New restraint guidelines could be a problem for risk managers
JCAHO guidelines meant to protect patients, but compliance difficult
New restraint guidelines for behavioral health care could be a burden for clinicians and expose the organization to several types of increased risk, says a risk manager who studied the issue for Healthcare Risk Management. The guidelines will be difficult to implement, and they might be unnecessary, she says.
The guidelines were proposed recently by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. HRM asked Leilani Kicklighter, RN, ARM, MBA, DASHRM, assistant administrator for safety and risk management in the North Broward Hospital District in Fort Lauderdale, FL, to review the guidelines for risk management concerns. Kicklighter is a past president of the American Society for Healthcare Risk Management in Chicago.
She says the proposed guidelines should worry risk managers. While the guidelines obviously are a well-intentioned effort to protect patients from the abuse of restraints and seclusion, she says facilities will find it difficult to comply with some of the specifications. "I know the intent is to protect the patient, but I think most facilities already are doing all they can to reduce the use of restraints," she says. "That may not be the perception sometimes because of some bad cases covered in the media, but I don’t think most organizations abuse restraints to the extent that we would need these guidelines to prevent it. I don’t understand why the restraint standards of care already in place aren’t good enough to be applied to the entire organization, instead of coming up with special guidelines for behavioral health."
Kicklighter says the new guidelines are not bad for the patient in any way, and she would not mind following them in a world where staffing and physician access were no problem. But she suspects they are an overreaction to the cases in which restraints have been abused by some behavioral health centers. Instead of requiring those providers to adhere to existing standards, Kicklighter says it appears the Joint Commission wants to impose stronger standards on all behavior health centers.
"It’s sort of like they’re punishing everyone for the acts of some," she says.
Input solicited from providers
The Joint Commission has solicited comments on the proposed guidelines for a short time and now is considering possible changes based on those comments, says spokeswoman Charlene Hill. It is unlikely that risk managers had a chance to provide much criticism, however, because providers were given less than a month to get their comments in by Nov. 22.
The Joint Commission sought input on the draft standards, sending them to more than 3,000 individuals and organizations, including professional associations, consumer groups, government agencies, all organizations accredited by the Joint Commission under the Com prehensive Accredi tation Manual for Behavioral Health Care, and those organizations accredited under the comprehensive Accreditation Manual for Hospitals that are freestanding psychiatric hospitals or hospitals with inpatient psychiatric units, residential treatment facilities, or partial hospitalization programs.
The Joint Commission’s restraint-use task force will review the results of the field evaluation in December. The feedback received will be incorporated into the standards for final consideration by specific Joint Commission advisory committees and the Standards and Survey Procedures Committee of the Board of Commissioners during the first quarter of 2000.
Among the provisions in the draft standards is the statement that restraint and seclusion be used only in emergency situations — that is, when there is an imminent risk of an individual physically harming himself or others. Lesser interventions should be the first choice, the standards suggest, unless safety demands an immediate physical response.
A key provision of the guidelines is that a "licensed independent practitioner" must authorize the restraint or seclusion and then monitor the patient frequently, at least every eight hours. The Joint Commission defines that person as "any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges (these individuals may be referred to by other terms, such as independent care provider’). In many behavioral health organizations, licensed independent practitioners include physicians, psychologists, and social workers."
The guidelines do not make clear whether some other potentially qualified professionals might fit the bill. Kicklighter wonders about a master’s-prepared psychiatric nurse, for instance, who usually is allowed more independence in Florida. Some clarification about who might be considered a "licensed independent practitioner" could eliminate some compliance challenges, she says.
If the periodic assessment must be made by a physician in most cases, Kicklighter says it will be a problem for some facilities that do not have access to physicians or social workers around the clock. At a minimum, she says, facilities will have to call on physicians more frequently and at all hours, which will increase costs and tension.
"If that’s at two in the morning, you’re going to be able to hear the doctor screaming from my office," she says. "I’m not belittling the need for patient safety, but I think we can get to that without the stringent criteria on who can make this assessment. If it’s four in the morning and you don’t have a psychologist or a physician in-house 24 hours a day, someone’s going to have to get out of bed and come in."
The cost of caring for the patient increases if you call the practitioner in or if you change staffing patterns to ensure that a licensed practitioner is present around the clock, she says.
Staff may back off necessary restraint use
Kicklighter raises the possibility that the new guidelines could backfire if the behavioral health staff think they are too difficult to comply with. No nurse wants to wake a doctor in the middle of the night to assess a patient in restraints, so the nurse might just decide to forego restraints in that case. If the patient truly were dangerous to himself or others and the restraints were justified, that decision would increase the risk of injury and liability, Kicklighter says.
There also is the possibility, though Kicklighter says it is less likely in a well-run institution, that staff will go ahead with the restraints but ignore the requirement to have the patient reassessed.
Either way, the result is a problem for the risk manager. "I’m concerned about people using restraints less because of the difficulty of the standards, putting our employees at risk, as well as other patients and even visitors," she says. "I would hope that good patient care and nursing judgment prevail."
[Editor’s note: Copies of the standards are available at www.jcaho.org or by calling the Joint Commission’s customer service center at (630) 792-5800.]
Source
o Leilani Kicklighter, Assistant Administrator for Safety and Risk Management, North Broward Hospital District, 303 S.E. 17th St., Fort Lauderdale, FL 33316. Telephone: (954) 355-4993. E-mail: [email protected].
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