Use of Force Policy, Training and Proper Technique

Although physical intervention is considered to be the method of last resort, sometimes hospital employees are left with no alternative but to use this approach when someone becomes a danger to themselves or others.  It is imperative that healthcare organizations have evidence based, well developed Use of Force policies governing how and when security officers should use force.  This policy should be developed by a multi-disciplinary team in order to consider use of force from all relevant angles to create the most comprehensive plan.

Specifically regarding handcuffing, the Use of Force policy should include when the use of handcuffs is permitted and when it is not, how to minimize risks associated with the use of handcuffs, and the training required.  The policy should state that handcuffs should only be used by competent staff members who are trained in their use, who receive continuing education and who are well-versed in any applicable regulations, laws and policies pertaining to their use.

Awareness of restraint-related positional asphyxia and how to avoid positioning that could restrict breathing is of critical importance in use of force policy and training as this can cause death.  Positional asphyxia is death as a result of body position that interferes with one’s ability to breathe.3[37]3  Especially dangerous is the facedown floor position most commonly used during handcuffing.  Security officers must be careful not to use their own bodies in a way that restricts someone’s ability to breathe, such as sitting or lying across a person’s back or stomach. When a person is lying face down, even pressure to the arms and legs can interfere with a person’s ability to move his or her chest or abdomen in order to breathe effectively.  Officers must be trained to watch for signs of distress from the individual being handcuffed and to move them to a side, seated or standing position as soon as it is safe to do so.[36][38]  Factors that can increase the risk of positional asphyxia or other significant medical issues during the handcuffing process include obesity, extreme physical exertion prior to or during a restraint, heart disease, breathing problems and use of alcohol or drugs.[37]  These risk factors should be incorporated into policies and training.

While the application of handcuffs seems fairly straightforward to those in the law enforcement and security profession, the risks are real and reviewing those risks in detail must be part of any training program.  Consider the recent use of handcuffs at a South Dakota facility.  On July 14, 2018, a 35-year-old man who was acting out died of an apparent heart attack in the emergency room at Rosebud Indian Health Service hospital.  He was involved in an altercation during which security officers pepper-sprayed him and restrained him, at one point handcuffing him faced down on the floor.  Inspection records show the man had been using methamphetamine and was hallucinating.  When physicians couldn’t get him to take medicine to calm down, they called on a security officer to restrain him.  He was placed on the floor, where a security officer handcuffed him while other hospital employees helped hold him down. They pepper-sprayed the man when he continued to resist restraints on the floor.  Following the incident, physicians noted an irregular heartbeat.  They moved him to the bed and began life-saving efforts to no avail.  The specific cause of the man’s death has not been released.  Rosebud was cited by CMS and placed in Immediate Jeopardy Status.[39]

Relationship with Local Law Enforcement

The final key to successful management of handcuff use in the healthcare security arena is to have a strong relationship with local law enforcement.  When a person is placed in handcuffs by security staff, the expectation is that the person will be removed from the property by local law enforcement and charged with a crime.  If law enforcement officers choose to take a different action or not press charges, it opens the hospital up to significant liability in detaining the person.  It also decreases the morale of security staff when they see their efforts to maintain campus safety are not taken seriously or handled in the way they expected.

Law enforcement in the jurisdiction where the healthcare facility resides should meet regularly with hospital administrators and/or security team members to discuss roles and responsibilities, expectations and policies to clearly define the incidents when security officers may use handcuffs.  The recent unlawful arrest of an on duty nurse in Utah[40] shows that poor relationships with law enforcement can have significant consequences for both employees and healthcare facilities.  Multiple organizations including the International Association of Health Care Security and Safety,[41] the Greater New York Hospital Association[6] and the Minnesota Hospital Association[7] have come out with specific recommendations for integration and collaboration between hospital staff and law enforcement.  If policies and procedures are discussed and agreed upon ahead of time, a smooth transition to law enforcement will occur.

There is one additional item worth noting regarding the interaction between healthcare organizations and law enforcement, specifically with regards to the use of handcuffs.  CMS requires healthcare staff, including security officers, to advocate for a patient during an incident in which law enforcement is used.  The same CMS Interpretive guideline quoted earlier goes on to say: “The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).”[14]  While it appears this is referring to prisoner patients, it is possible a hospital could be cited by CMS for law enforcement officer actions against any patient of the facility if it is deemed the hospital staff did not advocate and allow for the safe provision of care for the patient during a law enforcement intervention.

[37] US Department of Justice. “Positional Asphyxia – Sudden Death.” National Law Enforcement Technology Center Bulletin.  June 1995.  Retrieved September 1, 2018 from https://www.ncjrs.gov/pdffiles/posasph.pdf

[38] Schubert, Judith.  “Responding to Abusive Patient Behavior.”  Crisis Prevention Institute.  Retrieved September 23, 2018 from https://www.crisisprevention.com/Blog/June-2011/Responding-to-Abusive-Patient-Behavior-Part-2

[39] Ferguson, Dana.  “Federal report reveals patient died needlessly in South Dakota IHS hospital.”  Sioux Falls Argus Leader, August 17, 2018.  https://www.argusleader.com/story/news/politics/2018/08/17/indian-health-service-federal-report-details-deadly-deficiencies/1018539002/

[40] Kelly, Matt. “The Many Compliance Lessons From Utah Arrest.” Radical Compliance, September 4, 2017.  Retrieved September 21, 2018 at http://www.radicalcompliance.com/2017/09/04/compliance-training-lessons-utah/

[41] Kehoe, Bob.  “Spelling Out Collaboration with Law Enforcement.  New guideline sets points of communication.” Hospitals and Health Networks, October 19, 2017. https://www.hhnmag.com/articles/8661-spelling-out-collaboration-with-law-enforcement

[42] “Hospital Coordination with Local Law Enforcement.  Hospital Guidance Document.”  Greater New York Hospital Association.  Not dated.  Retrieved September 21, 2018 at https://www.gnyha.org/wp-content/uploads/2017/08/ NYPD_Coordination_FINAL_6Dec2016.pdf

[43] “Healthcare and Law Enforcement Collaboration Road Map.” Minnesota Hospital Association. 2017.  Retrieved September 21, 2018 at https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Health_Care_and_Law_ Enforcement_Collaboration_Road_Map.pdf