Scenarios for the use of the ERC Soft-Cuff
Having introduced the Emergency Response Cuff and explained something about its shape and function, I want now to explore the scenarios in which staff might consider the use of the ERC.
First we should cover the rights and responsibilities of staff which give them the power to use force. The right to make physical interventions is enshrined in law and guidance, for example:
- The Common Law
- The Mental Health Act
- The Mental Health Act Code of Practice
- The NICE Guidance on the Short-Term management of Violent Behaviour
- The Mental Capacity Act
The overarching principle or ‘golden thread’ which runs through these acts and guidance in care is that an intervention which limits the freedom of an at-risk person should be the “least restrictive option” available which achieves the legitimate aim being pursued.
In the Mental Health Act Code of Practice there are guiding principles:
15.9 Any such intervention must be used in a way that minimises any risk to the patient’s health and safety and that causes the minimum interference to their privacy and dignity, while being consistent with the need to protect the patient and other people.
15.11 Patients who are identified as being at risk of disturbed or violent behaviour should be given the opportunity to have their views and wishes recorded, in the form of
an advance statement. They should be encouraged to identify as clearly as possible what interventions they would and would not wish to be used.
15.12 dignity. These are essential values that must be engendered and asserted
in all policy, educational material, training, and practice initiatives related to the safe and therapeutic management of patients.
15.22 Any physical restraint used should: be used for only as long as is absolutely necessary;
In my experience of training teams in the use of the ERC, staff have been very keen to weigh and consider the appropriateness and effectiveness of the device in varied scenarios they see in their environments.
For example trainers have considered that ERC may assist staff with:
A) Reducing Risk during Transport
Staff have considered the use of the ERC in safely transporting service users from area to area or from secure settings to non-secure settings, using the device as an alternative to handcuffs made of metal.
The Soft-Cuff can be used as an alternative for traditional metal cuffs. For example, at the moment in many NHS trusts metal cuffs are used when transporting patients from secure areas to appointments in other less-secure hospital settings. Currently, metal cuffs are often applied to the patient with the patient’s consent and the method of application is to the front of the person in a palm-to-palm method.
In addition to this, teams often take steps to protect the dignity of service users by making the presence of a restraint device more difficult to see, for example when a patient is in a public area. Staff will sometimes use a sweatchirt or cardigan folded over a restraint device in order to make sure that it is as unobtrusive as possible.
B) Reducing Risk of Serious Self-Harm
Staff have considered the use of the ERC Soft-Cuff in effectively safeguarding service users who present a known risk of significant self-harm.
Many parts of the NHS look after extremely vulnerable people with learning disabilities or mental illnesses. A proportion of those vulnerable people in care exhibit exceptional self-harming behaviours.
Those behaviours include for example:
- constantly putting their fingers down their throat to induce vomitting
- striking their head against a wall at full force to deal with frustration
- pulling hair and peeling skin from their body to reveal underlying bones and tissue
At times these behaviours can be life-threatening or at the very least can present the risk of causing serious deterioration in the person’s quality of life or their health and safety. It then becomes incumbent on the nurses and carers to make an intervention – if it is absolutely necessary and in that person’s best interest – to stop that harm from occurring.
In many cases, staff will legitimately use physical restraint interventions to stop or minimise the harmful consequences of these behaviours. A team will employ a physical holding method to immobilise the person concerned in a way which makes it difficult or impossible for them to continue injuring themselves.
One issue which arises from this is that there are incidences where a team must continue to hold the person for long periods of time. This sometimes extends to many minutes, or even hours, extending into full shifts where staff will be employing a tag-team approach and swapping tiring team-members for fresh ones to maintain control of the person. I will explore this issue more deeply in a following post.
C) Reducing Risk during Emergency Restraint / Minimising Prone Restraint
During an incident where a patient becomes extremely agitated and violent, perhaps attacking another patient or attacking a member of staff, it is necessary to restrain the patient. These ‘emergency restraint’ interventiosn can be extremely chaotic and violent. Violent struggles during restraint often mean that the restraint will end up on the floor.
Staff in healthcare accross the UK are routinely trained in how to restrain a patient on the floor – often face-down in the ‘prone position’ – in order to gain the greatest safe control of the person in exceptionally dangerous circumstances.
The focus of much controversy and conflicting opinions, the relative safety of restraint in the prone position attracts much attention. Prone restraint has been associated with sudden deaths of people in care. This association between prone restraint and sudden deaths is constantly under examination and remains a controversial but strong association rather than a definite and recognised cause. For good reason, training programmes and policies tend to seek to limit the use of prone restraint to situations where it is an absolute last resort.
There are situations where staff have had to bring a person under control in the prone position, so we must then ask: “Prone position, and then what?”
If prone restraint is the last option, staff may have nowhere else to “go” once they have established physical control on the floor.
In some settings, the staff will be authorised to use chemical control or rapid tranquilisation to influence the patient’s behaviour and this is often administered to the patient when they are prone.
However, sometimes the standard medications used for this purpose to not have the desired effect on the patient, or do not have the desired effect soon enough to control the risk. The length of time it takes for rapid tranquilisation to take effect is often measured in terms of minutes, not seconds.
The more powerful the tranquilising medication, the greater the side-effects and potential health problems which may result, further complicating the control of risk in the scenario.
Given this type of scenario, it is appropriate for managers, trainers and staff to ask: “If we could use a restraint device to reduce the risk more quickly and comfortably – should we?”
In the next part of this blog, I want to explore how the ERC (and its older cousin the ERB) may reduce risk for all concerned by bringing situations under more control more quickly and comfortably.
NEXT: How do Restraint Devices such as the ERC positively reduce risk?
Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant. He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict. www.dynamis.training