THE ARGUMENT FOR PRONE RESTRAINT We address this section to the agencies, facilities and schools that need to use floor restraint in order to maintain a safe environment.   Floor Restraint While supine floor restraint is more effective than standing or seated restraint, it is not as effective in maintaining control and safety as prone restraint. Prone holds when done correctly where the staff or educator’s weight is not placed on the consumer’s or student’s back or chest; the consumer’s or student’s diaphragm can move unrestricted, and staff is instructed to carefully monitor (as should be done in all restraints regardless of their proximity to the floor) the consumer’s or student’s physical and emotional well-being are no more dangerous and in fact are safer than other holds.  In 1999 as a result of the investigative series on restraint published by the Hartford Courant in 1998, the General Accounting Office (GAO) issued a report on the use of restraint. The GAO did not find the use of prone restraint any more risky or dangerous than any other restraint technique they reviewed.  In fact, the GAO only found two techniques particularly concerning.  The first technique was the baskethold where the consumer’s arms are criss crossed over their solar plexis, chest or lower abdomen with a staff person placing their full weight and laying directly on top of the consumer. The second was the technique where staff places objects or towels in the consumer’s mouth to prevent him from biting or spitting.  GAO Report. Prone Restraint Prone restraint simply means that the subject of the restraint is in a face down position.  It is not the name of a particular restraint technique as there are many ways to restrain someone face down.  All prone holding methods are not unsafe, just as all standing, seated or face up holding methods are not safe. Put someone in a standing choke hold.  That’s a standing restraint, but it is unsafe.  Put someone in a face up choke hold, that is a face up restraint, but it is unsafe.   If you pile sufficient weight on someone who is held face-up, a catastrophic result can indeed occur.  In fact, you are even more likely to resort to adding additional weight because face-up holding methods, no mater how well engineered, lack sufficient mechanical advantage to work, especially when the staff person is not as physically capable as the person being restrained. Experts on restraint usage have ample documentation (see http://www.thetruthaboutpronerestraint.com/news.php) illustrating how face up restraint is not nearly as safe to either youth or staff as prone restraint as long as the prone restraint (as with any restraint) is done correctly i.e removing weight from the youth’s back and chest and monitoring the youth’s physical and emotional well-being.  When you have a restraint policy or program that is ineffective restraints go up, assaults go up, injuries go up, unsafe conditions go up and workers compensation goes up.  A Texas study showed that in a low safety climate staff were 5 times as likely to be assaulted than staff in a high safety climate.  Also staff that believed that restraint and seclusion were useful tools (not necessarily that these tools were used) were assaulted 2.5 less frequently.  If staff is assaulted1/4 -1/3 less frequently (on average) than other students or residents, the number of assaults increases or decreases exponentially depending on whether you are in a low safety or high safety environment.  Maryland is seeing the results of this first hand.  Maryland went from a high (or at least higher) safety environment to a lower safety environment and is experiencing an 88% increase in injuries and a 20% increase in assault incidents.  The assaults are not only on staff. Face up or face down, the real issue is chest compression that restricts breathing and not paying complete attention to the physical and emotional well being of the person being restrained during the entire time they are being restrained.  In summary, all of the histrionics about banning prone restraint exacerbates a problem that is easily remedied by thoughtfully designed safety protocols and methods.   Advantages of Floor Restraint – both face-up (supine) and face down (prone) It is easier to contain a person on the floor than it is in a standing or seated position.  Often times you will not be able to maintain a restraint in a standing position. When you are on the ground, you can't lose your balance and fall to the ground.  Floor restraint is a more effective holding method.  If a hold is effective, the consumer or student will receive little or no gratification in resisting because the only trouble he is causing is to himself. Trying to restrain someone who is actively resisting in a standing hold is extremely difficult and dangerous.  If a facility does not have seated or floor restraint options, the facility or school, if they cannot contain the youth or person while standing will have to let go of the person. This is problematic if the person especially when he or she is a danger to self or others. Advantages of Prone Restraint  Prone (face down) restraint is safer.  Prone restraint is the safest, most effective and most efficient way of containing a person on the floor.  Ask any facility staff person, and they will tell you that supine restraint is a poor substitute for prone restraint and one that leaves staff and youth/patient exposed to more injury.  The only people who are trying to market face-up or supine restraint as a "better" or "safer" alternative to prone restraint are people who do not have to use restraint. It generally takes 3-4 staff to maintain a consumer or child in a supine position, rather than just 1 person or 2 people in most face down restraint techniques. Facilities moving from prone restraint to supine restraint are forced to increase staffing levels by 40% and their injuries increase as much as 88%.  Also, many staff will not intervene when their only option is face up restraint because it's too dangerous for both them and the youth/patient -- so they call the police or security -- who places the youth/patient in prone restraint.  Thus the policy change accomplishes -- nothing. In a cost/benefit analysis of the actual effects of banning prone restraint safety and security at healthcare, childcare, youth and schools have been compromised.  Ancora - 50% increase in assaults; Maryland 88% increase in injuries; PA Schools 20% increase in assaults on school resource officers; Ohio 7 days of worker compensation to every 1 day worked; NY 60% of workforce out on comp.  The result of staff and teachers not feeling safe intervening -- an increased use of law enforcement.  We do not understand how advocacy groups would prefer to disempower line staff and instead hand over the control to law enforcement which only serves to criminalize rather than treat the child.  We think it would be much more preferable to empower the line staff, nurses and teachers in direct and daily contact with the student/patient with tools rather than fostering an increased reliance on law enforcement for behavioral infractions. Supine restraint is acceptable as a short-term holding method.  When supine restraint is used as an extended floor holding configuration, there is a predictable increase in injuries to staff, including biting and spitting, longer holding times and an increasing reliance on mechanical and chemical restraints and camisoles out of the shear terror caused by the inferior mechanical advantage that supine restraint offers.  As both State and Federal regulations and policies are clearly moving away from the use of chemical or mechanical restraints, utilizing chemical or mechanical restraints in order to compensate for the deficiencies in supine restraint is not at all in conformity with good care practices, objectives or policies.   Reduced safety and increased injuries is a problem with all supine methods.  This problem is a technical limitation with all supine holds because the client is face up, all of his core muscles and powerful arm and leg muscles are available to him. The consumer is able to maintain sustained eye contact and react to the affect and attitudes of, what is now, a frightened and frustrated group of staff doing their level best to restrain him. Comments and Statistics from Other States, Providers and Vendors We have been seeing media reports and hearing from facilities and staff from Maine to Oregon that supine restraint does not offer the necessary mechanical advantage to keep staff, their clients or the facility safe.  New York:  New York Residential Treatment Facilities (RTFs) issued a statement of concerns when confronted with the possibility of only being able to use supine restraint.  The RTFs said their staffing ratios were insufficient to maintain safety if they were forced to use supine and that staff felt unsafe, were unable to contain the consumer or maintain safety, the holding times were longer, the restraint was less therapeutic and they were being bit and spit upon.  These comments are consistent with a recent survey conducted by Cornell University on staff’s perceptions when forced to switch from prone restraint to supine restraint. The survey found that staff believed that the use of its prone hold was more therapeutic, produced fewer injuries, was less psychologically damaging to the client, resulted in shorter holding times and was safer than supine restraint.  New Jersey.  A State Mental Health hospital recently went from a policy that allowed floor (including prone) holds to a policy that only allows standing holds.  Restraints might have gone down, but assaults increased 50% from 1200 to 1800 assaults annually.  We have stories from all over the country illustrating what happens when staff does not or cannot maintain a safe environment. The damage is not just to the staff or educator.  Much of the time, the people most affected are the other students, patients and the person engaging in the dangerous behavior.  Failure to Train We have been watching the research and press reports on restraint.  What we are finding is that most of the restraint catastrophes are happening at facilities who need but are not trained how to do floor restraint.  Using the Michigan School fatality examples in NDRN's Report - one fatality took place at a school using a restraint program that only teaches standing holds (there were also several other fatalities at facilities in Texas that only used standing holds).  What happened in Michigan is not an isolated incident. See Chase Moody's story.  "Our staff was not trying to take this man into a prone position, but they ended up falling to the ground in the course of things."  The teachers could not safely maintain the student in a standing hold and had to place the child on the ground for his and others safety and were never trained how to do so.  In the second Michigan fatality, staff were not trained in restraint use at all.  Training staff in standing holds only when the facility is caring for persons that cannot be safely held in a standing position is a defect in the training and intervention program being given to staff.  Not training staff in the use of restraint when staff or teachers are expected to manage students with behavioral issues that may become a danger to self or others is a constitutional violation of the student's or patient's rights.  (See Youngberg, CMS restraint regulations, and HHS, Department of Appeals Board Rulings) You would not give a person a car with no brakes if the person expects to have a need to stop the car so why would you train staff in only standing restraint if staff needs to be able to contain a person in a seated or floor position.  Same as you would not give the keys of a car to someone to take on the road when the person never learned to drive so why would you place children who are behaviorally challenged that might need staff to physically intervene for their own or another's safety in a class where that teacher or caregiver was never trained to do the job they are expected to do.  Schools, hospitals, social services providers, States and administrators need to give staff the tools they need and teach them how to use those tools appropriately.  Otherwise you have created a dangerous condition by failing to train or by providing inadequate training.  For additional information, email us at:  Email: Info@thetruthaboutrestraint.com add text here