HCFA overrules JCAHO restraint standard
One-hour rule remains the law of the land
HCFA reigns. There is no longer a conflict between the regulations of the Baltimore-based Health Care Financing Administration (HCFA) and the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL regarding the use of restraints and seclusion for hospitalized patients.
In a final rule issued on May 1, the Joint Commission held that when the decision is made to restrain or seclude a patient, that patient must be evaluated by a licensed practitioner within four hours. (See story in Hospital Peer Review, June 2000, p. 73.) But HCFA continues to require that a patient under restraint or seclusion be evaluated within one hour.
Robert A. Streimer, deputy director of HCFA’s office of clinical standards and quality, did not favor the idea of the "four-hour" rule proposed by the Joint Commission. In a letter dated May 9, Streimer told Dennis S. O’Leary, MD, president and CEO of the Joint Commission, that the rule wouldn’t jibe with HCFA’s requirements. The Joint Commission will, therefore, add to its standards that hospitals seeking deemed status be required to honor HCFA’s one-hour rule for restrained or secluded patients.
"The higher standard would have to be applied in either case if the institution was a Medicare facility," according to Michael Allen, MD, immediate past president of the Bedford, MA-based American Association of Emergency Psychiatry in "Of course, if the hospital doesn’t take Medicare patients, then the standard for restraints could have been [the Joint Commission’s] four-hour requirement. However, Medicare is a big payer for most hospitals, so, in general, the one-hour rule would have applied for almost all institutions."
The JCAHO regulation goes into effect in January 2001. But it apparently means little to most hospitals because they would have been required to adhere to HCFA’s higher standards if they planned to take Medicare payments. The JCAHO already had stated that it would enforce the HCFA rule if there were a conflict.
This means the hospital industry remains under mandate to provide the often difficult and expensive assessment of patients under seclusion or restraint within an hour by a physician or licensed independent practitioner. It’s a big problem, especially for small facilities.
"In our case, we have our state mental health department to contend with in addition to HCFA and the Joint Commission," says Martha Stephan, MBA, RN, CPHQ, director of quality improvement at Laurelwood Hospital & Counseling Centers, University Hospital Health System, in Willoughby, OH. "We are still in a quandary as to where to go with this. We have no round-the-clock medical staff. To expect that we’ll get a licensed practitioner to come in within an hour is a real problem for us."
With 128 psychiatry beds and 32 alcohol and rehab beds, Willoughby is a good example of what small behavioral health hospitals will be facing with the standards.
"What we’re trying to do is to work with state and other authorities to get some kind of resolution to the problem," says Stephan. "We’d like to have advanced practice RNs who could be authorized by the state to handle these one-hour evaluations. Otherwise, we can’t meet the standard, and we’ll have to close or accept the fact that we can’t restrain our patients."
In addition to limiting restraints and seclusion, the Joint Commission standards emphasize education and training for staff and promote effective communication between the staff and the responsible physician or practitioner.
For example, staff must demonstrate an understanding of the factors that influence behavior and may result in the need for restraints or seclusion. These could include pre-existing medical conditions, physical disabilities or limitations that would place the patient at greater risk during seclusion or restraint, and any history of sexual or physical abuse that would create greater psychological risk.
The standards also address the holding of patients and call for staff training in the use of de-escalation techniques, mediation, and self-protection in order to avoid the use of restraint and seclusion. Competent staff members will be required to assess the restrained or secluded patient every 15 minutes.
The two organizations both claim that their standards are the best answer, particularly for vulnerable mental health patients, and that they are trying to work cooperatively.
"Because restraint and seclusion have the potential to produce serious consequences such as physical and psychological harm, loss of dignity, violations of an individual’s rights and even death," says the Joint Commission’s statement, "organizations should continually explore ways to prevent, reduce and strive to eliminate the use of restraint and seclusion through effective performance and improvement initiatives." The statement adds, "non-physical interventions are the first choice as an intervention unless safety issues demand an immediate physical response."
"Our new regulations are a major step in directly addressing the inappropriate use of seclusion and restraints in mental health facilities," HCFA deputy director Michael Hash told the Senate Finance Committee late last year. "We are profoundly disturbed by the reports of deaths and injuries resulting from the inappropriate use of seclusion and restraints in [these] facilities. Also, importantly, we are working with the Joint Commission to improve its performance in monitoring the use of seclusion and restraint. We are confident that our regulations will be effective in reducing inappropriate use of seclusion and restraints in inpatient hospitals."
The Joint Commission weighed in with its own statement released May 1. "In light of the federal regulations regarding patient rights that were issued last summer, the Joint Commission has shared the revised standards with HCFA officials. The Joint Commission acknowledges that the interim final rule set forth by HCFA in July 1999 provides for a one-hour time frame for the initial face-to-face evaluation by a physician or licensed independent practitioner of a patient in restraints." The Joint Commission claimed that its revised standards provide for an equal or greater level of protection and safety for these individuals. Shortly after that, however, the JCAHO rolled over and agreed to support the one-hour rule.
What can hospitals do to come up to speed?
"For now, we’re trying to reduce the use of seclusion and restraints to ensure that they are appropriate and to make sure our patients are safe," says Laurelwood’s Stephan. "We’re in the process of revising our policy, but the more we look at it, the more we realize we need to come to some agreement with the powers that be. Usually, they’ll give you some time to gear up and get yourself in compliance."
But the bottom line is that it appears that facilities must either follow the one-hour rule or simply refrain from using restraints or seclusion.
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