Restriction and Restraint Practices

Author:	Jono Erodotou
Responsibility:	All Staff
Effective Date:	01 June 2024
Review Date:	30th May 2025
Approved By:
Version Number:	01

Amendment / Review History #

Date	Author	Comments

Introduction #

K4 Medical Services is committed to delivering the highest standards of care and ensuring the safety and welfare of its patients and employees.

K4 Medical Services recognises that violence and aggressive behaviour can escalate to the point where restraint may be needed to protect the person, staff, or other members of the public from significant injury or harm, even if all best practice to prevent such escalation is deployed.

K4 Medical Services also recognises that at times there will be a need to implement restrictive interventions in the patient’s best interests.

Physical intervention must only be considered once de-escalation and other strategies have failed to calm the situation. These interventions are management strategies and are not regarded as primary treatment techniques. When determining which interventions to employ, the clinical need, safety of patients and others must be considered. The intervention selected must be a reasonable and proportionate response to the risk posed by the person.

This policy is intended to provide guidance in relation to the nature, circumstances, and use of approved restraint techniques currently adopted by the K4 Medical Services. Its aim is to help all involved act appropriately in a safe manner, thus ensuring effective responses in potential or actual difficult situations. It sets out a framework of good practice, recognising the need to ensure that all legal, ethical, and professional issues have been taken into consideration.

The policy covers all staff and persons within K4 Medical Services, and others who are acting on behalf of the K4 Medical Services, including sub-contractors. It covers interventions for adults, children, and young people. Sections will be divided where specific strategies are required due to age or presentation.

Policy Statement #

The aim of this policy is to provide staff with the guidance needed to practice in accordance with the law, professional standards.

The policy outlines the general principles that must be applied to practice across K4 Medical Services, including the legal position where appropriate.

Decisions about restrictive interventions or restraint are not easy or straightforward. It is acknowledged that decisions in urgent and emergency situations may have to be made quickly and without consultation with colleagues. Sometimes such interventions may lead to complaints by patients or their relatives.

Unlawful restraint may give rise to criminal or civil liability. It is self-evident that staff may be required to account for their actions in such circumstances. However, the K4 Medical Services will always support employees who act in a way that is deemed reasonable and measured at the time of the incident and in accordance with professional standards and training.

DEFINITIONS / ABBREVIATIONS #

The Mental Capacity Act 2005 (MCA) defines restraint as when someone “uses or threatens to use force to secure the doing of an act which the person resists OR restricts a person’s liberty whether or not they are resisting”. Section 6 of the MCA states that restraining people who lack capacity will only be permitted if, in addition to it being in their best interests, the person taking action reasonably believes that it is necessary to prevent harm to the person. In addition, the amount or type of restraint used, as well as the amount of time it lasts, needs to be proportionate to the likelihood and seriousness of potential harm.

Definitions of the types of restraint that are used by K4 Medical Services are outlined below:

– Physical restraint: any direct physical contact where the intention of the person intervening is to prevent, restrict, or subdue movement of the body, or part of the body of another person.

– Mechanical restraint: the use of a device (e.g., belt, handcuffs, or a Cat B cell) to   prevent, restrict or subdue movement of a person’s body, or part of the body, for the primary purpose of behavioural control.

Principles: Positive and Proactive Care states that: “The legal and ethical basis for organisations to allow their staff to use restrictive interventions as a last resort is founded on eight overarching principles”. These are:

• Restrictive interventions must never be used to punish or for the sole intention of inflicting pain, suffering or humiliation.
• There must be a real possibility of harm to the person or to staff, the public or others, if no action is undertaken.
• The nature of techniques used to restrict must be proportionate to the risk of harm, and the seriousness of that harm.
• Any action taken to restrict a person’s freedom of movement must be the least restrictive option that will meet the need.
• Any restriction must be imposed for no longer than absolutely necessary.

• What is done to people, why and with what consequences must be subject to audit and monitoring and must be open and transparent.
• Restrictive interventions must only ever be used as a last resort.

• People who use services, carers and advocate involvement is essential when reviewing plans for restrictive interventions.

Legal framework #

The legal framework underpinning the lawful use of restraint is complex and underpinned by the Human Rights Act 1998, with various statutes and the common law, making restraint lawful in certain situations:

• Common law
  The doctrine of necessity – there is a general power to take steps that are reasonably necessary and proportionate to protect people from the immediate risk of significant harm, whether the patient lacks capacity to make decisions for himself.
  To prevent a breach of the peace – harm to a person of their property in their presence.
• Police officers have certain additional powers.
• MCA applies to all people over the age of 16 years of age.

Legal Distinctions #

The MCA and Liberty Protection Safeguards (formally: Deprivation of Liberty Safeguards DOLS) operate to differentiate patients into three categories:

• Patients who have the capacity to consent to the use of a method of restraint.
• Patients who lack the capacity to consent to the use of a method of restraint, and for whom the use of such restraint would constitute a restriction of their liberty.
• Patients who lack the capacity to consent to the use of a method of restraint, and for whom the use of such restraint would constitute a deprivation of their liberty.

Distinguishing between the second and third category (i.e., between restriction and deprivation of liberty) is vital in determining whether the use of restraint is legally defensible, and this distinction is one of degree rather than the nature of the restraint.

In practice, a restraint technique may restrict a patient’s liberty, or deprive a patient of their liberty, depending on both the extent of its use, and the degree to which it stops them doing something they would otherwise want to do. In other words, the same restraint technique may be used in different ways with the consequences of a restriction or deprivation of liberty.

Patients with decision-making capacity #

As with all health-care interventions, a patient is presumed to have the capacity to give or refuse consent to the use of a particular method of restraint, unless there is evidence that they are unable to understand, retain and weigh up information and then communicate a decision due to an ‘impairment of, or a disturbance in the functioning of their mind or brain’. A patient’s capacity to make such a decision will depend on the nature of the decision and may fluctuate over time. Patients whose decision-making capacity is not impaired, and who are refusing to give consent to a particular method of restraint being used, cannot be restrained against their will, even if their decision appears to be unwise. The only exemption to this general rule is in those situations in which the act of restraint prevents immediate and serious harm to themselves or to other people.

Patients who lack decision-making capacity and whose liberty is being restricted. #

Some patients being transported by K4 Medical Services will be physically unwell and suffering a disorder of the mind, which means they may lack the capacity to make certain decisions about their care. If incapacity is established then such a patient must be treated in their best interests, a judgment made after examining, among other things, the patient’s known beliefs and values, and consulting people involved in the patients care/life. If restraint is used, it must not only be in the patient’s best interests and the least restrictive alternative, but also

(a) act to prevent him/her from coming to harm.
(b) be of a type and degree that is proportionate to the risk of him/her suffering harm.

Types of Restraints #

Restraint is an intervention that prevents a person from behaving in ways that threaten to cause harm to themselves, to others, or to property.
Restraint can occur in a number of ways including:

– Physical restraint
– Mechanical Restraint

Physical Restraint #

“Any direct physical contact where the intervener’s intention is to prevent, restrict, or subdue movement of the body, or part of the body of another person” Positive & Proactive Care: reducing the need for restrictive interventions.

The use of Physical restraint must be reported on K4 Medical Services restraint incident report form when there is: – direct physical contact, with or without resistance.

Where the intention is to prevent, restrict or subdue movement of the body, or part of the body of another person, by two or more staff.

Careful deliberation must precede the application of this practice and an assessment of mental capacity must be undertaken. The use of physical restraints does not ensure safety and staff must be always aware of the need for vigilance and constant supervision of these patients.

Any Staff using physical restraint must:

Wherever possible use de-escalation techniques irrespective of the stage of the restraint.

All K4 Medical Services staff always following the risk assessment pathway when any form of restraint is carried out the staff involved should complete a restraint risk assessment and care plan (Appendix A) and a restraint incident report form (Appendix B)

Ensure that one member of staff leads the team and assumes control of the person being restrained throughout the process (person in control).

• Head and neck are appropriately supported and protected.

• Airway and breathing are not compromised.

• Monitor the person’s overall physical and psychological well-being throughout.

• For safety reasons, during a restraint it is only permissible to hold / apply pressure to the person’s limbs. Under no circumstances must direct pressure be applied to the neck, thorax, abdomen, back or pelvic area.

• Every effort must be made to use skills and techniques that do not use the deliberate application of pain.

• The level of force applied must be reasonable and necessary and proportionate to a specific situation and be applied for the minimum possible amount of time.

Mechanical Restraint #

Mechanical Restraint- refers to: ‘the use of a device to prevent, restrict or subdue movement of a person’s body, or part of the body, for the primary purpose of behavioural control’.

Mechanical restraint must be used as a last resort when all other less restrictive options have been tried and failed and must only be used by trained staff.

K4 Medical Services only use hinged handcuffs manufactured by ASP, K4 Medical Services staff are only authorised for the use of mechanical restraints provided by the organisation.

K4 Medical Services handcuffs are checked daily by the crew signing them out to ensure they are safe to use with no damage that could cause harm.

K4 Medical Services Specialist Operations Manager conducts a monthly audit on all operational handcuffs that are used by the staff.

Use of Handcuffs #

• Any use of handcuffs would be considered as an exceptional event. They are never to be used routinely. They are to be used as one of several options to reduce the risk of physical harm being caused to the patient or staff around the patient.

• Handcuffs limit the patient’s ability to run quickly. They also limit the patient’s dexterity and might reduce the risk of inappropriate or harmful behaviour. They reduce the risk of the patient potentially striking out.

• When a patient is wearing handcuffs, the risk increases of them injuring themselves if they were to fall over. Over tightening the handcuffs may cause discomfort and soft tissue damage.

• Handcuffs should not be used in medical emergencies where they would interfere with any treatment that might be required.

• The availability and use of handcuffs within K4 Medical Services would not normally be discussed in the presence of the patient, visitors, or members of the public.

Protocol for the use of handcuffs #

• The decision to use handcuffs is made after a full risk assessment and care plan has been completed.

1.  

• The decision to use handcuffs must not be based upon prejudice on the grounds of race, gender, or age.

• If it is deemed necessary for handcuffs to be used, then the appropriate sections on the patient report form should be completed.

• A minimum of one escorting staff member (including the driver) should make up the team.

• Handcuffs should be used in such a way that causes the least amount of discomfort to the patient. The handcuffs should not be put into a back stack position where they patient’s hands are behind them. The patient should always be handcuffed where they hands are at the front of the body. Once the patient is secure in the vehicle the handcuffs may be removed based on a risk assessment from the accompanying staff.

• The lead member of the team must be qualified. They will not be handcuffed to the patient under any circumstances. The trained member of staff will control the application and removal of the handcuffs as per the approved handcuff course.

• Before handcuffs are applied staff must inform the patient in a clear and understanding manner so that the patient understands what they are going to do and for the reasons why the decision has been made. The patient should also be informed as to the risk if they were to fall to the ground.

Appendix A – Restraint Risk Assessment and Care Plan #

Appendix B – Restraint Incident Report Form #