Are paramedics permitted to restrain patients, and if so how?
Question# 777
I had a question and wanted to reach out. I’m not sure if you could answer or possibly point me in the direction of who can.
I wanted to reach out and ask RPPEO standpoint on restraints and the use of them in the field
My question is specifically if an ACP can physically restrain both of a Patients hands at the wrists tightly to the stretcher sides limiting nearly all movement with the upper extremities.
This question applies to a Patient who is NOT violent and has not been aggressive but is “agitated.”
The Patient has a line in place but Chemical restraints are not attempted.
It was always my understanding that we were NOT allowed to tie Patient’s up or restrain them outside of a Physician or the Police doing so or ordering such.
Has this changed?
Can we physically restrain now without Police or Physician instruction/approval/implementation and restrain people by tying them tightly to our stretchers if we deem it is needed?
I wanted to reach out and ask RPPEO standpoint on restraints and the use of them in the field
My question is specifically if an ACP can physically restrain both of a Patients hands at the wrists tightly to the stretcher sides limiting nearly all movement with the upper extremities.
This question applies to a Patient who is NOT violent and has not been aggressive but is “agitated.”
The Patient has a line in place but Chemical restraints are not attempted.
It was always my understanding that we were NOT allowed to tie Patient’s up or restrain them outside of a Physician or the Police doing so or ordering such.
Has this changed?
Can we physically restrain now without Police or Physician instruction/approval/implementation and restrain people by tying them tightly to our stretchers if we deem it is needed?
Answer:
Two types of patients may require restraints: (1) patients who are violent or aggressive; and (2) patients who are having an emotional disturbance and with erratic behaviour such as combativeness or agitation. Both of these patient groups represent a safety risk to themselves and paramedics, and both groups should be considered vulnerable until proven otherwise.
However, when faced with a violent or aggressive patient the police should be called for assistance prior to engaging the patient. Although the principles for restraint are the same as for those with emotional disturbance, in reality the police normally take over the restraining process. Thus, the remaining answer will deal with the patient who is considered not violent or aggressive, but is behaving erratically.
May patients who are agitated or combative, but not violent or aggressive, be restrained?
Prior to applying restraints, we should consider possible reasons for the erratic behaviour and try less invasive means of managing the situation. Patients with organic disorders (e.g.: dementia, pre-existing brain trauma) may be able to be talked down from their anxiety and then remain calm. If they have medication prescribed for these circumstances, reminding the patient or their caregiver to administer it as prescribed could be helpful. Patients with reversible causes (e.g.: hypoglycemia, hypoxia) may need to be physically held briefly in order to provide the immediate care.
If the less invasive methods are ineffective and the patient lacks capacity to provide consent, then the patient may be restrained to provide emergency care and/or transport. If a substitute decision maker (SDM) is present or reachable, consent should be obtained from the SDM for the restraint. If no SDM is available and the paramedic believes that an emergency exists that requires restraint for assessment, treatment and/or transport, then restraint may be applied.
May paramedics physically restrain a patient without police or physician instruction?
Paramedics may restrain a patient without the involvement of a physician or police officer if one of the following scenarios occurs: (1) an unescorted patient becomes violent en route; or (2) the use of restraints is required to provide emergency treatment and/or transport. This is authorized by the Health Care Consent Act and the BLS PCS and is irrespective of the presence or absence of a physician or police officer.
How are paramedics to apply restraints?
The main principles of applying restraints are that reasonable and minimal force should be used, and patients should not be placed prone once restrained. Applying restraints is a team process and should be done systematically. The BLS Mental Health Standard provides a process. It is acceptable just to restrain arms and not the full body if only arm restraint is required, such as to obtain and maintain IV access.
Soft restraints are used in healthcare. Commercially available restraints are preferable but triangular bandages are appropriate as well. Gauze bandages are not ideal as they tend to get tighter and more constrictive.
The patient response to restraints, including distal circulation, should be assessed while they are in your care, and the patient should not be left unattended.
When should chemical or physical restraint be used? Which is preferable?
Physical and chemical restraint may be used individually or together. Both of these place the patient at risk of harm, while also providing the benefit of being able to treat and transport safely. The preferable method of restraint is patient dependent and paramedics are expected to make a risk-benefit analysis. Generally speaking, any time physical restraint is required for more than a brief moment, the risk-benefit will favour combining this with chemical restraint, if available and safe, as this is much more comfortable and less traumatizing for the patient.
ACPs may use midazolam as a chemical sedation for patients who are at risk due to agitated behaviour (ketamine is not indicated outside of excited delirium or violent psychosis). When using midazolam as a sedative, keep in mind the patient's age, weight, presentation, and degree of sedation required: a full dose of 5 mg or 0.1 mg/kg is not always required.
Communication and documentation
Seeing a patient in physical restraints may cause distress to other persons, including the patient's family and unprepared hospital staff. Thus, we recommend letting the family know that you will be restraining the patient and notifying the hospital of the restraints, prior to arrival.
In your ACR, we recommend including the following information:
Please note
Some paramedic services have policies and procedures on physical restraint, possibly developed with local health services and risk management; this answer does not supersede those policies.
However, when faced with a violent or aggressive patient the police should be called for assistance prior to engaging the patient. Although the principles for restraint are the same as for those with emotional disturbance, in reality the police normally take over the restraining process. Thus, the remaining answer will deal with the patient who is considered not violent or aggressive, but is behaving erratically.
May patients who are agitated or combative, but not violent or aggressive, be restrained?
Prior to applying restraints, we should consider possible reasons for the erratic behaviour and try less invasive means of managing the situation. Patients with organic disorders (e.g.: dementia, pre-existing brain trauma) may be able to be talked down from their anxiety and then remain calm. If they have medication prescribed for these circumstances, reminding the patient or their caregiver to administer it as prescribed could be helpful. Patients with reversible causes (e.g.: hypoglycemia, hypoxia) may need to be physically held briefly in order to provide the immediate care.
If the less invasive methods are ineffective and the patient lacks capacity to provide consent, then the patient may be restrained to provide emergency care and/or transport. If a substitute decision maker (SDM) is present or reachable, consent should be obtained from the SDM for the restraint. If no SDM is available and the paramedic believes that an emergency exists that requires restraint for assessment, treatment and/or transport, then restraint may be applied.
May paramedics physically restrain a patient without police or physician instruction?
Paramedics may restrain a patient without the involvement of a physician or police officer if one of the following scenarios occurs: (1) an unescorted patient becomes violent en route; or (2) the use of restraints is required to provide emergency treatment and/or transport. This is authorized by the Health Care Consent Act and the BLS PCS and is irrespective of the presence or absence of a physician or police officer.
How are paramedics to apply restraints?
The main principles of applying restraints are that reasonable and minimal force should be used, and patients should not be placed prone once restrained. Applying restraints is a team process and should be done systematically. The BLS Mental Health Standard provides a process. It is acceptable just to restrain arms and not the full body if only arm restraint is required, such as to obtain and maintain IV access.
Soft restraints are used in healthcare. Commercially available restraints are preferable but triangular bandages are appropriate as well. Gauze bandages are not ideal as they tend to get tighter and more constrictive.
The patient response to restraints, including distal circulation, should be assessed while they are in your care, and the patient should not be left unattended.
When should chemical or physical restraint be used? Which is preferable?
Physical and chemical restraint may be used individually or together. Both of these place the patient at risk of harm, while also providing the benefit of being able to treat and transport safely. The preferable method of restraint is patient dependent and paramedics are expected to make a risk-benefit analysis. Generally speaking, any time physical restraint is required for more than a brief moment, the risk-benefit will favour combining this with chemical restraint, if available and safe, as this is much more comfortable and less traumatizing for the patient.
ACPs may use midazolam as a chemical sedation for patients who are at risk due to agitated behaviour (ketamine is not indicated outside of excited delirium or violent psychosis). When using midazolam as a sedative, keep in mind the patient's age, weight, presentation, and degree of sedation required: a full dose of 5 mg or 0.1 mg/kg is not always required.
Communication and documentation
Seeing a patient in physical restraints may cause distress to other persons, including the patient's family and unprepared hospital staff. Thus, we recommend letting the family know that you will be restraining the patient and notifying the hospital of the restraints, prior to arrival.
In your ACR, we recommend including the following information:
- The reason why restraints were required, including your risk-benefit analysis
- What restraints were used
- How the restraint was performed, including who was involved. Note if the order for the restraint came from a physician or police, or if paramedic-directed
- The patient's clinical response to restraint, including assessments performed
- The position of the patient once restrained
- If the patient was both chemically and physically restrained, why both were required and/or continued
- If there was any injury or potential harm to the patient, please complete a Patient Safety Incident Report (PSIR) - there is no need to complete such for every restraint case.
Please note
Some paramedic services have policies and procedures on physical restraint, possibly developed with local health services and risk management; this answer does not supersede those policies.
References
BLS PCS (v3.4)
Patient Refusal/Emergency Treatment Standard, section Emergency Treatment and Transport of an Incapable Patient Without Consent
Mental Health Standard, clauses 1, 2, 6(a, b, f), 7 & p56 guidelines
Violent/Aggressive Patient Standard, clause 3
ALS PCS (v5.2)
Combative Patient Medical Directive, Indications, Conditions, & Clinical Considerations
Assessment and emergency management of the acutely agitated or violent adult (https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult)