HCFA mandates new limits for restraint, seclusion use
Patient protections go beyond JCAHO’s edicts
On July 2, the Health Care Financing Admini-stration (HCFA) published strict new rules on patient restraints — stricter, in fact, than the standards already mandated by the Joint Com-mission on the Accreditation of Healthcare Organizations (JCAHO).
John K. Stanwood, PhD, chief of psychology at the Hospital for Special Care in New Britain, CT, says this is the first time HCFA has been so specific in its guidelines on restraint and seclusion. "In the past, HCFA has basically gone along with JCAHO and our Connecticut State Health Department in ensuring that restraint standards were met by hospitals," Stanwood says. In these latest regulations, too, the federal agency states that it will consider JCAHO accreditation a sign of compliance for a hospital.
"HCFA picked the stricter standards that JCAHO first came out with, then backed off from after receiving feedback from providers," he says. But HCFA didn’t back off on everything. "For example, JCAHO takes out any mention of chemical restraint in its current guidelines, and HCFA mentions chemical restraints right along with physical restraints," Stanwood notes.
He says that until HCFA published its latest regulations, both the feds and Connecticut focused more on inpatient mental health units than on acute care hospitals. But he notes that HCFA appears to have adopted the stricter guidelines for all hospitals. JCAHO had reserved those specific guidelines just for behavioral health or psychiatric facilities, including varying time lines for use of physical restraints by age of patient and how soon an independent practitioner must evaluate a patient placed in restraints.
Stanwood says that he and his colleagues aren’t sure how HCFA will be able to monitor the stricter guidelines without doing their own inspections separate from JCAHO and the state.
Here’s a summary of how the HCFA and JCAHO restraint standards compare:
- HCFA adopted JCAHO’s concept of time-limited orders. In the 1999 Hospital Accreditation Standards, the intent statement for standard TX.7. 1.3.1.8 provides that written orders for restraint or seclusion for behavioral health patients be limited to four hours for adults, two hours for children and adolescents 9-17, and one hour for patients younger than 9. HCFA emphasizes that the time frames represent maximum intervals for which each order can be written. And, while patients are being restrained or secluded, their status must be continually monitored, assessed, and reevaluated with an eye toward releasing them at the earliest possible time.
-r JCAHO states in its explanation of intent for standard TX.7.1.3.1.7 that providers every day should review restraint and seclusion use related to their patients. HCFA adopted a parallel philosophy by specifying in its regulation that an order for restraint or seclusion may only be renewed in the previously mentioned increments for up to a total of 24 hours. After that, practitioners must reevaluate their patients face to face before writing new orders.
- HCFA differentiates between situations where restraints are used to provide medical-surgical care and those where restraints or seclusion are used to manage behavior, an approach similar to that adopted in existing JCAHO standards. But the new HCFA regs are not specific to the treatment setting, but to the situation the restraint is being used to address. "When a restraint is applied in the course of acute medical-surgical care, the intervention is generally not undertaken because of an unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger to the patient and others," states the HCFA document. Rather, they may be necessary to ensure that an IV or feeding tube will not be removed, or that a patient will not re-injure himself by moving after surgery has been completed. "The use of restraints or seclusion to manage behavior is an emergency measure that should be reserved for those occasions when an unanticipated, severely aggressive, or destructive behavior places the patient or others in imminent danger," states the document.
• HCFA adopted JCAHO’s definition of seclusion: "the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving."
Michelle Camicia, RN, MS, CRRN, clinical manager at California Pacific Medical Center, a community teaching hospital in San Francisco, says that, in general, HCFA’s new regulations require practitioners and institutions to treat restraint use as it is — a high-risk intervention that requires competent staff who have to be able to manage patient behavior and properly apply restraints. But she sees problems as well.
"I disagree with having two separate standards for observation," she says. "HCFA terms it continual assessment.’ I agree that we should always be assessing the appropriateness of discontinuing the restraint. However, this does not require constant observation. The frequency of observation requirements should be the same regardless of the indication for the restraint. And I disagree with constant observation. Observation should be based on assessment of the patient’s behavior."
The word "discipline" appears for the first time in the new HCFA regs: "The patient has the right to be free from the use of seclusion or restraint, of any form, as a means of coercion, discipline, convenience, or retaliation by staff." The authors explain that discipline is not an acceptable reason for secluding or restraining a patient, and "in the treatment environment, it is impossible to distinguish between discipline’ and punishment.’"
The regulations also include new requirements for staff training ensuring that providers will learn the appropriate and safe use of seclusion and restraints. The HCFA authors state that these training programs should review alternatives to restraint and seclusion, to teach skills so that staff who have direct patient contact are well-equipped to handle behaviors and symptoms as much as possible without the use of restraints or seclusion.
The document containing HCFA’s new restraint regulations in the July 2 issue of the Federal Register introduces new conditions of participation (COP) relating to patients’ rights.1 (COPs must be met by hospitals to be approved for, or to continue participation in, the Medicare and Medicaid programs.) In addition to those previously mentioned regulations ensuring "freedom from restraints . . . unless clinically necessary," six protective standards are presented by HCFA in the document including assurances of a patient’s privacy and safety, confidentiality of patient records, and the right to make decisions about care. According to the new regulations, upon admission, hospitals are required to notify patients of their rights.
The regulations became effective on Aug. 2. HCFA has already issued regulations restricting the use of restraints in other settings, including intermediate care facilities for the mentally retarded and nursing homes. The agency is working with the Office of Inspector General to obtain information about existing patient abuse reporting systems and oversight of psychiatric hospitals.
(Editor’s note: To see the entire document, visit the Federal Register Web site at: http://www.access.gpo. gov/su_docs/fedreg/frcont99.html. Click "Friday, July 2, 1999" and scroll down the table of contents to "Health Care Financing Administration: Hospital participation conditions; patients’ rights." You can view the document either in html or PDF format.)
Reference
1. 64 Federal Register 36,069 (July 2, 1999).
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