Prone restraint is a physical intervention where an individual is forcibly held in a face-down, or prone, position. This technique is employed by trained personnel to manage violent or severely aggressive behavior that poses an immediate threat to the person or to others. The use of prone restraint is highly controversial because of the serious safety risks associated with this position. Due to the potential for severe medical complications, this method is subjected to stringent regulations across health and safety sectors.
The Mechanics of Prone Restraint
Prone restraint requires a coordinated team effort involving multiple staff members to safely bring an agitated individual to the ground and secure them. The team works to control the person’s limbs and torso to prevent further struggle or injury. Specific points of contact are maintained on the individual’s back, shoulders, hips, and limbs to immobilize them completely. The prone position is the defining characteristic of this intervention, and staff are trained to secure the individual while minimizing pressure.
Situational Application in Crisis Management
Prone restraint is reserved for extreme circumstances where less restrictive methods, such as verbal de-escalation, have failed to manage dangerously aggressive behavior. This intervention is intended only as a last resort to ensure the immediate physical safety of all people involved. Settings where this practice may be used include psychiatric hospitals, emergency departments, and behavioral health units managing acute behavioral crises. Law enforcement and school settings may also utilize physical restraint, but it is intended only as a temporary measure to address an immediate, severe threat, not a prolonged method of containment.
Physiological Risks and Complications
The greatest danger associated with prone restraint is the risk of positional or restraint asphyxia, where the body’s position interferes with the ability to breathe adequately. When a person is held face-down, their body weight, combined with any pressure applied by staff, compresses the chest and abdomen. This compression restricts the diaphragm’s movement and prevents the lungs from fully expanding. This compromises the ability to take in enough oxygen.
This restriction is particularly dangerous for individuals who are struggling intensely, as their body demands increased oxygen. The combination of physical exertion and impaired respiration leads to a rapid drop in blood oxygen levels. This also causes a buildup of metabolic acids in the bloodstream, a state known as metabolic acidosis, which can quickly overwhelm the body’s systems.
Struggling and agitation can lead to a state called agitated delirium, which involves extreme mental and motor excitement. This condition significantly increases the risk of sudden cardiac arrest, especially when coupled with the respiratory compromise of the prone position. Individuals with underlying health issues, such as heart conditions or chronic lung disease, or those who are overweight, are at an even higher risk because the body has less reserve capacity to cope with the stress.
The lack of sufficient oxygen, or hypoxia, and the cardiovascular stress can quickly lead to a sudden fatal cardiac arrhythmia or respiratory arrest. Maintaining the prone position for even a short period after the person has stopped struggling can be extremely dangerous. This is because the lack of physical movement may be a sign of critical medical deterioration, not compliance. Restraint-associated deaths can occur in as little as a few minutes.
Protocols for Safe Application and De-escalation
Regulations established by bodies like the Centers for Medicare and Medicaid Services (CMS) impose strict requirements to mitigate the dangers of restraint use in healthcare settings. Prone restraint must be immediately discontinued, and the individual must be moved to a safe position, such as on their side or seated, once the immediate threat is over. Prolonged use is strictly prohibited, with time limits for restraint orders varying based on the age of the individual. Continuous monitoring is mandated throughout the period of restraint, requiring staff to assess vital signs, respiratory status, and circulation. Training emphasizes observing for early warning signs of distress and immediately ceasing the application of weight to the back or abdomen, promoting the use of less restrictive alternatives to eliminate the need for prone restraint entirely.