NYS Protocol for Restraining Patients?

[PFDRes47cue 653]

I'm just curoius to see if there is a NYS Protocol for restraining patients in the back of an ambulance. Is there is list of items that may be used to restrain patients (ie: triangular bandage, restraints, etc)?

The reason I'm asking is because I just saw an episode of The Bravest (Yes, I know this is an old show) in which the City of Dallas FD used lage zip ties to restrain patients. These seem to work well and can only tighten, unlike triangular bandages which often losen or allow the pt to slip out. The only concern would be the zip tie becoming too tight. Could these be used? Or does protocol not allow this?

[JohnnyOV 2]

I'm just curoius to see if there is a NYS Protocol for restraining patients in the back of an ambulance. Is there is list of items that may be used to restrain patients (ie: triangular bandage, restraints, etc)?

The reason I'm asking is because I just saw an episode of The Bravest (Yes, I know this is an old show) in which the City of Dallas FD used lage zip ties to restrain patients. These seem to work well and can only tighten, unlike triangular bandages which often losen or allow the pt to slip out. The only concern would be the zip tie becoming too tight. Could these be used? Or does protocol not allow this?

IIRC the only people allowed to issue restraints are Doctors and Police officers in NYS... i'll get back to you with the DOH reg

edit: I was wrong. 2008 NYS BLS Protocols from the Behavioral Emergencies section:

Restrain, only if necessary, using soft restraints to protect the patient and others from harm.

Restraints should only be used if the patient presents a danger to themselves or others!

Note:

Restraints must be utilized in accordance with New York State

Mental Health Law. Police or Peace Officer should be present

at the scene prior to the application of restraints.

Edited February 18, 2011 by JohnnyOV

[ny10570 745]

There was a bulletin out several years ago clarifying that each agency was responsible for determining what was an acceptable method of soft restraint with their medical director. The rules are vague, but clearly put the liability on the agency. If pt's are escaping your cravats then you are tying them wrong. Its not easy, especially skinny people with narrow hands however if done right cravats are effective. I've long ago lost count between EDPs, head traumas and combative intox/od's how many, but after they escape a few times you figure out what you're doing wrong.

[PFDRes47cue 653]

So it is up to the agency to decide what is appropriate for use as soft restraints and they assume all liability in doing so. The ideas should be run past that agencies Medical Director.

Sounds fair enough.

[JM15 386]

It's a good policy also that if a cop is handcuffing a PT they are riding in the back with you....

[Goose 188]

x2 on developing a policy w/ you're medical director. Likewise, PD are the experts on restraining people, let them do it. As far as sedation for the combative or in cases of excited delirium, Westchester does not have an ALS protocol in place for that (probably should?)....i believe NYC does as well as other parts of the tri state area (namely Connecticut)

[WAS967 97]

Here's a question for everyone. How many times have you been called for an EDP transport from a hospital to psychiatric facility and been given an Rx for Restraints PRN. Did you know that's illegal?

[ny10570 745]

NYC has it, but specifically to facilitate restraint. Once they're tied up or bagged we're supposed to just transport. Luckily many docs are compassionate and allow us to sedate pts that continue to risk harm by fighting against the restraints. I saw one guy break his own hand fighting against his cuffs. I didn't like that sound.

Illegal or outside our scope? As EMTs we're allowed to dictate restraint. We just require the presence of PD for the act of restraining, but this is along the lines of implied consent. I transported several restrained EDPs across White Plains not knowing the rules. They taught me about restraints in my EMT program, I restrained EDPs as volley, and was handed a restrained patient in the ER. Never thought anything of it till I got to NYC and was told what's up.

[Bnechis 3,961]

Here's a question for everyone. How many times have you been called for an EDP transport from a hospital to psychiatric facility and been given an Rx for Restraints PRN. Did you know that's illegal?

Care to explain this.

[Guest alsfirefighter]

First..one of the most important things to keep in mind is you must use the minimal level necessary for the safety of your patient and yourself. Meaning from verbal and if need be restraint. I'm not sure what some of you are using as knots and around the wrist for a restraint if needed with a kravat...but I've never had one slip. Guess the rope rescue technician does come in handy in other ways.

Few other things to keep in mind:

No one, including in police custody should be left in the prone position.

A very good technique which I use if its a case where I need or may need IV access is the one up...one down method. Meaning one arm is secured in the up position, the other down.

You have to look at your stretcher to find a good hard point to tie off to as they are not made for this. Any movement will able them to get to some part of the body to untie or get out..ie mouth other hand.

A clove hitch around the wrists with the kravat left as wide as possible...(I use and highly recommend wide restraints to lower the risk of potential nerve injury) has always worked for me. Also do not allow them if you can to flex their wrists when tying or it will be hard to keep it snug. That's the good thing about the clove hitch (or any hitch for that matter) is that it tightens under load.

Bottom line is documentation. And I mean detailed documentation. From beginning to transfer. How the patient presented in detailed. How things esculated, what you did to right up to the point that you opted for restraints and I always document "decision was made to use a soft restraint for the safety of the patient and crew." I document what I used, what I tied, where and that I continually checked to ensure that extremities had circulation.

[SRS131EMTFF 471]

First..one of the most important things to keep in mind is you must use the minimal level necessary for the safety of your patient and yourself. Meaning from verbal and if need be restraint. I'm not sure what some of you are using as knots and around the wrist for a restraint if needed with a kravat...but I've never had one slip. Guess the rope rescue technician does come in handy in other ways.

Few other things to keep in mind:

No one, including in police custody should be left in the prone position.

A very good technique which I use if its a case where I need or may need IV access is the one up...one down method. Meaning one arm is secured in the up position, the other down.

You have to look at your stretcher to find a good hard point to tie off to as they are not made for this. Any movement will able them to get to some part of the body to untie or get out..ie mouth other hand.

A clove hitch around the wrists with the kravat left as wide as possible...(I use and highly recommend wide restraints to lower the risk of potential nerve injury) has always worked for me. Also do not allow them if you can to flex their wrists when tying or it will be hard to keep it snug. That's the good thing about the clove hitch (or any hitch for that matter) is that it tightens under load.

Bottom line is documentation. And I mean detailed documentation. From beginning to transfer. How the patient presented in detailed. How things esculated, what you did to right up to the point that you opted for restraints and I always document "decision was made to use a soft restraint for the safety of the patient and crew." I document what I used, what I tied, where and that I continually checked to ensure that extremities had circulation.

Regarding documentation, theoretically, could a provider take picture of the restraint without the face of the patient in the photo to document the restraint used to show in case of a court case that the restraints used were not excessive?

[JM15 386]

Personally, I wouldn't take a picture of a PT under any circumstances... I don't know about the legal issues though

[gpeifer 89]

I'm just curoius to see if there is a NYS Protocol for restraining patients in the back of an ambulance. Is there is list of items that may be used to restrain patients (ie: triangular bandage, restraints, etc)?

The reason I'm asking is because I just saw an episode of The Bravest (Yes, I know this is an old show) in which the City of Dallas FD used lage zip ties to restrain patients. These seem to work well and can only tighten, unlike triangular bandages which often losen or allow the pt to slip out. The only concern would be the zip tie becoming too tight. Could these be used? Or does protocol not allow this?

NYS DOH Paramedic Curriculum:

Management considerations

a. Treat existing medical problems

b. Maintain safety

c. Control violent situations

d. Medical legal considerations

(1) Standard of care

(2) Consent

(3) Limitations of legal authority

(4) Restraints

e. Remain with patient at all times

f. Avoid challenging personal space

g. Avoid judgements

h. Transport against patient's will when

(1) Patient presents threat to self or others

(2) Ordered by medical direction

(3) Implemented by law enforcement authorities, if at all possible

i. Types of restraints

(1) Wrist/ waist/ ankle leather or velcro straps

(2) Full jacket restraint

(3) Other

Lesson Outline:

Physical restraint of the violent patient

a. Improvised restraint devices (materials from the ambulance)

b. Commercially made restraints (leather or nylon, padded for comfort) that prevent

movement of the arms and legs

c. Make sure you have sufficient personnel (police assistance is required); minimum of

five people.

d. Move quickly to restrain the patient.

e. Leader should maintain verbal contact with the patient (even if the patient is not

paying attention).

f. Check the patient’s peripheral circulation to make sure the restraints aren’t too tight.

g. Document everything in the patient’s chart.

4. Skill Drill: Restraining a Patient

a. Assemble four or five rescuers and have the stretcher or carrying device and soft

restraints (wide cloth or commercial leather restraints) nearby (Step 1).

b. Designate a leader who will communicate with both the team and the patient.

c. Assign positions to each member: four extremities and the head (Step 2).

d. If possible, corner the patient in a safe area with the least obstruction and no glass

(Step 3).

e. On the direction of the team leader, who will be talking to the patient calmly, move

together toward the patient (Step 4).

f. Each team member should grasp the assigned body part and carefully, with the least

amount of force needed, bring the patient to the ground (Step 5).

g. Carefully place the patient on the stretcher or carrying device in a face-up position

(Step 6).

h. Tie the patient with soft restraints at each wrist and ankle as well as over the chest

and pelvis with sheets (Step 7). If the patient is spitting, place an oxygen mask or

surgical mask on his or her face.

Other articles:

http://www.emsworld.com/print/Firehouse-Magazine---EMS-Features/Restraining-The-Combative-Patient/3$7696

http://wearcam.org/decon/full_body_restraint.htm

http://www.acep.org/content.aspx?id=29836

This is a copy of a local agencies policy:

Restraint

When necessary for the patient and/or crew’s safety, in addition to the straps on the stretcher, a patient may be restrained using the least amount of force and restraint necessary.

Remember that the most effective restraint device is a calm, firm, professional demeanor.

The first step is to request the police to place the patient in temporary police custody. In the absence of the police, the EMT should attempt to gain permission from the patient’s parent (if a minor) or guardian, or contact medical direction for advice. In the event that neither the police nor a parent or guardian (for a minor) is present, the EMT may restrain the patient if it is safe (for both the crew and patient) and you determine that the patient may be a danger to himself or others. It is preferred that there be at least three crew members present. If the crew is in danger, the appropriate thing to do is retreat!

Patients should be transported with a crew member of the same gender, if possible. Patients not in police custody should not be handcuffed. Patients should never be transported face down or with their respiratory capacity restricted in any way. All restrained patients must be continually monitored.

[Bnechis 3,961]

NYS DOH Paramedic Curriculum:

Guy, How dare you use the facts to prove your point. Well done!

[Guest JR Fireman]

Oh just hog tie them and go. It's quicker. Never been to a rodeo.

[Dinosaur 844]

Regarding documentation, theoretically, could a provider take picture of the restraint without the face of the patient in the photo to document the restraint used to show in case of a court case that the restraints used were not excessive?

Probably a bad idea. Look at the stupid debates started on this forum by a single picture.

Documenting that four point restraints were used and circulation was checked to insure that they were not to tight is enough.

You'd probably start a riot taking the picture in some places too and then we'd all have to be issued cameras. Just not worth the crap.

[PFDRes47cue 653]

This is a copy of a local agencies policy:

Restraint

When necessary for the patient and/or crew's safety, in addition to the straps on the stretcher, a patient may be restrained using the least amount of force and restraint necessary.

Remember that the most effective restraint device is a calm, firm, professional demeanor.

The first step is to request the police to place the patient in temporary police custody. In the absence of the police, the EMT should attempt to gain permission from the patient's parent (if a minor) or guardian, or contact medical direction for advice. In the event that neither the police nor a parent or guardian (for a minor) is present, the EMT may restrain the patient if it is safe (for both the crew and patient) and you determine that the patient may be a danger to himself or others. It is preferred that there be at least three crew members present. If the crew is in danger, the appropriate thing to do is retreat!

Patients should be transported with a crew member of the same gender, if possible. Patients not in police custody should not be handcuffed. Patients should never be transported face down or with their respiratory capacity restricted in any way. All restrained patients must be continually monitored.

Thanks! So there is the answer "Least amount of force and restraint necessary." Sounds like Zip Ties would be perfect (for that agency) at least.

[Dinosaur 844]

I'm just curoius to see if there is a NYS Protocol for restraining patients in the back of an ambulance. Is there is list of items that may be used to restrain patients (ie: triangular bandage, restraints, etc)?

The reason I'm asking is because I just saw an episode of The Bravest (Yes, I know this is an old show) in which the City of Dallas FD used lage zip ties to restrain patients. These seem to work well and can only tighten, unlike triangular bandages which often losen or allow the pt to slip out. The only concern would be the zip tie becoming too tight. Could these be used? Or does protocol not allow this?

I would never use zip ties. They're too narrow and can cause soft tissue, circulatory, and/or nerve damage.

It can also become a real challenge to remove them if they're really tight.

[PFDRes47cue 653]

I would never use zip ties. They're too narrow and can cause soft tissue, circulatory, and/or nerve damage.

It can also become a real challenge to remove them if they're really tight.

Thats what I would think too. Thats why it is not used anymore i guess. I'll stick with having a cop handcuff them or triangular bandages. Even though handcuffs are narrow and harder, they seem to work wonders.

[PEMO3 523]

Never understood the use of zip ties even as hand cuff for mass arrests. They do not have a lock on them to prevent over tightening and require them to be cut off which puts the restrained individual and the person removing them in a position of risk during the removal. A triangular bandage when proper applied and knotted posses little risk for further injury and is simple to remove. My understanding was always the PD could place the patient in "protective custody" for restraint in such that they were being protected from themselves.

[ny10570 745]

PEMO3 Nailed it. Cuffs are both adjustable and lockable to prevent accidental over tightening. Zip ties are not.

[WAS967 97]

Explanation on my statement is simple. Order for "PRN" restrains I believe is illegal. Either they are restrained or they are not. Hospitals who restrain patients have to renew the order on (I believe) a daily basis. Correct me if I am wrong as this has been my understanding for years and is the basis of a developing protocol/SOP in Westchester.

EDIT: Found the following. It's a far shorter time frame than I thought. 2 Hours.

From http://www.omh.state.ny.us/omhweb/patientrights/inpatient_rts.htm

Restraints and Seclusion

Restraint and seclusion of patients are last-resort safety measures to prevent injury, and Office of Mental Health policy states that they are to be used only in emergency situations.

Specific types of restraining devices which doctors may order include four-point restraints, five-point restraints, wrist-to-belt restraints and calming blankets. Camisoles and restraining sheets may be used only upon authorization of the OMH chief medical officer or his designee, and only with the particular patient for whom authorization is given. Staff people are expected to use the least restrictive type of restraint which is appropriate and effective.

Seclusion occurs when a person is placed alone in a room which he or she cannot leave at will.

You can be restrained or secluded only upon the written order of a doctor, based on personal examination. If a doctor is not immediately available, a senior clinician can start the procedure while waiting for the doctor to arrive only if the patient presents an immediate danger to self or others. An order is valid for no more than two hours for adults and to renew an order, the physician must conduct another examination and write another order. Patients in restraint or seclusion must be monitored continuously and their vital signs taken regularly. Restraint and seclusion are not to be used as punishment, or for the convenience of staff or as a substitute for treatment, and excessive force shall not be used.

As soon as practicable after a person has been restrained or secluded, and as soon as the person is willing, staff must review the circumstances surrounding the episode with the individual. They must try to identify with the person’s help what could have been done differently and how a future emergency could be averted.

Hospital quality assurance programs also are expected to monitor restraint and seclusion.

Edited February 21, 2011 by WAS967

[helicopper 1,050]

Explanation on my statement is simple. Order for "PRN" restrains I believe is illegal. Either they are restrained or they are not. Hospitals who restrain patients have to renew the order on (I believe) a daily basis. Correct me if I am wrong as this has been my understanding for years and is the basis of a developing protocol/SOP in Westchester.

EDIT: Found the following. It's a far shorter time frame than I thought. 2 Hours.

What is the source of that quoted material?

I don't believe that an order to restrain a person should that become necessary is illegal. What makes you think that?

[WAS967 97]

I'm talking about interfacility transports specifically getting a written prescription for PRN restraints. (See my original post). It is my belief and what I have been taught going back to my days at Abbey, that PRN restraint orders are "technically" illegal. Like I said, if I'm wrong, let's discuss it.

That quote is from the Office of Mental Health, my bad. I'll go back and edit in the reference properly. I quoted that because as someone quoted from the DOH BLS protocols, restrains must be consistent with OMH guidelines.

Edited February 21, 2011 by WAS967

[WAS967 97]

Now as far as the cuffs, the protocols and mental health laws don't seem to allow the use of handcuffs as restraint. As PEMO3 mentioned, can they be used if the patient is placed in police custody/arrest (not sure of the LEO procedures for this).

I personally would like to see better local protocols for the treatment of the emotionally disturbed. Nasal versed could be an option, but could also be complicated in someone who is toxicologically impaired. Haldol might be an option but I'm wary of going near a combative person (restrained or otherwise) with a needle for obvious reasons.

[Goose 188]

Now as far as the cuffs, the protocols and mental health laws don't seem to allow the use of handcuffs as restraint. As PEMO3 mentioned, can they be used if the patient is placed in police custody/arrest (not sure of the LEO procedures for this).

I personally would like to see better local protocols for the treatment of the emotionally disturbed. Nasal versed could be an option, but could also be complicated in someone who is toxicologically impaired. Haldol might be an option but I'm wary of going near a combative person (restrained or otherwise) with a needle for obvious reasons.

There isn't a local protocol for emotionally disturbed / excited delirium patients in Westchester, thats the real issue. These are sick people who have a very good chance of becoming far more ill (ie: many go into cardiac arrest from being so acidotic) if their episode is not properly treated. Nasal versed is surely an option for sedation as is Ketamine...im also not sure Haldol is much of an option because of it's tendency to prolong QT interval. Would be nice to have a well written protocol, hopefully its something being worked on

[ckroll 101]

Guess the rope rescue technician does come in handy in other ways.

A clove hitch around the wrists with the kravat left as wide as possible...(I use and highly recommend wide restraints to lower the risk of potential nerve injury) has always worked for me.

My favorite is the Texas loveknot with a cravat. Never fails. It is pre-tied and can be put on your own wrist; hold hands with the patient and slide it on. Of primary importance is to have a system that works for you, know where you will attach it to a stretcher, and practice....because you shouldn't be needing it more often than once a year.

I'm not a fan of medication because psychiatric emergencies should be talked down and pharmaceutical emergencies.. well I don't know how more drugs will interact with those already on board.

And duct tape! Let us not forget duct tape.

[ny10570 745]

because you shouldn't be needing it more often than once a year.

That all depends on your environment and the citizens inhabiting that environment.

I'm a fan chemical restraint when use appropriately. I'd rather worry about R on T or some rare and obscure drug interaction than the patient harming myself, my partner, a police officer, or themselves. Versed, Haldol, and Ketamine are all used frequently around the world with little adverse reaction. Hell, as soon as we reach the ER with that EDP or drug induced psychosis that we spend so much energy trying to physically restrain the first thing the MD usually does is order up the old Haldol/Ativan cocktail.

My 2 cents about nasal drug administration, it sucks. It works great on paper and with compliant patients. I've used it with great success to sedate for pacing on a diabetic with zero IV access. Also used it for Narcan on a cyanotic heroin OD. Just pinched his lips, waited for the inhale and bingo right to the turbinates.

Now take a comabtive EDP who will likely try and bit anything you put near his mouth. So, you're not getting the best access to the nose. If they're severely congested you're drug isn't going anywhere. Squirt something up your nose, and your first reaction is to blow it back out. EDPs do the same thing. More of your drug winds up on your hand and running down their face. If you can control the head well enough to put your hand next to their mouth then you can control the arm well enough for an IM injection.

[helicopper 1,050]

I'm talking about interfacility transports specifically getting a written prescription for PRN restraints. (See my original post). It is my belief and what I have been taught going back to my days at Abbey, that PRN restraint orders are "technically" illegal. Like I said, if I'm wrong, let's discuss it.

That quote is from the Office of Mental Health, my bad. I'll go back and edit in the reference properly. I quoted that because as someone quoted from the DOH BLS protocols, restrains must be consistent with OMH guidelines.

The guidance from OMH applies to in-patient restraint within Pysch facilities. I don't believe that it has any bearing on EMS operations as we're not governed by OMH and once we accept a patient they're not an in-patient anymore.

I've heard a great many things from jail-house and locker-room lawyers andthey can be incorrect as often as they are correct. I do know that I've got many "PRN" orders for things over the years and have no doubt that the order was valid.

Are there any current CIC's (Guy) who can speak to this issue?

[ny10570 745]

Since when can we follow the facility docs orders? In NYC there's a whole procedure for following direction from a non-FDNY OLMC physician. I know in Westchester orders come from the physician at your destination hospital. If thats the case, anything the originating facility doc writes is just a waste of paper.