1. Safety Awareness for Reactive Strategy Use
State of Florida

2. Reactive Strategies
Reactive strategies may previously have been referred to as “emergency, procedures”, “restrictive procedures” or “restraint procedures”
Reactive strategies are those techniques used in an emergency or crisis situation with individuals exhibiting dangerous, out-of-control behaviors as well as those techniques which involve reacting to dangerous or out-of-control behaviors at the time of the incident in order to stop or interrupt such episodes.

3. Why are we reviewing these strategies?
The health, safety and well-being of consumers and staff are the primary responsibilities of the Agency and service providers.
Best practices for the use of manual and mechanical restraint should be followed to maximize safety for consumers and staff during reactive procedures.
It is necessary to review these strategies on a regular basis with all staff in order to maintain a high level of safety awareness.

4. Legal Authority Governing Restraint (Italics added for emphasis)
FS (g) Clients shall have the right to be free from unnecessary physical, chemical, or mechanical restraint.
Restraints shall be employed only in emergencies or to protect the client from imminent injury to himself or herself or others.
Restraints shall not be employed as punishment. for the convenience of staff. or as a substitute for a habilitative plan.
Restraints shall impose the least possible restrictions consistent with their purpose and shall be removed when the emergency ends.
Restraints shall not cause physical injury to the client and shall be designed to allow the greatest possible comfort.

5. F.S (continued)
Mechanical supports used in nonnative situations to achieve proper body position and balance shall not be considered restraints, but shall be prescriptively designed and applied under the supervision of a qualified professional with concern for principles of good body alignment. circulation, and allowance for change of position.
Totally enclosed cribs and barred enclosures shall be considered restraints.

6. Best Practices for
Maximizing Safety

7. Medical review of consumers by their primary care physician
Must be done upon admission, and regularly throughout service period to determine health and safety concerns for any technique that might be used and/or for contraindications in the use of specific techniques
A plan for possible techniques should be reviewed and approved by the physician prior to use

8. Maintain Sufficient Staff-to-Client
The facility must maintain sufficient staff-to- client ratios to safely address crisis situations.
All direct care staff who have responsibility for consumers must be trained in physical crisis management procedures and physical sigps and symptoms indicating medical emergency and appropriate responses

9. Direct care staff who have responsibility for consumers are trained in:
CPR techniques
The physica1 signs and symptoms indicating a medical emergency and
The appropriate response to these signs and symptoms
Procedures to prevent the need for physical crisis management procedures

10. Methods to prevent the need for physical crisis management procedures
Must be the key component of staff training & in environmental design
Emphasize constructive, non-coercive interactions,
Maintain an enriched and engaging environment and
Ensure supervision and planning for possible problems

11. Curricula and Training Requirements
All curriculums must be approved by the APD Central Office in Tallahassee per F.A.C. 65G-8.
Crisis management curricula and staff training must include prevention and de-escalation techniques that should be employed prior to use of a physical management technique.
Training should include the physical signs of medical emergency which must be monitored throughout a crisis situation

12. Requirements for staff training for physical crisis management
Training must be competency based
Certification of staff must be maintained as required by the specific technique to be utilized
If a staff person is not trained and current in certification, he/she cannot assist in ANY physical crisis management procedures
Training must include the caveat that all procedures must CEASE immediately upon the recognition of a medical emergency and staff should INTIATE medical intervention immediately

13. Physical crisis management procedures must be used as designed
The techniques must be implemented as designed in the curriculum.
NO variations, such as alternate pressure points, use of helmet or additional verbal interactions, may be used.
Other variations may be employed only when designed specific to the consumer evaluated and approved by the LRC chair and the Senior Behavior Analyst in APD Central Office, prior to implementation.

14. Procedures and Strategies
If procedures cannot be used as designed, with safety as primary concern, they should not be used and other strategies must be planned and implemented.

15. Limit Use of Physical Crisis Management
Physical crisis management procedures must only be used in situations of imminent danger to the individual or others;
Procedures must not be implemented automatically or as part of a deceleration plan for undesirable behaviors.

16. Physical Management Procedure
Each instance of a physical management procedure use must be subsequently reviewed by the administrator (or designee) of the facility who will:
Assure debriefing of involved staff to include the prevention of need in the future
Adjustment of the process to improve the health, safety and outcome for the individual and staff and
Documentation of the review, debriefing and adjustments to the process (if necessary)

17. Staff Training
Staff must be trained in the application of alternate procedures if:
the physical management techniques are unsuccessful,
there is a lack of sufficiently trained staff available to safely implement, or
the environment is otherwise unsafe for the use of a physical management procedure.

18. Extreme care must be taken with potentially dangerous procedures
Physical management techniques that involve pressure on the chest cavity or abdomen or possible impairment of a open airway (e.g. wrapping arms around the chest, applying pressure on the back or chest, or pressing the individual to the floor, wall or chair)

19. Procedures Involving Pressure:
Must include close monitoring for correct implementation and health/safety signs of the individual.
Must be time-limited as prescribed by the primary care physician. (Recommend less than 2 minutes of continuous pressure.)
Must have prior review by the primary care physician, and
Must have regular review throughout the service period and if there are any changes in the health of the individual (e.g. weight gain, respiratory illness, medication change or injury)

20. Reactive Strategy Reporting Requirements

21. F.S. 393.13(g) continued: (italics added for emphasis)
Daily reports on the employment of physical, chemical, or mechanical restraints by those specialists authorized in the use of such restraints shall be made to the appropriate chief administrator of the facility.
A monthly summary of such reports shall be relayed to the APD Area Program Administrator and the Florida Local Advocacy Council.
The reports shall summarize all such cases of restraints and include the type used, the duration of usage, and the reasons for use.
Area offices shall submit area-wide reports of these summaries to the APD Central Program Office in Tallahassee on a quarterly basis.

22. Reactive Strategy Reporting Requirements
Specified in F.S
Format has now been developed to insure consistent information to allow analysis and incorporate information as recommended by best practices
Reports should be submitted electronically to the Area APD Program Office person designated by the 5th working day of the month
Begin use of the new format for reporting April Reactive Strategies report due May 5, 2006

23. Instructions for use of format
Microsoft Excel file
Will be completed electronically and submitted electronically
Leave no blank rows in the file
Complete one report for each month and submitted to the APD local Area program office by no later than the 5th day of each month.
Use the definitions provided to complete the fields
This may require a change in the data collection systems utilized in your programs

24. Saving The Form As A File
Save the file as RS, name of facility, and month of report year with no spaces example:
RShappyhomesjuly06

25. Using The Reporting Form
Exercise

26. Restraint
Restraint refers to physical restriction, mechanical devices, or any device that limits freedom of movement.

27. Restraint does not include ...
For purposes of reporting, "restraint " does not include manual devices, such as orthopedically prescribed appliances, surgical dressings and bandages, and supportive body bands, or other physical holding when necessary for routine physical examinations and tests or for orthopedic, surgical and other similar medical treatment · purposes or when used to provide support for the achievement of functional body position or proper balance' or to protect an individual from falling out of bed

28. Medical Restraint
Chemical restraint - occurs when an individual is given medication for the purpose of immediate control of that individual's behavior (PRN medications.)

29. Mechanical Restraint
Mechanical restraint occurs when a physical device or devices are used to restrict the movement of an individual or the movement of normal function of a portion of his or her body. (i.e. mat wraps, wrist poseys, ankle poseys, restraint vests, helmets etc.)

30. Manual Restraint
Manual restraint occurs when a caretaker or staff manually hold an individual so that their freedom of movement or normal access to his or her body is restricted
Physical crisis management procedures such as PCM, MANDT, TEAM, CPI, ACT, ABC etc. All training programs must be approved by the Central Office in Tallahassee per F.A.C. 65G-8

31. Manual Restraint (continued)
Blocking procedures if the physical contact is less than 15 continuous seconds should not be included in reporting.
Procedures that involve physical movement of the individual from one place to another and involve the person participating in the movement (such as escorting) should be included as restraints if the hold/physical contact lasts for more than 2 continuous minutes.

32. Seclusion, Isolation, Exclusion
These terms are used (in literature and law) for such procedures that involve: Confinement of an individual in a room or an area of a room where the individual is prevented from leaving, or reasonably believes that he or sHe will be prevented from leaving, by means that include, but are not limited to, the following:

33. Confinement through procedures such as:
Manually, mechanically, or electrically locked doors, or "one-way doors," d1at, when closed and unlocked, cannot be opened from the inside;
Physical intervention of staff,
Verbal interventions of staff such as statements of consequences if person does not remain in the designated area

34. Isolation
Individuals required to stay in an area separated from others for a period of time.
(Note: The door to any area or room in which an individual is held, without the caregiver in the room or area, must not be locked but it can be held shut by the caregiver, using a spring bolt, or magnetic hold. Consumer must be visually monitored at all times.)

35. Exclusion
The individual is separated from others (by a screen, for example) while remaining in the same physical area or the individual is in another open room with the caregiver either inside or outside of the room. (Note: Consumer must be visually monitored at all limes.)
This would include being sitting/standing in a comer.

36. Contingent Observation
Requiring an individual to stop participating in the ongoing activity or task and observe others for a period of time.
Time out procedures that involve contingent observation by Ute individual of the activities in an environment and excluding the individual from participation in those events should not be included in the reported reactive strategies.

37. Law Enforcement
As a reactive strategy, the involvement of police to assist in the control of an individual whether the involvement is initiated by caretaker, family, individual, or another member of the community.

38. Baker Acting or Hospitalization
As a reactive strategy, the utilization of the Baker Act law to control an individual.

39. Protective Equipment
The use of a device placed on the person to attenuate or prevent the unwanted effects of some action of that person inflicted upon themselves.
Protective equipment does not restrict the client's movement or the movement of any part of the person's body.
An example would be a helmet worn to prevent injury which may result from head banging.
Use of a helmet to prevent injury that may occur during seizures is not considered a reactive strategy.

40. Thank You