficult.
   
   Staff members must be especially careful not to use their own bodies in a way that restricts someone's ability to breathe, such as sitting or lying across a person's back or stomach. When a person is lying face down, even pressure to the arms and legs can interfere with a person's ability to move his or her chest or abdomen in order to breathe effectively.
    
3. Be aware of risk factors that increase the danger of restraints: Some people are more at risk for restraint-related positional asphyxia than others. Risk factors include obesity; extreme physical exertion or struggling prior to, or during a restraint; heart disease; breathing problems, such as asthma or emphysema; and use of alcohol or drugs.
    
4. Monitor the person being restrained: Staff must be trained to watch for signs of distress from the individual being restrained. This can best be accomplished by assigning a staff member who is not directly involved in performing the restraint to monitor for signs of trouble, such as breathing difficulties. It's important to note, however, that there are documented cases of individuals who have gone from a state of no apparent distress to death in a matter of moments. Monitoring the person's status is not a substitute for avoiding high­risk positions that interfere with breathing.
    
5. Debrief: When restraints are deemed necessary, a debriefing process should follow so that staff can take a closer look at the circumstances before and during the restraint. What triggered the event? Could it have been prevented? Were any warning signs missed? Is there anything that could have been handled differently? The purpose of the debriefing is not to point fingers or place blame but to creatively consider alternatives that might prevent the next restraint.
    
6. Use Physical Techniques Sparingly on Abusive Individuals: Following these guidelines will reduce the risk of injury for everyone involved in a situation requiring the use of restraints. But the very best way to eliminate injuries due to restraint—both for staff and for the person being restrained—is to eliminate the need to restrain in the first place. Remember, the safest restraint is the one that doesn't happen.

National Regulatory and Accrediting Organizations: Key Elements of Restraint-Related Standards

Centers for Medicare & Medicaid Services (CMS)

• Requires training for hospital employees who may work with violent patients. Training must include:
  • Identifying events or factors that may trigger a need for emergency intervention
  • Using nonphysical intervention skills
  • Choosing least restrictive intervention based on patient's condition or status
  • Safe application of all types of restraints used at a hospital
  • How to recognize and respond to signs of distress
• Requires staff to demonstrate competency in application of restraints and in caring for patients in restraint
• Requires training to be ongoing. Training must be part of initial orientation and on a periodic basis thereafter

Joint Commission on Accreditation of Health Care Organizations (JCAHO)

• Differentiates restraint used for an aggressive patient for behavioral reasons and restraint used for medical purposes to prevent substantial harm to patient
• Staff using restraint to manage assaultive or abusive behavior must be trained in the following areas:
  • Identifying underlying causes of threatening behavior
  • Understanding possible links between medical conditions and aggression
  • Understanding how staff behaviors can affect patient behaviors and vice versa
  • Use of de-escalation, mediation and other nonphysical techniques
  • Recognizing signs of physical distress in persons being restrained or secluded

Occupational Safety and Health Administration (OSHA)

• Recommends that employees receive at least annual training in workplace violence prevention
• Encourages hospitals to make a concentrated effort to reduce identified risks factors. These could include long waits; presence of gang members, people with substance abuse problems and distraught family members; and low staffing levels during times of increased activity
   

Judith Schubert is president of the Crisis Prevention Institute (CPI).

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• Read Part 1— Responding to Abusive Patient Behavior: 3 Pitfalls to Avoid When Training Staff
   
• Read Part 2—Responding to Abusive Patient Behavior: 10 Ways to Defuse Incidents
  

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