Regions Hospital Emergency Medical Services
Year 2000 EMS Guidelines

Patient Restraint

INTRODUCTION:

Patients have the right to refuse treatment and/or transport if they are of legal age and are competent. Competence is defined as the capacity or ability to understand the nature and effects of one’s acts or decisions. A person is considered to be competent until proven otherwise. There are situations, however, in which the interests of the general public outweigh an individual’s right to liberty:

  1. The individual is threatening self-harm or suicide.
  2. The individual presents a threat to the community because of a contagious disease or other physical dangerousness.
  3. The individual presents a specific threat to innocent third parties.

Certain medical, traumatic and psychological conditions can cause incompetence and behavior that interferes with the ability of EMS personnel to care for the patient, or that threatens the physical well being and safety of the patient or others. These conditions include, but are not limited to: drugs, metabolic disturbances, central nervous system injury or insult, infections, hypo/hypertension, hypo/hyperthermia, hypoxia, psychological disorders, poisons and toxins. Minnesota law (609.06) authorizes the use of "reasonable force upon or toward the person of another without the other’s consent when the following circumstances exist or the actor reasonably believes them to exist: when used to restrain a mentally ill or mentally defective person from self injury or injury to another or when used by one with authority to do so to compel compliance with reasonable requirements for the person’s control, conduct or treatment." If an EMS provider feels uncomfortable with any patient, even when they have not been actively combative, the provider has the right and duty to provide the patient and others with the security of patient restraint. Verbal threats are a legitimate reason for restraint. The following is a guideline for the use of restraints in the prehospital care setting. It is not intended to dictate police action that may be necessary to subdue someone.

INDICATIONS:

  1. Behavior or threats that create or imply a danger to the patient or others
  2. Safe and controlled access for medical procedures
  3. Change in behavior that results from improvement or deterioration of patient condition, i.e. hypoglycemia, overdose, intubation
  4. Involuntary evaluation or treatment of incompetent combative patients

PRECAUTIONS:

  1. Be aware of items at the scene or medical equipment that may become a weapon.
  2. Assure that the scene is safe before approaching the patient.
  3. Patients that are actively seizing should never be restrained.
  4. The patient should be restrained in the prone position only as a last resort and only with continuous monitoring. This position may interfere with the patient’s ability to breathe.
  5. Restraining a patient’s hands and feet together behind the patient (hog-tying) is not allowed. The only exception is a prisoner or suspect in the custody of law enforcement or prison authorities.

GENERAL RESTRAINT PROCEDURES:

  1. Make every attempt not to aggravate or worsen pre-existing injuries or medical conditions.
  2. Attempt first to control the patient with verbal counseling.
  3. The least restrictive means of control should be employed.
  4. Only "reasonable force" may be used when applying physical control. This is generally defined as the use of force equal to, or minimally greater than, the amount of force being exerted by the resisting patient.
  5. Restraints should not interfere with the assessment or treatment of the patient’s ABCs.
  6. The decision to restrain a patient should usually be made prior to transport.
  7. Do not remove restraints once applied unless the patient seizes. If circulation becomes compromised, the benefit of removing the restraints must be weighed against crew safety.
  8. EMS does not apply handcuffs or hard plastic ties (flex cuffs), but if already in place and circulation is adequate, may be left on. Handcuffs must be double locked to prevent inadvertent tightening, and should allow one little finger to fit between the handcuff and the wrist. Assure that a key is available during transport.
  9. Restraints should be individualized and afford as much dignity to the patient as the situation allows. Attempt to accommodate patient comfort or special needs whenever possible.
  10. Ensure that enough help is available to insure patient and provider safety during the restraint process. Optimally, five people should be available to apply full body restraint (one for each limb and one for restraint application). Communicate the restraint plan to all help.
  11. Assure that the patient’s clothing and personal belongings have been searched for weapons prior to transport.
  12. An emergency transport hold must be obtained and completed whenever a patient is transported against their will for the above mentioned reasons.

ADVANCED LIFE SUPPORT CARE:

  1. For combative behavior that is compromising the ability to provide patient care, consult with medical control for sedation medication orders.

PEDIATRIC CONSIDERATIONS:

  1. Always attempt to involve parents when restraining children.

PREGNANCY CONSIDERATIONS:

  1. Pregnant women should be restrained in a semi-reclining or left lateral recumbent position.

DOCUMENTATION REQUIREMENTS:

  1. An emergency existed
  2. The need for treatment was explained to the patient (regardless of competence)
  3. The patient refused treatment or was unable to consent to treatment
  4. Evidence of the patient’s incompetence to refuse treatment
  5. Failures of less restrictive methods of control (such as verbal counsel)
  6. The restraints were used for the safety of the patient or others
  7. The reasons for restraint were explained to the patient (regardless of competence)
  8. The type/method of restraint used and which limbs were restrained
  9. Injuries that occur during the restraint procedure
  10. Which agency placed the restraints
  11. Continuously assess CMS (distal to the restraints) and the patient’s ability to breathe

SPECIAL NOTES:

  1. The use of SaO2 monitoring may be useful in assessing distal circulation, but does not take the place of CMS checks.

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©2000 Regions Hospital Emergency Medical Services - All Rights Reserved
Last Update: October, 2000