Introduction
At the request of the Office of the Chief Coroner of Ontario, the Geriatric and Long-Term Care Review Committee (GLTCRC) released a report on the death of a hospital patient following a near asphyxia episode while in a wheelchair with a lap belt.
Summary of Case Review
The GLTCRC reviewed the death of a 91‐year‐old male with advanced dementia who died in July 2023 following a near asphyxia episode while in a wheelchair with a lap belt.
The patient was seen by an occupational therapist in an acute care hospital for a seating and wheelchair assessment. Recommendations were provided to his family about wheelchair measurements, cushion and an “auto” positioning belt which means a buckle with a button that can be pushed to release. The wheelchair was intended to be a rental, to be used while he was in hospital and for the Assistive Devices Program (ADP) assessment post discharge. There was no documentation by the occupational therapist to indicate whether the patient could undo the belt or when the belt should be used. The physiotherapist documented that the patient could not undo the belt, but the care team did not recognize that this made the lap belt a restraint.
The patient was transferred to an Alternative Level of Care (ALC) unit managed by the same hospital. The family entered his room to find that he had slid down from the wheelchair and was trapped by the seat belt around his chest. He was holding the lap belt with both hands trying to relieve some of the pressure. Staff were able to release the belt and lift the patient to bed. Following this incident, the patient continued to medically decline, and he died 11 days later. The physician’s discharge summary states “the decedent was restrained without authorization of a physician”. The physician’s summary also stated, “the indications of use of the restraint is not clear but presumably inferred to have been used to mitigate falls risk.”
GLTCRC recommendation to the College:
When prescribing a lap belt, a “wearing schedule” or instructions on use should also be provided. Alternatives to a lap belt for positioning should be considered such as wedge cushions and tilt wheelchairs. Occupational Therapists should assess the user’s ability to release the belt buckle, and if unable, then remove the lap belt or initiate the facility restraint policy.
Use of wheelchair lap belts
A lap belt (also commonly known as seat belt or safety belt) is a device that is worn over a person’s lap to help position their pelvis in a wheelchair to optimize seating posture. The lap belt is attached to the wheelchair and has a front buckle with a push button to release. A lap belt may be included as a standard part of the wheelchair from the manufacturer. It can also be ordered separately to be installed on a wheelchair. While lap belts and wheelchairs are usually prescribed by a health professional for people in facilities such as hospitals or long-term care homes, they can also be purchased by clients and caregivers without input from a health professional from home medical supply stores.
| Benefits of using lap belts | Risks of using lap belts |
|---|---|
| • Promote postural support and alignment in the wheelchair by positioning the pelvis. • Increase sitting tolerance and stability in a wheelchair which in turn can enhance function, engagement and independence. • Promote safety and security in the wheelchair when being transported outdoors, moving in a power wheelchair or while riding on public transit. | • Used as a restraint. A restraint refers to any method—physical, chemical, or environmental—that restricts an individual’s freedom of movement or access to their own body, that they are unable to easily remove or refuse. • If a physical device is used and the client is both physically and cognitively unable to remove it independently, it is considered a restraint which can cause harm, injury and even death. • Improper fit or changes in the belt’s positioning can cause harm such as pressure points, discomfort, skin irritation/abrasions, or even entrapment and death. • Improper use for purposes it was not intended for, such as restrict movement to mitigate falls, can cause harm such as agitation, mental distress and physical injury. |
College Response
Occupational therapists are trained healthcare professionals with the knowledge and skills to assess clients and their environments and identify the risks and benefits of appropriate equipment and devices to optimize safety, functioning and well-being.
When assessing clients and implementing intervention plans, occupational therapists are expected to follow the Standard for Assessment and Intervention, 2023:
- Manage risks, and collaborate and communicate with clients, other professionals, partners, and interested parties to support evidence-informed decision-making.
- Communicate assessment and intervention effectively such as results, opinions, recommendations, and updates.
- Review and evaluate plans regularly in partnership with clients.
- Know and follow workplace policies and applicable legislation.
Considerations
The following reflective questions can help occupational therapists in their assessment and intervention process when recommending devices such as a lap belt:
Step 1: Understanding wheelchair lap belts
- Do I have the competencies (knowledge, skills, judgement and training) to assess, recommend and implement lap belts or alternatives?
- Do I have knowledge about lap belts and their potential risks including being a restraint in some settings?
- What legislation applies to my practice? For example:
- What workplace or facility policies apply to my practice? For example, restraint policies or equipment policies in the community.
- Are there any legislative and policy requirements for a physician to provide a medical order for an occupational therapist to assess for a device or restraint?
- Is there evidence to support the use of lap belts or alternatives based on the client’s condition/status?
- Is there any manufacturer’s information about intended use, set up and risks of their product?
- What should I consider for clients and families who purchase their own wheelchairs with lap belts who are not in hospitals, long term care or retirement homes?
Step 2: Assessment
- What is the occupational issue being addressed?
- Why is a device such as a lap belt being considered for the client?
- Does this client have any limitations (physical, cognitive, behavioural) that could impact their ability to use a lap belt safely?
- Does the client’s abilities or functional status change or fluctuate?
- Can the client independently and reliably undo the buckle and release the lap belt?
If not, the lap belt is considered a restraint, which has risk of harm, injury and even death. Consider:
- is there a restraint policy and protocol that needs to be followed in the facility?
- Do you need to develop a protocol for your private practice?
- Is the lap belt positioned properly with the client in the wheelchair and serving its purpose?
- Are there opportunities when the client or the lap belt may shift position over time?
- Are there other factors (social, environmental, cultural) that could impact the safe use of a lap belt?
- Are other options and alternatives such as wedge cushions or tilt wheelchairs being considered?
- Does the client, family and caregivers understand the risks and have the capacity to monitor the safe use of the lap belt over time?
Step 3: Analysis/Collaboration
- Is a lap belt appropriate for the client and environment?
- Are there any contraindications for recommending a lap belt for this client?
- Could a lap belt be a restraint or become a restraint for this client?
- Is there additional information from the interdisciplinary team that can guide decision-making, such as the effect of medications, fluctuations in condition, or history of falls.
- Is there any information from the manufacturer about recommended installation and intended use?
- Have all options been considered to ensure the minimization of restraining in hospitals, long term care and retirement homes?
- If a restraint is required, should another device be used (for example: 3-point belt or harness)?
- Has education been provided to clients, caregivers and care team members? Education should include:
- instructions on how to use and position the lap belt
- a wearing schedule on when the client should use the lap belt and duration
- information about its intended use (for example: to promote sitting alignment) and the risks when used improperly for other purposes (for example: to restrict movement)
- What is the plan to monitor the client’s safety and use of lap belt?
- When will the device be re-assessed?
Step 4: Monitoring and Re-evaluation
- Have I reassessed the client using the lap belt within the planned timeframe?
- Are adjustments to the lap belt positioning or wearing schedule needed?
- Should the lap belt be removed if no longer safe or indicated?
- Is further training to the client and caregivers necessary?
- Is there clear accountability for ongoing monitoring of device use
- Is there clear documentation of the processes involved?
Summary
The Office of the Chief Coroner of Ontario has requested the College educate occupational therapists about the risks of lap belts on wheelchairs. It is important that occupational therapists understand the legislative and policy requirements of their practice setting, perform thorough assessments, and collaborate with all parties involved, including the client, their family, and other healthcare professionals to address safety risks. Providing education is key to prevent any future deaths from the use of this type of equipment.
General implications for occupational therapy practice
While the recommendations from the Coroner’s report focus on hospitals and long term care settings, it has implications for other practice areas. Occupational therapists also work with clients in homes, schools and the community where they may prescribe wheelchairs and lap belts. They may also encounter clients who have purchased their own lap belt for use without the input from a health professional. Any equipment or device can have the potential to become a restraint. Occupational therapists are encouraged to use the reflective questions to guide their practice when recommending devices to clients and caregivers.