UTSW/BioTel Policy: Restraint of Patient

Purpose: To provide guidance for the use of physical or chemical restraint in the management and transport of patients who become violent or potentially violent, or who may harm themselves or others. Paramedics, EMT-Intermediates, and EMT-Basic level EMS providers may use these guidelines.

1. GUIDELINES:
   1. When following this policy, the paramount concern is the safety of the patient, community, and the responding EMS provider.
   2. Use restraints only when necessary in situations where the patient is potentially violent or exhibiting behavior deemed dangerous to self or others.  Administer restraint in a humane and professional manner.
   3. EMS personnel should contact BioTel prior to the application of any restraining device, whenever possible.  As crew safety comes first, EMS personnel may apply restraints BEFORE consulting BioTel, if the patient represents an immediate threat to self or to the EMS provider(s).
   4. Prehospital providers must consider that aggressive, violent behavior may be a symptom of medical conditions such as head trauma, alcohol, or drug related problems, and metabolic or psychiatric disorders. (Refer to the EXCITED DELIRIUM Guidelines, and to the EVALUATION and TRANSPORT Policy.
   5. The method of restraint used shall allow for adequate monitoring of vital signs and shall not restrict the ability to protect the patient’s airway, or compromise neurologic, respiratory, or vascular status.
2. PATIENTS IN POLICE CUSTODY:This policy does not negate the need for law enforcement personnel to use appropriate restraint equipment approved by their respective agencies for arrest and control.
   1. The responsibility for patient health management rests with the highest medical authority on the scene.
   2. A patient who is capable of understanding the consequences of his/her decisions never loses the right to participate in the decision making process regarding his/her medical care, regardless of the arrest status.
   3. In situations where law enforcement officers apply handcuffs:
      1. Do not cuff the patient to the ambulance stretcher.
      2. The law enforcement officer shall accompany the patient in the ambulance if the handcuffs are to remain applied.  However, if EMS personnel restrain the patient according to the procedure outlined in this policy, the law enforcement officer may elect to follow the ambulance in a patrol car to the receiving facility.
3. POLICY DETAILS:
   1. Restraint devices applied by prehospital personnel must be either padded leather or soft restraints (e.g. Posey vest, Velcro, or seatbelt-type).
   2. Suggested restraint technique is a six-point restraint system.  Ideally, restraint devices should connect the patient to a backboard for ease of transfer at the receiving facility.
      1. Use a snug-fitting device at the ankles and wrists to secure both legs and arms, respectively.  Extend the legs and arms and draw the restraint straps taut.
      2. Prevent the patient from sitting up by applying an appropriate restraint device across the chest and knees.  Draw the restraint straps taut, but do not restrict chest wall excursion.
      3. If using a backboard, restrain the patient supine.  If a lateral position becomes necessary, tilt the backboard to the appropriate angle and provide support.  In the lateral position, the patient must face EMS personnel, not the wall of the ambulance.
      4. Paramedic Level – Paramedics must continuously monitor all restrained patients using pulse oximetry, capnography, and the ECG monitor as soon as they become available.
      5. EMS personnel should evaluate restrained extremities for pulse quality, capillary refill, color, temperature, and nerve and motor function immediately following application of the restraint device and every 5 minutes thereafter.  Any abnormal findings require removal of the restraint device; however, after reevaluation, medics may reapply the device, if indicated.  The Medical Direction Team recognizes that the evaluation of nerve and motor status requires patient cooperation and thus may be difficult to monitor.
      6. Do not place restraints in such a way as to prevent evaluation of the patient’s medical status (e.g., airway, breathing, circulation, neurologic status), to prevent necessary patient care activities, or to in any way jeopardize the patient.
      7. EMS personnel must have a means of immediately releasing the restraints.
      8. Carefully document the use of restraint with the following information:
         1. Reasons for restraint;
         2. Technique and materials used;
         3. Assessment findings of the patient’s extremities, including periodic reevaluation;
         4. The patient’s mental, respiratory and circulatory status, including periodic reevaluation;
         5. Time of call to BioTel for the restraint order. 
4. METHODS OF RESTRAINT PROHIBITED IN THE UTSW/BIOTEL EMS SYSTEM:
   EMS personnel within the BioTel system may NOT use any of these forms of restraint:
   1. The Sandwich Technique, whereby personnel place the patient between two objects, such as a backboard and a scoop stretcher;
   2. Hobble (hogtie) restraint, whereby personnel bind or handcuff the wrists and ankles behind the back;
   3. Any prone restraint position;
   4. Any restraint procedure that restricts the movement of the abdomen (diaphragm) or chest, either by direct compression or hyperextension of the chest wall;
   5. Hard plastic ties or any restraint device requiring a key to remove.
5. CHEMICAL RESTRAINT (PARAMEDIC-LEVEL ONLY):
   For patients who continue to struggle following the application of medical restraints, including patients who may have ingested a stimulant or hallucinogen, paramedics may administer:
   1. Diazepam 2.5 mg – 5 mg slow IVP/IO/IN/IM, OR
   2. Midazolam 2.5 mg – 5 mg slow IVP/IO/IN/IM, OR
   3. Ketamine 2 mg/kg IV/IO or 5 mg/kg IM.
   BioTel may authorize further sedation, if required.
   Pediatric patients: Contact BioTel for authorization and dosing of midazolam sedation; do not administer ketamine.