August 31, 2007
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.