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Policy needed when using officers for medical restraint purposes

Healthcare Security and Emergency Management, April 28, 2003

HCPro Online Subscriptions Policy needed when using officers for medical restraint purposes

A nurse or doctor trying to calm an agitated patient can resort to calling in a member of the security team, according to the intent statement of TX.7.1.4 and TX.7.1.4.1 of the Joint Commission on Accreditation of Healthcare Organizations’ Comprehensive Accreditation Manual for Hospitals.

While nonphysical restraint techniques are preferable, security can employ force “only when nonphysical interventions are ineffective or not viable, and when there is a risk of a patient physically harming himself or herself, staff, and others,” the manual says.

But hospital security officers who restrain patients under clinical care face a different set of rules than when restraining visitors or intruders for security reasons, says Fred Roll, MA, CHPA-F, CPP, president of Roll Enterprises, Inc., a Denver-based health care security and training firm.

“Whatever the policy is for your hospital, it should come from patient care officials, not the security department,” he says.

Elements of the policy
Even though you don’t write the policy, review it to make sure it provides guidance for security officers called to assist in a restraint procedure.

“The policy must break down what restraint actually involves and how to assess the situation as it progresses,” says Steve MacArthur, a safety and security consultant with The Greeley Company in Marblehead, MA. The Greeley Company is a division of HCPro, which publishes HSEM.

The restraint policy developed by patient caregivers must include the following:

Training standards for officers. For example, officers must know that physical restraint is a “last resort” option and that caregivers are ultimately in charge of the ongoing assessment and management of the episode.

Observation techniques for different situations. Officers are not involved in the assessment phase of the restraint other than identifying behaviors where an intervention is necessary. These behaviors include a patient muttering or walking around in an agitated state.

Specific competencies, including the appropriate steps and actions to take during a restraint episode. Officers also must know how to take directions from caregivers, “safe hold” techniques used to restrain a patient, and how to safely take a patient down without hurting the patient or themselves.

Evaluating the physical environment of the restraint area is also important in preventing injury to those involved in the restraint. For example, the officer must notice whether sharp objects are within the patient’s reach or whether there are other items the patient can use as weapons, such as a chair or small table.

Deescalation techniques, such as proper show-of-force, talk-down methods, and avoiding a worsened situation when the goal is deescalation.

“If you bring in a uniformed officer and the patient reacts in a negative way, the caregiver must make the call to remove the officer and try a different technique,” Roll says.

In other cases, a quick change of scenery is all that is necessary to calm a patient. “Sometimes, a patient just needs to go outside for a breath of fresh air,” says MacArthur. Other ideas include closing or opening doors or lowering or raising light levels within the room.

Other general guidelines
In addition to the specific elements mentioned above, the following common rules apply to all personnel involved in restraint incidents.

The number of people on the restraint team—A general rule is one person per limb, one person for the head, and a clinician to supervise.

However, not all situations will require that many people. For example, restraining a nine-year-old male is going to be much different than restraining a 40-year-old male.

“The clinician in charge of the patient and the lead security person must know how to make the call on how many people are necessary,” MacArthur says.

The use and recognition of excessive force—All restraint personnel must realize when they use too much force. Injuring a patient during a restraint episode unnecessarily harms the patient and subjects the hospital to legal liability and unwanted bad publicity.

Tip: Train officers to recognize the signs of a restrained patient in pain. Body language as well as verbal moans and groans are good indicators.

Tip: Exercise caution when deciding to use handcuffs in a medical restraint situation, Roll says. Handcuffs are a legal restraint and normally used only after an arrest. Make sure the caregiver understands this if he or she asks an officer to use them.

“If physical restraint by an officer is the last resort, then the use of handcuffs is the ‘last resort’ of the last resort,” MacArthur says.

What will surveyors look for?
Proof of certain competencies is critical, especially when survey time rolls around. A high number of episodes in your hospital can pique a surveyor’s interest in the training levels of officers, MacArthur says.

“If the security team is used often in behavioral health management, surveyors can ask to see the human resources file of officers to see if they are trained properly,” he says.

Tip: Contracted security teams require the same training as officers who work directly for the hospital, whether the hospital or the contractor provides it. Make sure you document competency training regardless of who conducts the training session.



Managing aggressive behavior is the key to successful outcomes with unruly patients

A nurse or security officer dealing with a disgruntled patient sitting for hours in the emergency room can use several methods to help calm the patient.

“A good passive technique is to reflect a person’s emotion back to him or her,” says Roland Oullette, president and founder of R.E.B. Training International, Inc., a training organization specializing in MOAB,© or the management of aggressive behavior.

For example, in the above situation, the officer or clinical caregiver acknowledges the patient’s frustration and assures the patient that the officer understands how he or she feels.

“Showing empathy for a patient’s situation is a good way to get the patient to talk,” Oullette says. “If the patient is talking, there is less of a chance he or she will turn to aggressive behavior.”

Solid results in the field
When security officers at Newton-Wellesley Hospital, in Newton, MA, began using this method in 1999, physical interventions dropped almost immediately, says Evelyn Meserve, CHPS, director of security, safety, and parking at the hospital.

“This training gives officers the ability to identify an escalating situation and the techniques to step in and take action before things get bad,” Meserve says.

All 18 officers on the hospital’s security team undergo the two-day training program and refresh their training every two years.

Nonsecurity employees also benefit
Security officers aren’t the only employees who take advantage of the instruction. Meserve offers a one-day training program to employees throughout the hospital. Staff from human resources, registration, finance, psychiatry, and the emergency room have all learned from the program, taking MOAB© techniques back to their desks.

Editor’s note: For more information on MOAB© training techniques, go to www.rebtraining.com.