D. Emergency Behavior Interventions

Many trauma-informed care trainings promote specific strategies including self-care approaches, peer-provided services, arts programs, and comfort rooms to enhance healing and as means to avoid the use of restraint and seclusion. In Texas, the Administrative Code offers the following guidelines on utilizing Emergency Behavior Interventions, such as restraints and seclusion, on children in General Residential Operations and Residential Treatment Centers.

1. Restraint/Seclusion May Only Be Used:

•   As last resort

26 Tex. Admin. Code § 748.2455(a)(1) and (2); 26 Tex. Admin. Code § 749.2055(a)(1) and (2); 26 Tex. Admin. Code § 748.2551(a); and 26 Tex. Admin. Code § 749.2151

•   After less restrictive and more positive measures have been tried and failed

26 Tex. Admin. Code § 748.2455(a)(1) and (2); 26 Tex. Admin. Code § 749.2055(a)(1) and (2); 26 Tex. Admin. Code § 748.2551(a); and 26 Tex. Admin. Code § 749.2151(a)

•   Only in an emergency situation or to administer intra-muscular medication or other physician prescribed medication

26 Tex. Admin. Code § 748.2455(a)(2); 26 Tex. Admin. Code § 749.2055(a)(2); 26 Tex. Admin Code § 748.43(21); and 26 Tex. Admin. Code § 749.43(23) (Definition of emergency situation)

•   Where immediately necessary

26 Tex. Admin. Code § 748.43(19); 26 Tex. Admin. Code § 749.43(21) (Definition of Emergency Behavioral Intervention (EBI); 26 Tex. Admin Code § 748.43(21); and 26 Tex. Admin. Code § 749.43(23) (Definition of emergency situation)

•   To prevent imminent probable death or substantial physical injury

26 Tex. Admin. Code § 748.43(19); 26 Tex. Admin. Code § 749.43(21) (Definition of (EBI)) 26 Tex. Admin. Code § 748.43(21); 40 Tex. Admin. Code § 749.43(23) (Definition of emergency situation) 26 Tex. Admin. Code § 748.43(64); and 26 Tex. Admin. Code § 749.43(66) (Definition of substantial physical injury)

•   NEVER as punishment, retaliation, means of compliance, convenience, or treatment

26 Tex. Admin. Code § 748.2463 and 26 Tex. Admin. Code § 749.2063

2. Types of Restraints That May Be Administered with Restrictions:

•   Short personal restraint and personal restraint

26 Tex. Admin. Code § 748.2451(a)(1) and (2); 26 Tex. Admin. Code § 749.2051(a)(1) and (2); 26 Tex. Admin. Code § 748.43(48) and (61); and 26 Tex. Admin. Code § 749.43(48) and (64) (Definition)

•   Emergency medication

26 Tex. Admin. Code § 748.2451(a)(3); 26 Tex. Admin. Code § 749.2051(a)(3); 26 Tex. Admin. Code § 748.2753 (simultaneous use with another EBI) 26 Tex. Admin. Code § 749.2233 (simultaneous use with personal restraint) 26 Tex. Admin. Code § 748.43(20); and 26 Tex. Admin. Code § 749.43(22) (Definition)

•   Seclusion

26 Tex. Admin. Code § 748.2451(a)(4); 26 Tex. Admin. Code § 748.2651; 26 Tex. Admin. Code § 748.43(59); 26 Tex. Admin. Code § 749.43(62) (Definition) and 26 Tex. Admin. Code § 749.2051(b)

•   Mechanical restraint

26 Tex. Admin. Code § 748.2451(a)(5); 26 Tex. Admin. Code § 748.2701; 26 Tex. Admin. Code § 748.2703; 26 Tex. Admin. Code § 748.2755 (simultaneous use with emergency medication) 26 Tex. Admin. Code§ 748.43(37); 26 Tex. Admin. Code § 749.43(38) (Definition) and 26 Tex. Admin. Code§ 749.2051(b)

3. Restraint/Seclusion May Only Be Administered by:

•   A caregiver qualified in emergency behavior interventions

26 Tex. Admin. Code § 748.2453; 26 Tex. Admin. Code § 749.2053; 26 Tex. Admin. Code § 748.947; 26 Tex. Admin. Code § 749.947; (Annual Training) 26 Tex. Admin. Code § 748.903; 26 Tex. Admin. Code § 749.903; (Pre-service training) 26 Tex. Admin. Code § 748.863(a); 26 Tex. Admin. Code § 749.863(a); (Training hours) 26 Tex. Admin. Code § 748.901; and 26 Tex. Admin. Code § 749.901

•   Whose duties include the direct care, supervision, guidance, and protection of child

26 Tex. Admin. Code § 748.43(5) and 26 Tex. Admin. Code § 749.43(8)

4. A Child Must Be Released from a Restraint/Seclusion:

•   IMMEDIATELY if an emergency health situation arises

26 Tex. Admin. Code § 748.2553(1)(A), (2)(A), (4)(A), and (5)(A); 26 Tex. Admin. Code § 749.2153(1)(A) and (2)(A); 26 Tex. Admin. Code § 748.2603; and 26 Tex. Admin. Code § 749.2203

•   IMMEDIATELY once the danger is over

26 Tex. Admin. Code § 748.2553(2)(C) and 26 Tex. Admin. Code § 749.2153(2)(C)

•   Once maximum time allowed is reached

26 Tex. Admin. Code § 748.2553(2)(E); 26 Tex. Admin. Code § 749.2153(2)(E); and 26 Tex. Admin. Code § 748.2553(2)(E) and (4)(D)

Figure: 26 Tex. Admin. Code § 748.2553

Type of Emergency

Behavior Intervention

The caregiver must release the child:

(1) Short personal restraint

(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; or

(B) Within one minute, or sooner if the danger is over or the disruptive behavior is de-escalated.

(2) Personal restraint

(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately;

(B) Within one minute of the implementation of a prone or supine

hold;

(C) As soon as the child's behavior is no longer a danger to himself or others;

(D) As soon as the medication is administered; or

(E) When the maximum time allowed for personal restraint is reached.

(3) Emergency medication

Not applicable.

(4) Seclusion

(A) Immediately when an emergency health situation occurs during the seclusion. The caregiver must obtain treatment immediately;

(B) As soon as the child's behavior is no longer a danger to himself

or others;

(C) No later than five minutes after the child begins exhibiting the required behaviors;

(D) When the maximum time allowed for seclusion is reached;

(E) If the child falls asleep in seclusion. In this situation, the

caregiver must:

(i) Unlock the door;

(ii) Continuously observe the child until he awakens; and

(iii) Evaluate his overall well-being; or

(F) If the child is receiving emergency care services:

(i) As soon as the child is no longer a danger to himself or others; (ii) Upon the arrival of a medical professional; or

(iii) Upon assistance from law enforcement or the fire department.

(5) Mechanical restraint

(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately;

(B) As soon as the child's behavior is no longer a danger to himself or others;

(C) No later than five minutes after the child begins exhibiting the

required behaviors;

(D) When the maximum time allowed for mechanical restraint is reached; or

(E) If the child falls asleep in the mechanical restraint. In this situation, the caregiver must release the child from the restraint and continuously observe the child until he awakens and evaluate him.

The maximum amount of time for a restraint/seclusion (26 Tex. Admin. Code § 748.2801):

Figure: 26 Tex. Admin. Code § 748.2801

Types of Emergency

Behavior Intervention

The maximum length of time is:

(1) Short personal restraint

One minute.

(2) Personal restraint

(A) For a child under nine years old, 30 minutes;

(B) For a child nine years old or older, one hour; or

(C) A prone or supine personal restraint hold may not exceed one minute.

(3) Emergency medication

Not applicable.

(4) Seclusion

(A) For a child under nine years old, one hour.

(B) For a child nine years old or older, two hours.

(5) Mechanical restraint

(A) For a child under nine years old, 30 minutes.

(B) For a child nine years old or older, one hour.

When restraining/secluding, a written order is required:

26 Tex. Admin. Code § 748.2501(3) and 26 Tex. Admin. Code § 749.2101(3)

26 Tex. Admin. Code § 748.2501(5)

26 Tex. Admin. Code § 748.2501(2); 26 Tex. Admin. Code § 749.2102(2)(A); 26 Tex. Admin. Code § 748.2751(3); and 26 Tex. Admin. Code § 749.2231(a)

26 Tex. Admin. Code § 748.2501(2); 26 Tex. Admin. Code § 749.2101(2)(A); 26 Tex. Admin. Code § 748.2753(a)(3) and (b); 26 Tex. Admin. Code § 749.2233(a) (Emergency medications with personal restraint) and 26 Tex. Admin. Code § 748.2755(a)(3) and (b) (Mechanical restraints with emergency medications)

26 Tex. Admin. Code § 748.2805; 26 Tex. Admin. Code § 749.2283

Figure: 26 Tex. Admin. Code § 748.2501

Type of Emergency Behavior

Intervention

Are written orders required to administer the intervention for a specific child?

Who can write orders for the use of the intervention for a specific child?

(1) Short personal restraint

NO.

Not applicable.

(2) Personal restraint

NO. However, successive restraints, a restraint simultaneous with emergency medication, and/or a restraint that exceeds the maximum time limit all require orders as specified in this subchapter. PRN orders are also permitted under

§748.2507 of this title (relating to Under what conditions are

PRN orders permitted for a specific child?).

Not applicable.

(3) Emergency medication

YES.

A licensed physician.

(4) Seclusion

YES, except written orders are not required when you provide emergency care services to the child placed in seclusion.

A licensed psychiatrist, psychologist, or physician.

(5) Mechanical restraint

YES.

A licensed psychiatrist.

A review is triggered when:

26 Tex. Admin. Code § 748.2901(a)(2)(A) and 26 Tex. Admin. Code § 749.2331(a)(2)(A)

26 Tex. Admin. Code § 748.2901(3) and 26 Tex. Admin. Code § 749.2331(3)

26 Tex. Admin. Code § 748.2901(a)(4) **NOTE: Not applicable to foster care placements.

26 Tex. Admin. Code § 748.2901(a)(5) **NOTE: Not applicable to foster care placements.

Restraint/Seclusion that is NOT allowed:

*Foster care placements may never administer chemical restraints, mechanical restraints, or seclusion.

26 Tex. Admin. Code § 748.2757 and 26 Tex. Admin. Code § 748.2507(5)

26 Tex. Admin. Code § 748.1119(1); 26 Tex. Admin. Code § 749.1021(1); 26 Tex. Admin. Code § 748.2451(b); 26 Tex. Admin. Code § 749.2051(b); 26 Tex. Admin. Code § 748.43(7); and 26 Tex. Admin. Code § 749.43(11) (Definition)

26 Tex. Admin. Code § 748.2605(b); 26 Tex. Admin. Code § 749.2205(b) and (c); 26 Tex. Admin. Code § 748.2461(b)(1); 26 Tex. Admin. Code § 749.2061(b)(1); 26 Tex. Admin. Code § 748.2553(2)(B); 26 Tex. Admin. Code § 749.2153(2)(B); 26 Tex. Admin. Code § 748.2801(2)(B); and 26 Tex. Admin. Code § 749.2281(2)(B)

Also see other relevant provisions:

•   26 Tex. Admin. Code § 748.2705 (types of mechanical & other restraint devices prohibited)