ABSTRACT: According to an Urban Emergency Department study, nearly half (50%) of all patients requiring involuntary treatment and restraint while in an Emergency Department are brought to the hospital by ambulance. Despite this fact, most Prehospital (and Inhospital!) care providers receive very little – if ANY – training in techniques for safe and effective restraint application.

Even more unfortunate than this universal lack of training is the fact that hardly ANY emergency care providers have PROTOCOLS that provide adequate direction for realistic restraint decision-making processes, or safe and effective restraint application techniques. [In fact, it has been well over ten years (perhaps even more than twenty years) since the DOT has updated the "National Standards" for Basic or Paramedic emergency care restraint!] Thus, most emergency care responders remain entirely untrained and undirected, yet they are still routinely required to employ restraint. Considering these facts, it is not surprising that bad things often happen when restraint is employed. Additionally, in the absence of adequate training and protocols, when litigation results from their use of restraint emergency care responders are left entirely unsupported by those responsible for their training and direction.

Charly's highly charged session begins with a brief discussion of basic patient restraint medicolegal aspects: restraint decision-making factors and documentation requirements. "Who" requires restraint is discussed in a clear, concise, and complete manner. Participants learn that – contrary to common misunderstanding – "combative" or "behavioral" patients are not the only patients who legitimately require restraint. In fact, "combative" or "behavioral" patients are the least-frequently-encountered patients who require restraint!

The bulk of this important and informative session features didactic explanations and live demonstrations of proven techniques that promote provider and patient safety – techniques that safely and effectively facilitate access for thorough medical assessment and unimpeded care procedure performance; techniques that ultimately promote improved patient prognoses and significantly diminish the likelihood of restraint-related litigation.

If a "Workshop" is selected, participants actually practice the restraint techniques described, using nothing more than strong, soft roller gauze.

LEARNING OBJECTIVES: After attending this presentation, participants will:

1. understand the most important reasons for patient restraint
   (and that these reasons least-often involve patient "combativeness.")
   
2. recognize the legal rights and needs of patients, the duties of health care providers,
   and the legal rights and needs of involved third parties.
   
3. recognize the variety of patients who legitimately require restraint and involuntary treatment.
   
4. learn how to provide complete legal documentation of restraint situations.
   
5. employ specific communication techniques that enhance patient cooperation
   and encourage a positive response to restraint.
   
6. understand the dangers of inappropriately-applied manners of restraint.
   
7. understand the advantages of using a long back board for prehospital patient restraint.
   
8. employ altered restraint techniques for pregnant patients, to ensure the safety of mother and fetus.
   
9. safely and effectively manage patients who are spitting, biting, and/or head-thrashing.
   
10. (if a workshop is afforded) learn to apply restraints safely and effectively,
    facilitating improved access for medical examination and emergency medical care.

The "handout" for this presentation is a version of Charly's article,
ALL TIED UP & NO PLACE TO GO

This presentation is available as an abbreviated 90 minute didactic session (with brief demonstrations by the instructor); or, as 2-to-3 hour sessions including more in-depth didactic instruction and some hands-on practice.

Frequently-updated Half-Day (4-hour) and Full-Day (8-hour) Restraint Workshops are also available; providing in-depth didactic instruction regarding ALL restraint medicolegal issues and application techniques information, as well as extensive hands-on participant practice sessions.

1. REASONS FOR RESTRAINTS:
   Patient safety, safe access for medical procedures, anticipation of "improved patient condition," and involuntary treatment of persons incompetent to refuse treatment. (ALL patients with an altered level of consciousness require some form of restraint!)

2. MEDICOLEGAL ASPECTS OF RESTRAINT:
   An overview of issues regarding competence and the right to refuse treatment, assault, battery, false imprisonment, duty to provide care, duty to provide protection of others, negligence, and standards of care. Utilization of "police assistance" is realistically discussed.

3. A "QUICK LOOK" METHOD OF DETERMINING "INCOMPETENCE" TO REFUSE TREATMENT

4. RESTRAINT DOCUMENTATION REQUIREMENTS

5. SAFETY BELT USE: Positioning of pram (wheeled stretcher) safety belts purely for transportation "safety" purposes – unrelated to "restraint" positioning purposes.

6. SAFETY BELTS AS RESTRAINTS: Pram safety belt "RESTRAINT" positioning; appropriate and effective methods of chest and lower extremity restraint.

7. LEATHER RESTRAINTS

8. MECHANICAL RESTRAINTS

9. RESTRAINT ASPHYXIA: Pathophysiology of restraint-related positional asphyxia and the relationship of forceful-pone-restraint (or prone "hog-tie" restraints) to patient death.

10. LONG BACK BOARD use restraint benefits.

11. ROLLER GAUZE (KERLIX / KLING) USED AS RESTRAINTS

12. PATIENT COMMUNICATION TERMINOLOGY RELATED TO RESTRAINTS

13. Why "A COOPERATIVE" PATIENT WILL COOPERATE WITH RESTRAINTS

14. ALLOWANCE OF OPTIONS (CONTROL) AS MUCH AS POSSIBLE: Ways to alleviate patient anxiety regarding restraints by enhancing the patient's sense of self-determination and control.

15. ANCHORING RESTRAINTS: Importance of appropriate anchoring of restraints to avoid patient injury and enhance effectiveness of restraint.

16. SINGLE LIMB (WRIST) RESTRAINT: Discussion of patients requiring only a single wrist restraint and techniques for application.

17. BILATERAL WRIST RESTRAINT: Discussion of patients requiring bilateral wrist restraint and techniques for application.

18. IV ACCESS = ELBOW CONTROL: Methods of restraint that enhance control during IV access.

19. UNILATERAL WRIST/ANKLE RESTRAINT: Discussion of patients requiring only unilateral wrist/ankle restraint and techniques for application.

20. ANKLE RESTRAINTS: Discussion of ankle restraint (stressing their use only in combination with bilateral wrist restraint) and techniques for application.

21. SPINAL IMMOBILIZATION & COMBATIVE PATIENTS: Suggestions for alternative spinal immobilization procedures when faced with a combative patient.

22. SHEETS AS RESTRAINTS: Situations requiring the use of sheets as restraints and techniques for application.

23. SEIZURES & RESTRAINTS: Necessity of quick release from restraints in the event of seizures for protection of patient from harm.

24. "SPIT SHIELDS": Discussion of spitting patients and the dangers of hypoxia or airway occlusion if inappropriate devices are used. Techniques for the use of transparent oxygen delivery devices as "spit shields."

25. SPECIAL CONCERNS; RESTRAINING PEDIATRIC PATIENTS

26. SPECIAL CONCERNS; RESTRAINING PREGNANT WOMEN

27. SPECIAL CONCERNS; RESTRAINT of DEVELOPMENTALLY DISABLED Patients and PATIENTS ON PCP

28. MALE vs. FEMALE PATIENTS and RESTRAINTS

29. RELEASE FROM RESTRAINTS: "ONCE RESTRAINED ALWAYS RESTRAINED" vs. SEIZURES requiring quick release from restraints.

30. HEAD RESTRAINT TECHNIQUES: Use of the jaw thrust maneuver to control violent head movement without compromising the airway.

31. "HANDS ON" PERIOD: Practice of the various restraint techniques discussed in presentation using strong roller gauze restraint; including SINGLE-HANDED-PROVIDER RESTRAINT APPLICATION (while physically restraining patient with other hand), and the use of a CLOVE HITCH to create a restraint that "locks" (will not become restrictive to circulation).
    Host facility must provide one roll of strong (6-ply) roller gauze per student if hands-on work shop selected.

32. SUMMARY

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"