AACP Newsletter, Volume 13,
Number 4, Autumn 1999
AACP Response to HCFA Seclusion and Restraint Regulations
The Health Care Financing Administration (HCFA) has published regulations that govern use of restraints and seclusion in Medicare and Medicaid financed hospitals. These are included as a part of a section on Patient Rights and Protections. This position statement was drafted to specifically respond to these HCFA rules by the August 31, 1999 time deadline. AACP feels further discussion is needed to study these complex issues and to give input to pending Federal legislation. May 30, 2003 - Web Editor's Note: The HCFA is now called the CMS - Centers for Medicare and Medicaid Services.
In general, AACP applauds the rules and regulations as spelled out by HCFA. We agree that restraint and seclusion should be used only in an emergency to ensure the safety of the patient and others, and when less restrictive alternatives have been ineffective. We also support training of all treatment staff in de-escalation methods. We also support debriefing with the patient after a restraint/seclusion incident to reduce the traumatic process of the event. We support the reporting of deaths, injuries, and other "sentinel" events to Protection and Advocacy Systems (P & As) to help investigate trends and possible misuse.
AACP does take issue with the so-called "1-hour rule" in the HCFA guidelines. This rule stipulates that a physician or "other licensed independent practitioner" must do a face-to-face evaluation within one (1) hour of initiation of restraint or seclusion, and must continue this process on the hour to continue restraint or seclusion. There has been reference to "best practice" in the state hospitals in Pennsylvania. We feel there is significant difference between a non-acute state hospital and an acute care psychiatric inpatient unit or psychiatric hospital. Acute care facilities treat patients often admitted when they are a danger to themselves and others. Often these patients have a concomitant substance abuse problem, and may be severely intoxicated. In such an acute setting seclusion and restraint may be necessary for the protection of the individual and others.
Rural hospitals may not have the availability of a physician within one (1) hour. Some hospitals could use a non-psychiatrist "house doctor" in an emergency to comply with the rule. We would argue that this would not help in any way regarding proper use of restraint or seclusion. Requiring a physician on-site evaluation to authorize the restraint or seclusion does not recognize the highly professional role of clinically sophisticated psychiatric nurses. The assessment of the nurse who is present on the unit and is aware of the dynamics of the patient and the ward situation is vital. Physicians not trained in psychiatry generally would be less capable of exercising professional judgment regarding the need for restraint or seclusion than properly trained psychiatric nurses. When psychiatric staffing is not readily available in the community, some facilities may turn away patients that have a potential risk for restraint or seclusion, and require them to go much farther to get care. The costs of hiring physicians to be "in house" 24 hours a day, seven days a week, or paying for physician staff to come in for emergencies within one (1) hour time frame would be significant. Our psychiatrists who serve rural communities warn that the one (1) hour rule will cause many rural hospitals to refuse to serve psychiatric patients in emergent situations, and to refer difficult patients to police and jails to provide the necessary security, far outside the protections for patient rights offered by HCFA rules. Funds for increasing availability of physicians to serve the one (1) hour rule would better be used in providing community services, discharge planning, or residential services.
The core issue in this discussion of accountability in authorizing the use of restraints and seclusion is that they should be authorized only by staff that have been trained to safely and humanely apply restraint and seclusion interventions, and who demonstrate competencies in alternative methods, de-escalation, and safety issues. Physicians who may authorize such interventions should also be trained and demonstrate these competencies. The physicians who most reliably have such training are psychiatrists.
The AACP offers the following recommendations regarding regulations on the practice of restraint and seclusion in psychiatric in-patient units.
- The AACP supports regulations whereby use of restraint and seclusion be limited to an emergency to ensure the safety of the patient and others, and when less restrictive alternatives have been ineffective.
- Restraint or seclusion episode should be initially authorized by an RN who has demonstrated competencies in use of restraint and seclusion. The RN should immediately consult with the attending psychiatrist (or on-call psychiatrist if after regular hours) to discuss the case and decide on a treatment plan. This treatment plan should address the emergency situation in the most efficient manner so the restraint and seclusion can be most promptly discontinued when safety is re-established. During the period of restraint or seclusion, the RN should check the health status of the patient every fifteen minutes.
- Formal renewal order for maintaining the episode of restraint of seclusion should be drafted no less than every four (4) hours after the patient's progress has been reviewed and charted by the psychiatrist and psychiatric nurse. This review will include a documented psychiatric face-to-face clinical evaluation of the patient continuing in restraints or seclusion and a documented nursing staff consultation.
The majority of community psychiatrists in the AACP, many of whom work in acute care situations and who have a great deal of practical experience with the practice of restraint and seclusion, believe that our last recommendation regarding the timing and nature of physician reviews will meet the goals of the HCFA and those in the advocacy community regarding patient care and safety. It is our belief that the level of involvement by a psychiatrically trained physician which we have recommended above is sufficient to assure competent practice when the treatment team includes psychiatric nursing staff on site who have had training in the use of restraints and seclusion. Such a team, which is specially trained, is preferable to using non-psychiatric physicians, who do not necessarily have competencies in acute care practices, including restraint and seclusion, for psychiatrically ill patients.
The AACP will continue to study this issue. Further study is needed in different settings (Medical-Surgical units, residential care) and with different populations (youth, elderly, culturally diverse groups). We look forward to playing a role in continued discussions of this critical topic. Our discussions with community psychiatrists practicing in hospital and residential settings with children have highlighted the critical importance of considering age and developmental status. Some forms of restraint, such as special procedures for holding children, may have therapeutic merit in younger age groups. In addition, we need to consider how the guidelines may impact on the practice of applying soft restraint to the demented elderly. In it important that HCFA examine its regulations to make room for exceptions, so as to avoid unintended consequences.
Charles Huffine, MD
President, AACP
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