Evaluation of Incarcerated People in Custody-ordered Restraints

Posted on August 13, 2009 –


Recognizing that restraints can be a necessary tool that custody staff must sometimes use to control the behavior of incarcerated individuals, the American College of Correctional Physicians adopts this position statement with a goal to enhance safety for both incarcerated individuals and staff.

Restraints are used by criminal justice agencies and in correctional facilities for a variety of purposes, including:

  • the safe escort of incarcerated people within and between secure environments (e.g., wrist, waist and leg restraints);
  • seclusion or restraint, as an emergency measure, by a physician’s order for mental health or medical reasons to prevent imminent harm to the patient or other persons when other means of control are not effective or appropriate; and
  • custody-ordered restraints to control an incarcerated person’s problematic behavior by strictly limiting movement (e.g., four point restraints, restraint chair).

This position statement focuses solely on the last example: the use of custody-ordered restraints when they are used to control an incarcerated person’s aggressive or self-destructive behavior by strictly limiting movement. Note: Guidance on physician-ordered restraints and seclusion may be sought from other sources, such as the statement of a workgroup of the Council on Psychiatry and Law.1

Groundbreaking work by Strumpf and Evans resulted in a marked change in restraint standards and decreased use of restraints for patients in nursing homes and hospitals.2 When physical restraint is used as the measure of last resort, the result has generally been enhanced institutional, patient and staff safety. ACCP endorses the extension of this key concept to correctional justice facilities.

Incarcerated people may have medical or mental conditions that bring about, or may be a result of, the use of custody-ordered restraints that strictly limit movement. Because custody personnel are not clinicians, they do not have the background or training to make clinical assessments. Therefore, evaluation by qualified health care professionals3 is required in most circumstances and should always be available and used. The availability of such services must be considered before security staff make a decision to place an inmate into physical restraints for behavior control.

There is no use of physical restraint that is without risk. Physical restraint, for even brief periods of time, may be associated with a variety of harmful outcomes, including local trauma, myocardial infarction, asphyxia, aspiration, venous thrombosis, pulmonary embolism, rhabdomyolysis and death. Even with monitoring by qualified health care professionals, bad outcomes may occur. Qualified health care professionals should provide adequate information to security staff to assist them in assessing the possible health risks as well as the possible benefits in the use of custody ordered restraints.

The National Commission on Correctional Health Care addresses the use of restraints in its Standards for Health Services (standards J-I-01,P-I-01 and Y-I-01). The compliance indicators for these standards require immediate notice to health services staff, reviewing the health record for contraindications or required accommodations, and health monitoring during restraint. Further, the NCCHC standards require notice to the physician and communication of concerns regarding improper use of restraints to appropriate custody staff.4,5,6 ACCP supports and endorses the NCCHC standards and presents this position statement as an elaboration on them.

Position Statement
The American College of Correctional Physicians endorses the following principles for the medical evaluation of incarcerated people placed in custody-ordered restraints to control problematic behavior by strictly limiting movement:

  • Restraints are only used when less restrictive measures are, or would be, ineffective to protect the incarcerated person or others from harm.
  • Potential risk to the incarcerated person from the use of restraints that strictly limit movement should be considered before such restraints are used to control behavior.
  • Facilities should have and use policies and procedures regarding the use of custody-ordered restraints. The policies and procedures should include specific plans for the medical and mental health evaluation and monitoring of all incarcerated people who remain in custody-ordered restraints for behavior control for more than a few minutes. The medical director of the facility or system should have input into the development and periodic review of these policies and procedures.
  • Qualified health care professionals evaluate incarcerated people as patients and do not give clearance, permission or consent to the use of custody-ordered restraints. These health care professionals are present for the benefit of their patients and to advise security regarding the medical best interests of the restrained individual.
  • If further medical evaluation and treatment, including off-site care, is ordered by a qualified health care professional, timely arrangements should be made for such care. This requires a collaborative effort by health care and custody staff.
  • Incarcerated people in custody-ordered restraints to control behavior need access to adequate hydration, food, hygiene, toileting and ongoing health monitoring by qualified health care professionals.
  • While custody staff should frequently assess the need for continued restraints as a security procedure, health staff should frequently assess the potential health risks of continued restraints, as these may change over time. Any change in health risk must be communicated to the appropriate custody staff.
  • All health services and custody staff should be trained regarding the safe evaluation of incarcerated people with problematic or dangerous behavior and the requirements for the care of restrained individuals before, during and after being physically restrained. Staff should also be trained to recognize possible injuries and adverse reactions that may be associated with the use of this form of physical control, and to recognize that negative outcomes may occur even with monitoring by qualified health care professionals.
  • All health services and custody staff have a duty to report occasions of possible abuse and patient deterioration (physical or mental).

Adopted by the ACCP Board of Directors
July 31, 2008


1 Strumpf, N.E., Robinson, J., Wagner, J., & Evans, L. (1998). Restraint Free Care: Individualized Approaches for Frail Elders. New York: Springer Publishing Company.
2 Metzner, J.L., et. al., “The Use of Restraint and Seclusion in Correctional Mental Health Care”. Resource Document, Approved by the Joint Reference Committee, December 2006, American Psychiatric Association.
3Qualified health care professionals include physicians, physician assistants, nurses, nurse practitioners, dentists, mental health professionals, and others who by virtue of their education, credentials, and experience are permitted by law to evaluate and care for patients.
4 Standards for Health Services in Jails. (2008). Chicago, IL: National Commission on Correctional Health Care.
5Standards for Health Services in Juvenile Detention and Confinement Facilities. (2004). Chicago, IL: National Commission on Correctional Health Care.
6 Standards for Health Services in Prisons. (2008). Chicago, IL: National Commission on Correctional Health Care.