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Government News
Train Nurses to Evaluate Seclusion, Restraint, APA Says
Psychiatric News
Volume 37 Number 24 page 10-34

APA and the Pennsylvania Psychiatric Society recommended to the Centers for Medicare and Medicaid Services (CMS) that it revise the one-hour rule on seclusion and restraint to allow trained registered nurses (RNs) to evaluate patients face to face within one hour of initiating a procedure.

The controversial "one-hour rule" on seclusion and restraint is part of the federal interim rule on seclusion and restraint published in 1999. The rule says that only physicians and licensed independent practitioners (LIPs) can perform the face-to-face evaluation.

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Kenneth Certa, M.D., says nurses can be trained to evaluate patients for risk factors related to using seclusion and restraint.

Kenneth Certa, M.D., testified on behalf of APA and the Pennsylvania Psychiatric Society at a CMS town hall meeting in Baltimore in October that RNs who are competent in the prevention, use, and evaluation of seclusion and restraint should be allowed to perform the face-to-face evaluation in telephone consultation with the treating physician.

"If nurses can be trained to read a heart monitor, adjust settings on a ventilator, and triage patients in emergency settings, I see no reason why they cannot be trained to evaluate patients for the limited set of risk factors related to using seclusion and restraint," said Certa in an interview with Psychiatric News.

The American Medical Association, American Hospital Association (AHA), National Association of Psychiatric Health Systems (NAPHS), and the American Psychiatric Nurses Association (APNA) also testified in support of allowing trained RNs to perform the evaluation. APNA emphasized that RNs will need additional specialized training beyond their two years of general training to evaluate complex psychiatric patients. APNA recommended that RNs demonstrate their competency in several specific areas before being allowed to assess or use the procedure.

APA, AHA, NAPHS, and APNA also interviewed member clinicians about strategies to decrease the use of seclusion and restraint. The information collected was published in a jointly sponsored resource guide titled Learning From Each Other: Success Stories and Ideas for Reducing Seclusion and Restraint in Behavioral Health. The guide will be available in January from NAPHS.

Psychiatrists Sul Ross Thorward, M.D., and Robert Roca, M.D., testified on behalf of AHA and NAPHS, respectively, that clinicians interviewed for the project "stressed the importance of patients and staff working together on a daily basis to create an appropriate clinical atmosphere. They also used, when necessary, techniques of de-escalation and crisis management."

No one reported that automatically requiring the physical presence of the physician within one hour of initiating seclusion or restraint seems to have improved safety or patient care. "Nor did anyone recall a physician’s face-to-face evaluation within an hour being different from the evaluation already done by the on-site registered nurse responsible for the care of the patient," Thorward and Roca testified.

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"Many hospitals reported spending between $3,000 and $7,000 per month on hiring adequate numbers of psychiatrists and LIPs to meet the requirements of the one-hour rule," testified Roca. "Millions of dollars are being diverted from a mental health budget that is already stressed, resulting in fewer physicians and nurses available to care for severely mentally ill patients," said Roca.

These are among the problems resulting from the one-hour rule:

• Some hospitals can no longer provide court-ordered evaluations or care for patients involuntarily committed because they may need to be restrained. Some of these individuals have been diverted to the criminal justice system instead.

• Patients, particularly children and adolescents, have less access to inpatient services in their communities because units have closed that were unable to meet the one-hour rule requirements.

• Physicians have withdrawn from hospital staffs because they cannot meet the requirements of the one-hour rule, leaving fewer physicians to care for patients.

• Some hospitals have cut nursing staff to cover the cost of psychiatric evaluations necessitated by the one-hour rule, leaving fewer nurses to provide quality care for patients.

Patient advocates and the National Association of State Mental Health Program Directors (NASMHPD) testified in support of maintaining the current physician/LIP requirement.

The Advocates Coalition for the Appropriate Use of Restraints, representing eight organizations including the National Alliance for the Mentally Ill, Bazelon Center for Mental Health Law, and National Association of Protection and Advocacy Systems, testified that "the interim final CMS Conditions of Participation regarding restraints and seclusion was a major step forward. This is not the time to eliminate or weaken the one-hour rule," said Wanda Moore on behalf of the coalition.

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Andrew Hyman testified on behalf of NASMHPD and urged CMS to use its leadership role to "send the message nationally that the use of restraints and seclusion are treatment failures that can and must be prevented."

Hyman also encouraged CMS to join the Substance Abuse and Mental Health Services Administration (SAMHSA) in developing and implementing a comprehensive strategy to reduce seclusion and restraint in all settings. SAMHSA is supporting a national initiative by NASMHPD to reduce and eliminate coercion and violence in behavioral health treatment settings (see box on page 10).

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Robert Streimer, acting director of the CMS Office of Clinical Standards and Quality, said that the agency was aware from complaints it received that the one-hour rule imposed a tremendous clinical and financial burden on physicians and their facilities.

Streimer presented four options for discussion at the town hall meeting, two of which were maintaining the current standard or deleting the one-hour evaluation requirement and adding continuous monitoring. No one testified in support of the latter option.

Streimer said that CMS appeared to favor a third option that would waive the one-hour requirement for physicians and allow RNs to perform on-site evaluations. "In exchange, a new independent review committee would be established to scrutinize the use of restraint and seclusion. If violations occurred, the physician/LIP requirement would be reinstated," said Streimer.

Certa commented that "requiring an outside committee to review the use of seclusion and restraint raised several questions including how members would be named, how independent they would be, and how confidentiality would be maintained."

APA’s recommendation closely resembled a fourth CMS option that would delete the current physician one-hour requirement and create a new requirement allowing an appropriately trained RN or other LIP to perform the one-hour evaluation.

Streimer assured participants at the meeting that CMS would review their statements, but did not indicate what the outcome might be or when it would be announced.

Certa’s CMS testimony is posted on the APA Web site at www.psych.org/pub_pol_adv/ppsspeak.cfm. The resource guide Learning From Each Other: Success Stories and Ideas for Reducing Seclusion and Restraint in Behavioral Health will be available next month on the Web at www.naphs.org.

Anchor for JumpAnchor for Jump

Kenneth Certa, M.D., says nurses can be trained to evaluate patients for risk factors related to using seclusion and restraint.

Kenneth Certa, M.D., testified on behalf of APA and the Pennsylvania Psychiatric Society at a CMS town hall meeting in Baltimore in October that RNs who are competent in the prevention, use, and evaluation of seclusion and restraint should be allowed to perform the face-to-face evaluation in telephone consultation with the treating physician.

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