How do Restraint Devices like ERB and ERC “Soft Cuff” address risk positively?
We have looked at how there are a number of scenarios in which staff are faced with difficult decisions about how they can maintain care and control of their patients and clients, while being aware of the the risks involved. Some staff, as we have seen, are exploring ways of using restraint devices such as the Emergency Response Belt (ERB) and Emergency Response Cuff (ERC) to control those risks in the best interests of the client.
We mentioned the risks from traditional metal cuffs, from prolonged manual restraint and from the reliance on prone restraint or medication to subdue violent clients. I want to delve a little deeper into those risks now so that we can be clear on why a team might choose to use the ERB or ERC.
Some of the issues involved are what are the Employer’s duty of care obligations as follows:
- the manual handling issues when staff engage in prolonged manual restraint of patients?
- the medical and psychological considerations for the patient in prolonged manual restraint?
- care planning issues for the patient who is subject to long periods of manual restraint?
- the risks attendant to the use of traditional metal cuffs?
Employers are responsible under Management of Health & Safety at Work Regulations 1999 to carry out risk assesssments, so it becomes important to question the risks to everyone involved, both physical and psychological, when higher-risk interventions are required in the client’s best interests.
Issue 1: Subject Fatigue
The tragic death of Anthony Pinder in a care home in Grimsby in 2004 serves to underline the risk of prolonged restraint:
Forty-two year-old Anthony Pinder, who had learning and behavioral issues, was physically restrained for around 90 minutes by staff at the Old Vicarage nursing home in Stallingborough, near Grimsby, on 1 October 2004. He was eventually released and crawled unaided to his room, but was found dead a short time later.
Prolonged physical restraint is exhausting for the subject – whether their mental state will allow them to be aware of it or not. In fact, in Police Complaints Authority guidance issued in 2002, entitled “Policing Acute Behavioural Disturbance”, the advice is as follows:
The amount of time that restraint is applied is as important as the form of restraint and the position of the detainee. Prolonged restraint and prolonged struggling will result in exhaustion, possible without subjective awareness of this, which can result in sudden death.If possible, avoid the situations in which prolonged restraint and prolonged struggling, become necessary. If the person has to be restrained, avoid pressing down on the trunk. Use the limbs. Binding the ankles wand wrists will be considerably safer than kneeling on the back of someone’s chest.
The combination of fatigue, prolonged struggling, physiological arousal, respiratory distress followed by cardiac arrythmia and arrest is an all too common deadly mix seen in restraint-related sudden deaths.
Violently struggling against a team of staff who are holding the client for significant time periods is an identified risk-factor in these cases.
Is it possible that the use of a restraint device would significantly cut the amount of time during which the person would be struggling in a vulnerable position?
Issue 2: Staff Fatigue
We have explored subject fatigue and the position of the subject as complicating factors in safeguarding during physical interventions, however there is one more reason why a restraint device should be considered within the range of options – staff fatigue.
In fact, in the tragic case of the restraint-related death of Geoffrey Hodgkins, there is the suggestion that staff were ‘swapping out’ due to fatigue during the long period of time in which restraints were going on with him. Prolonged restraint is known to increase the risk of sudden death for the subject, however it is often overlooked that the staff in our services are also vulnerable to the effects of sustained physical exertion.
It can be, for some administrators, difficult to imagine the sheer physical exertion which is necessary when frontline staff successfully carry out a restraint intervention. For example, there is at least one instance that I am aware of whereby a member of a restraint team suffered a heart-attack while involved in the prone restraint of a violently struggling subject.
There exists a phenomenon in personal safety training which is called the Fatigue Threshold – “the sudden physical exhaustion experienced during a force encounter when an [staff member] cannot effectively perform to either control a [person] or defend himself.” This threshold can be reached within as little as 30 seconds or in the case of a very physically well-conditioned staff member, just 5 minutes.
The practitioner who researched this phenomenon and coined this term states that
“The closer an officer gets to his or her personal fatigue threshold, the more dangerous the situation becomes, not only to the officer, but often to the subject as well. You’ll do anything to avoid it, including using what may otherwise be considered excessive force.”
“Don’t figure on most people being able to hold out for more than 2 minutes or so,” he advises. “You don’t have much time to get a subject under control before you’re going to be in trouble.”
Is it possible that by having a secure way to restrain the subject – which uses the mechanical advantage of velcro straps rather than muscular exertion – would reduce the risk of reaching the fatigue threshold?
Issue 3: Prone Position and then what?
The prone position remains a highly controversial subject, as evidenced by the recent storm created when MIND released the results of the Freedom of Information study about the Prone restraint of people in mental health care.
Importantly, it is recognised that staff who are struggling to restrain a particularly violent individual will often end up on the floor as confirmed in the 2002 PCA guidance:
If the person has a knife of gun, taking them down to the prone position may be absolutely necessary. However, “the prone position should be avoided if at all possible, and the period that someone is restrained in the prone position needs to be minimised.”
In addition, the chairman of ACPO’s Self-Defence, Arrest and Control Working Group has said in 2013:
“The initial control and restraint of violent individuals is usually a fluid and dynamic process, which often ends up on the floor. The reasons for this are twofold. Firstly, gravity will of course prevail in fast moving incidents where one’s balance is often lost. Secondly, the floor is often the safest place (for all) to achieve control and subsequent restraint of a violent person”.
The issue we have in healthcare, which distinguishes it significantly from the use of force by police, is that the police will use the prone position in order to secure the individual in a set of handcuffs and other restraining devices. Healthcare staff do not typically have this final step in a Control & Restraint process.
In some healthcare environments, there is a possible resort to chemical restraint, however this option comes with its own significant limitations. The application of rapid tranquilisation can:
- take a significant amount of time (see fatigue threshold above) measured in minutes not seconds
- sometimes not have any or enough effect on the person’s behaviour
- if delivered in enough amounts to have a significant effect on the person, can subsequently put their life in danger.
Healthcare staff are therefore left with some less-desirable options:
- continue to hold the person down until they become calm / weak / unresponsive
- let the person up out of the prone hold but sacrificing the control which necessitated it
- use Rapid Tranquilisation which may or may not work in time to control the risk
The report into the tragic case of the death of psychiatric patient Geoffrey Hodgkins, who died in 2004 after being restrained on the floor in the prone position for over 25 minutes while waiting for medication to take effect, is a sobering example of this forseeable scenario.
Is it possible that SoftCuff and ERB devices could offer healthcare staff a safer ‘next step’ to move towards, once some control has been achieved in prone restraint?
NEXT: let’s look at three criteria which are often applied to any analysis of the suitability of a restraint procedure – Manual Handling, Duty of Care and the Best Interests of the client.
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