The Role of Prone Immobilizations in Crisis
There are a variety of ways to contain individuals in crisis whose behavior is physically assaultive, disruptive or self-injurious. There is chemical sedation, seclusion, mechanical restraint, and physical (manual) restraint. Each of them has an appropriate place to help provide for the safety of individuals in crisis. Each one of these methods of controlling individuals has resulted in and may, unfortunately, continue resulting in the deaths of individuals in crisis. Death is not a frequent problem in crisis management, but it does occur nonetheless. Although there are risks involved with any method of crisis management, in this paper, the focus will be on physical restraint procedures.
There have been two primary ways to deal with methods of physical restraint that have resulted in death, one is to initiate a ban on a particular procedure (a one-person prone basket hold) or even on an entire category of procedures (prone restraints of any kind). The other way is to carefully control, monitor, and limit the application of theses procedures or categories of physical restraint. Generally, It makes far more sense to put a ban on a particular procedure than an entire category of procedures. Unfortunately there is a great deal of “throwing the baby out with the bathwater” whenever procedural problems arise. It is understandable to ban a particular procedure (a particular way of immobilization) that has resulted in numerous deaths or injuries, but it is often a disservice to the people we are trying to help to ban entire categories of immobilization without first trying to establish if some particular procedures can be clinically effective yet safe. Before looking at issues in the use of a prone immobilization, there needs to be an examination of some general issues in the safe use of physical restraint.
General Safety Issues in Physical Restraint
The following issues can affect a broad range of physical restraint
categories and procedures. We will examine the importance of:
Design: The design
of a particular physical intervention is perhaps the most critical element
regarding safety and clinical effectiveness. The design refers to both the
position that staff are required to assume and the position that the
individual in crisis is placed in. The positions of all persons involved
are equally important. If the staff are comfortable, but the individual is
in an awkward or unnatural position, the procedure will be susceptible to
problems. If the individual is comfortable, but the staff have little
ability to safely contain them, or the staff feel like they are positioned
in an awkward manner, they are likely to alter the design to make
themselves more comfortable. A procedure should be designed so that it is
relatively easy to maintain the position for more than a few seconds or
even minutes. Positions that are difficult to hold invite staff to alter
their bodies (and hence the procedure) to maintain their comfort. There
must be a good balance between the comfort of the individual and the
comfort of staff. Other design elements to consider are the number of
people needed to safely implement the procedure and whether the procedure
applies equally well to children, adolescents and adults or whether it
needs to be modified based upon the size of the person.
Training: Staff training is especially important in physical interventions as poorly trained staff will undoubtedly implement the procedure incorrectly. Training should be competency-based vs. attendance-based. Individuals who can demonstrate competency as part of the criteria for passing a course will be less likely to show “behavioral drift.” Drift, very simply, is a description of deviations in a staff member’s behavior over time. Everything that occurs during training should be carried out with an eye towards minimizing the likelihood of drift. Drift can result from lack of practice (resulting in forgetting), or staff may learn, over time, that certain ways of holding “feel” better than others and they make small adjustments to the procedure until it only vaguely resembles the one that they were taught initially. The duration of the training is also important as there must be ample time for staff to practice the procedures they learn. Trainings should make use of "distributed practice" in which physical procedures are practiced throughout the training instead of being taught only at the end of a training. Finally, the class size must be limited to ensure that all participants may be adequately observed, assisted, and evaluated.
Skill Retention: As mentioned above, drift may occur as a function of failure to use the skills learned during training. It is for this reason that there must be (at least) annual re-training of individuals. After several years of re-training, the behavior of staff will tend to drift less often and less severely. Furthermore, without regular re-training and re-evaluation staff may become physically incapable of performing certain procedures yet they may continue to attempt using these procedures. This can endanger the staff member as well as the people they serve. Annual re-training can catch these sorts of problems.
Utilization Criteria: Rules for when to use and when not to use physical interventions can be called “utilization criteria.” If a crisis intervention course or a facility policy does not adequately define when to use and when not use physical interventions, there can be a resulting over-utilization or under-utilization. Either extreme is problematic. Over-utilization means that clients will be physically assisted when there really is no need. This results in a very high incidence of physical restraint. This can also produce subsequent aggression in a client who may feel that the physical procedures were unwarranted. Under-utilization can put clients at risk by not stopping their aggressive, disruptive, or self-injurious behavior. In most facilities, the norm is more towards over-utilization. This means that the criteria for intervening are poorly defined, or staff have few or no other skills at their disposal for handling the problem in a more appropriate manner e.g., prevention, de-escalation, behavior programs.
Oversight: Staff who are poorly supervised, or supervised by an individual with little or no knowledge of the system of physical intervention are at risk of over-utilization and drift. Even with very clear utilization criteria there are times when individuals must make a “judgment call” as to whether or not physical intervention is warranted. Poorly supervised individuals may not have the judgment necessary to make the right decision. Staff working at a facility where there are a variety of people serving as instructors in physical intervention will have the benefit of the accumulated experience and judgment of those individuals. It is much more difficult for a staff member to continue to implement a procedure incorrectly or unnecessarily when there is a high probability that their behavior will be observed by a supervisor who is knowledgeable in that system of physical intervention.
Medical Evaluation: Although there are occasions when an individual with no history of aggression may experience a severe aggressive episode, most facilities are familiar with the behavioral patterns of the people they serve. These individuals (especially) should receive proper medical clearance to use physical interventions (any sort of restraint, mechanical or otherwise). For example, individuals prone to heart problems or very high blood pressure, brittle bones, recent fractures, morbid obesity, respiratory problems, etc. should have clearance from their physician before implementing restraint procedures of any kind. The point here is that, for a small percentage of the population, any kind of strenuous activity can precipitate medical problems, be it struggling against a mechanical restraint, resisting staff, running, or even participating in sports. Often times deaths may be blamed on restraint (which is sometimes accurate) but there are numerous instances of “healthy” individuals who die suddenly during or right after strenuous exercise. Individuals with existing medical conditions might need alternate means for controlling their behavior such as seclusion rooms, or chemical sedations. Finally, there may be some instances where particular procedures are not advised for particular individuals (pregnant women should not be restrained in a prone position). This does not mean that a particular procedure is “dangerous” for everyone.
Existing Treatment Programs: Finally, one of the most important variables that impacts the use of physical interventions is existing treatment programs. Facilities that do not adequately address an individual’s crisis behaviors through de-escalation, skill acquisition (prevention), environmental re-structuring, or general “quality of life” improvements will need to use physical interventions regularly and (possibly) indefinitely. Many facilities, hence the staff who work there, are good at “putting out fires.” Facilities must, however, have the means necessary to move people forward in their treatment. This is the difference between behavior management and behavior change. Many facilities pride themselves on their ability to “handle” clients with challenging behavior problems, but the ability to contain crisis behaviors is only one small part of an integrated teaching and treatment program. Facilities that rely too heavily on physical interventions will find that their use becomes more and not less necessary over time.
The Importance of Prone Immobilization
As a means of controlling high magnitude aggressive, self-injurious and disruptive behavior, the prone immobilization is a safe and valuable tool if used properly by well trained staff. The are a variety of reasons for this. There are specific reasons for both horizontal immobilization in general, (prone or supine) and reasons that favor a prone over a supine position.
Reasons to immobilize in a horizontal rather than a vertical position:
Reasons favoring a prone position over a supine position:
Safety Issues In Using Prone Immobilizations
The argument has been made that horizontal immobilizations can be
much more effective than vertical for high magnitude aggressive behavior,
specifically, prone immobilizations. There are however some caveats that
must be observed to ensure the safety of any prone immobilization. They
are as follows:
summary, prone immobilizations can be both safe and effective in
stabilizing the behaviors of individuals in crisis. There are a number of
reasons that favor horizontal immobilizations over vertical, and those
that favor prone over supine positions. We believe that the overall safety
of any given procedure is a culmination of the seven factors listed
above (design, training, skill retention, utilization criteria,
oversight, medical evaluation, and existing treatment programs). The
extent to which these factors are violated can adversely affect the
safety of ANY form of physical restraint (including prone
“Physically restrained prone on the floor”
“Physically contained in a prone position”
“three staff members contained (name of client) on the floor in the prone position”
“one staff used his body weight to contain (name of client)”
“(name of client) was taken to the floor initially on his back, but was then turned into a prone position.”
Based on these descriptions, it is entirely possible that ALL the staff
Winston, Ph.D., BCBA
N. Fleisig, M.S. BCBA
Copyright 2002, PCMA Inc.