IAHSS Releases Updated Healthcare Use-of-Force Guidelines

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By Dom Nicastro

The International Association for Healthcare Security and Safety (IAHSS) has released updated guidance on use of force in healthcare security settings.

Use of force in healthcare environments involves a variety of circumstances, including patient restraint, patient elopement, involuntary commitment, criminal incidents, and other situations, according to IAHSS officials.

Naturally, healthcare security officers, whether proprietary, contracted, or law enforcement, are frequently called upon to intervene in these difficult circumstances, IAHSS officials reported.

“These incidents are frequent and fraught with potential injury to staff, patients, and others,” officials from the IAHSS Council on Guidelines wrote in their announcement of revisions to Guideline 02.02.05, Security Officer Use of Physical Force. “Security staff are sometimes perceived as overreacting or underreacting as they respond when called to a call for assistance. Providing a ‘reasonably’ safe environment is important to all healthcare facilities and this guideline can assist organizations as they strive to meet that goal.”

The revision includes a definition of use of force, suggested policy and training considerations, use of behavioral health emergency response teams, and a defined incident notification and review process.

Tom Smith, CHPA, CPP, Council on Guidelines member, said the guideline has been significantly updated and all healthcare organizations should consider it as they review and update their use-of-force policies, procedures, and training.

The IAHSS Council on Guidelines is composed of volunteer IAHSS members who are healthcare security professionals and leaders. Each year the council develops new industry guidelines and reviews existing guidelines on a three-year cycle.

The IAHSS is an association dedicated to professionals involved in managing and directing security and safety programs in healthcare facilities. IAHSS has more than 2,000 members, who are healthcare security, law enforcement, safety, and emergency management leaders.

Smith, who serves as president of Healthcare Security Consultants, Inc., says those responsible for healthcare security functions must stay aware of and respond to best practices, guidelines, and standards as they evolve.

“Healthcare facilities that do not maintain awareness of a changing environment risk harming patients, visitors, and staff as well as their reputations in the communities they serve,” Smith says. “An area of risk and opportunity for improvement for many healthcare facilities includes security officer use of force.”

Whether your security staff are armed (firearms, handcuffs, pepper spray, etc.) or unarmed, they are often involved in use of force, so appropriate and updated policies and training are vital.

What is use of force anyway?

In its updated guidelines, IAHSS defines use of force as “the amount of physical effort used to compel cooperation and compliance beyond a guiding touch.”

IAHSS says healthcare facilities should develop policies that identify circumstances where security (or contracted/proprietary law enforcement acting on behalf of the healthcare facility) is called upon and permitted to use force.

Use-of-force policies should contain:

  • Language requiring the use of only the minimum amount of force necessary to accomplish lawful objectives, and its immediate cessation once an individual is under control
  • The authorized level of force that may be deployed in various situations, including clinical and nonclinical circumstances
  • A use-of-force continuum of action that includes facility-approved techniques and authorized defensive equipment
  • Training requirements, which should include:
    • Initial and annual use-of-force training covering administrative and security policies
    • Proficiency testing and demonstrated physical competency in use of force and use of defensive equipment where authorized
    • For security programs using more than one type of use-of-force training (i.e., patient holds and restraint training versus law enforcement/corrections defensive tactics training), clear direction as to when each technique may be used
    • Knowledge of the totality of circumstances when applying the use of force
    • Awareness to prevent positional asphyxia
  • Procedures for rendering first aid and medical treatment to an injured party following the use of force
  • Documentation requirements for each use-of-force situation

“The (healthcare facility) should determine what physical restraint devices and physical techniques, if any, may be used by security personnel and under what circumstances they may be applied (clinical vs non-clinical situations),” IAHSS officials wrote in their guidance. “Use of Behavioral Health Emergency Response Teams (BERT) should be considered when evaluating use-of-force options, tools, and resources available within the (healthcare facility).”

When identifying and selecting restraint devices, physical techniques, defensive equipment, and use-of-force tools, if any, a security vulnerability assessment should be conducted, IAHSS officials added.

“Selected use-of-force techniques and tools should be aligned with the intention to use the least restrictive intervention possible,” they added. “A defined incident notification and review process should be in place to evaluate each use-of-force event.”

Florida’s view on use of force

It’s good to know what other institutions say about use of force, such as the prison system.

According to the Florida Administrative Code and Department of Corrections guide for use of force (33-602-210), some helpful definitions around terms and practices involving use of force include the following (keep in mind these are guidelines for state prison inmates):

  • Crisis intervention techniques: Methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, or behavioral distress.
  • Custodial grasp: The firm grasp by department staff of the tricep(s) or elbow(s) of an inmate who is being transported internally and who is proceeding appropriately.
  • Deadly force: Force that is likely to cause death or great bodily harm.
  • Electronic immobilization device: A device (handheld, dart-fired, shield, or belt/band) that delivers an immobilizing electric charge of predetermined and preset duration.
  • Less-than-lethal force: Any force that is neither intended nor likely to cause death or great bodily harm.
  • Psychiatric restraints: Devices, procedures, or techniques used to restrict movement or behavior so as to greatly reduce or eliminate the ability of an individual to harm themselves or others, including four-point and five-point psychiatric restraints.
  • Rapid response team: A team comprised of correctional officers specially trained in less-than-lethal and lethal munitions, chemical munitions, crowd control, and riot suppression.
  • Authorization to use force: Those who are responsible for supervising inmates are authorized to apply force on an inmate only when they reasonably believe it to be necessary to:
    • Defend themselves or others against imminent or already occurring unlawful force
    • Prevent a person from escaping from an institution when the staff member reasonably believes that person is lawfully detained in that institution
    • Gain custody of an escaped inmate
    • Prevent damage to property
    • Quell a disturbance
    • Overcome an inmate’s physical resistance to a lawful order
    • Prevent an inmate from inflicting self-injury or attempting to commit suicide
    • Restrain an inmate to permit the lawful administration of medical treatment under the supervision of a physician or the physician’s designee when treatment is necessary to protect the inmate from self-injury or death, or to protect the health of others

“Force is necessary only when it would be unreasonable to pursue other means of attempting to achieve one of the objectives listed [above],” according to Florida law. “Force is an option of last resort, to be used only after non-force options have been attempted and were ineffective or when the circumstances reasonably preclude attempting or continuing non-force alternatives to achieve one of the objectives listed.”

Healthcare policies need to be clear

Paul Sarnese, CHPA, MAS, MSE, CAPM, immediate past president of IAHSS and assistant vice president of safety, security, and emergency management for Virtua Health, says security leadership should use the IAHSS guidelines to ensure all recommended elements are included and to include legal/risk management, regulatory compliance, quality, nursing, behavioral health, and patient relations in the review process.

“Since many departments use nonlethal vocational aids like pepper foam or electroshock weapons, the policy must be very clear as to when those tools can be utilized,” Sarnese says. “The policy must include the kind of force that can be used. Who can use force to prevent someone from harming themselves or others? When can force be used to prevent someone from harming themselves or others? How much force can be used to control an individual? Where can force be used?”

Training matters, greatly

Security leaders must ensure that all security officers and supervisors are aware of the organization’s use-of-force policy. The policy should be reviewed and discussed with all new hires and at least annually with the veteran staff, according to Sarnese.

“I prefer a pre-test before providing the use-of-force training to measure staff awareness and ability to apply the policy in certain situations,” Sarnese says. “The pre-test can also help to identify weakness in the onboarding or continuing education provided to staff. The post-test provides a tool to measure competency and retention of the information provided. Scenario-based questions help to reinforce what circumstances can warrant the use of force.”

Be able to back up use of force

William S. Marcisz, JD, CPP, CHPA, president & chief consultant at Strategic Security Management Consulting and past executive director of security, safety, and emergency management at AdventHealth Central Florida, says security teams often implement sprawling use-of-force policies that cover every single situation imaginable because they’re afraid of getting sued.

He reminds security leaders that every situation is different, and hardly any use-of-force situation is black and white. For example, a 250-pound security guard encountering an agitated, 90-year-old Alzheimer’s patient will have different use-of-force considerations than a smaller security guard encountering an agitated, 250-pound, 35-year-old male.

“I think the things that [IAHSS] have identified here are good bare minimum requirements,” Marcisz says. “You’ll have some folks that are on the extreme end of the continuum and need to be told everything. They don’t want to be able to think for themselves. Whereas you’ll also have other folks that totally get this and are empowered to make these decisions. And the one thing that I’ve told staff over and over again is that you’re empowered to make these decisions. As long as you can substantiate the actions you have taken, you should not be concerned.”

Remember, Marcisz says: Any time security personnel involve tools in a use-of-force matter in healthcare (taser, mace, etc.), they need to be able to articulate why they took those actions.

“Otherwise, if you don’t do that, and then they turn around and file a complaint with a regulatory agency, the Joint Commission comes in and investigates, and they’re going to be asking those questions,” Marcisz says. “As long as you can articulate what was going on and why you needed to take that action, you’re fine.”

This article originally ran in Healthcare Safety Leader, an HCPro publication.