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Use restraint when using restraint chairs

Use of restraint chairs to manage unruly inmates has been the focus of recent lawsuits

Use of restraint chairs to manage unruly inmates has been the focus of recent lawsuits, such as this one in South Carolina and another in Georgia. Most mental health professionals caution to avoid use of physical restraint in favor of chemical restraint whenever possible. Even better is to pre-empt the need for restraint through effective de-escalation actions whenever possible.

However, sometimes a restraint chair is necessary to keep both the inmate and staff safe for a short period of time, say, to be able to administer chemical restraint or to get a handle on a situation before moving forward. Most problems with the use of restraint chairs come from use as the solution to a problem rather than a short-term intervention in a larger treatment plan.

Many deaths have been documented while initiating and maintaining physical restraint. The use of force necessary to establish control of a violent and combative person, especially if this person is large, can result in broken bones or back injury. Death from physical restraint can result from asphyxiation, aspiration, cardiac arrest and other reasons. Restraint chairs are often used in combination with spit masks or pepper spray that can impede breathing. For all these reasons it is important to be vigilant for health problems when using physical restraints.

Risky Business

Staff must be observant for physical injury during the initial and ongoing periods of confinement in a restraint chair. Prolonged fighting against the restraint can lead to muscle breakdown which then can progress to kidney damage as the byproduct of muscle breakdown – myoglobin – concentrates in the blood. The inmate may easily become dehydrated and prone to blood clots in the legs and lungs. Lack of physical movement over time can lead to skin breakdown, urinary tract infection and nerve damage.

An Ounce of Prevention

Steps should be taken to reduce the risk of injury and death during restraint chair use. An individual in a restraint chair is totally incapacitated and vulnerable to any physical threat. Restrained inmates should be in a protected location and not accessible by other inmates. Although there is not currently an absolute standard for monitoring those in a restraint chair, continuous visual observation is recommended. If this visual observation is by video camera, direct visualization should take place every 15 minutes. At a minimum, respirations should be verifiable and some standards also suggest a circulation check. Custody staff trained in CPR would have the qualifications to perform respiratory and circulation checks. The high risk of blood clots and nerve damage due to immobilization of arms and legs requires that each limb should be removed from restraint every 2 hours and exercised. Skin condition can also be evaluated at this time.

Healthcare staff, usually a nurse, should make an initial assessment of the inmate immediately after restraint placement and then at least every 4 hours thereafter. Health care staff will monitor vital signs, neurovascular status, hydration, mental status, skin breakdown, signs of blood clots, and any physical injury from the takedown. In addition, healthcare staff should review the inmate’s medical record for any health history concerns such as cardiovascular or respiratory disease.

Medical or mental health consultation regarding any underlying physical or mental health cause for the inmate safety risk is highly recommended. A multidisciplinary approach to behavioral management has been very successful in reducing the frequency and extent of physical restraint use in many correctional settings.

Put It in Writing

The use of restraint chairs in a custody setting should be governed by written policy and procedure. This not only protects the inmate, but it provides a safety net for custody officers involved in restraint chair use – a highly litigious activity. Be sure to know the key elements of your facility’s restraint policy and know where to find it for review each time the chair is used. A physical restraint policy should contain the following components:

  • The conditions that allow application of a physical restraint
  • The types of restraints permissible in the facility
  • The need to notify healthcare staff to evaluate health status after application
  • Monitoring procedures (both custody and healthcare staff) during restraint
  • Required documentation during the restraint period – including any less restrictive treatment alternatives and de-escalation actions taken before physical restraint
  • Release criteria
  • After-incident review process

Avoiding the use of restraint chairs through early intervention, de-escalation, and crisis management are always best. But, if you must use a restraint chair for inmate and staff safety, be sure to use it correctly and safely.

Do you use restraint chairs in your setting? Share your experiences in the comments section of this post.

Dr. Schoenly has been a nurse for 30 years and is currently specializing in correctional healthcare. She is an author and educator seeking to improve patient safety and professional nursing practice behind bars. Her web-presence, Correctional Nurse, provides information and support to those working in correctional health care. Her books, Essentials of Correctional Nursing and The Correctional Health Care Patient Safety Handbook are available in print and digital on Amazon.

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