New federal seclusion-and-restraint regulations include a requirement
that nurses and physician assistants must contact the attending physician when
they believe there is a need to use these interventions.
Psychiatric, rehabilitation, and alcohol/drug treatment centers are among
the medical facilities that will need to ensure that their training complies
with new federal guidelines on the use of seclusion and restraint.
The Centers for Medicare and Medicaid Services (CMS) published a final rule
last month governing the use of seclusion and restraints by physicians and
health care workers who treat patients in hospitals that participate in
Medicare or Medicaid.
The regulations, which go into effect on February 6, establish more
rigorous training requirements that aim to assure appropriate treatment and
protect patients' rights.
The regulations are part of Medicare's revised conditions of participation
(CoPs) in the Medicare and Medicaid programs and apply to a wide range of
settings including short-term, psychiatric, rehabilitation, long-term,
pediatric, and substance abuse treatment facilities.
“Through this regulation, CMS will hold all hospitals accountable for
the appropriate use of restraint and seclusion,” said Leslie Norwalk,
acting administrator of CMS. “Today's action reinforces this
administration's commitment to patient safety and the delivery of high-quality
health care services.”
The final regulation strengthens staff-training standards and details
aspects of the training. It expands the category of practitioners who may
conduct patient evaluations when a restraint or seclusion strategy has been
The regulation also details several patients' rights. These include the
right to be informed by hospital staff of all issues relevant to their care
and rights to privacy and safety, confidentiality of medical records, and
freedom from the inappropriate use of restraints and seclusion.
The new regulations also have strict standards that govern when a health
care facility must report deaths that may be associated with the use of
restraint and seclusion.
“Today, we are taking needed steps to solidify training requirements
and essential reporting to reduce and ultimately eliminate seclusion and
restraints,” said Eric Broderick, acting deputy administrator of the
Substance Abuse and Mental Health Services Administration (SAMHSA), in a
statement issued in conjunction with the regulations.
A report issued by the General Accountability Office in September 1999,
documented dangers associated with the inappropriate use of restraint and
seclusion. It noted, for example, that children are subjected to seclusion and
restraint at higher rates than adults and are at greater risk of serious
injury or death as a result of improper restraint and seclusion practices.
Other recent federal actions in this area include development of
first-of-their-kind guidelines by SAMHSA in June 2006, which aimed to help
mental health facilities train staff in alternatives to seclusion and
restraint (Psychiatric News, July 7, 2006).
The final regulations were seven years in the making. An interim final rule
drew more than 4,000 public comments since it was published in July 1999.
APA, which submitted comments on the interim rule, has been active on the
issue and developed a publication in 2003 that described strategies for
reducing the use of seclusion and restraint. The 42-page booklet, titled“
Learning From Each Other: Success Stories and Ideas for Reducing
Restraint/Seclusion in Behavioral Health,” was created by APA, the
American Psychiatric Nurses Association, and the National Association of
Psychiatric Health Systems, with support from the American Hospital
Association's Section for Psychiatric and Substance Abuse Services
(Psychiatric News, February 7, 2003).
In response to public comments, for example, CMS revised the regulation to
expand staff training requirements and added a requirement that once trained
in seclusion and restraint practices, registered nurses or physician
assistants who may implement those interventions must consult the attending
physicians or other licensed independent practitioner responsible for the
patient's care as soon as possible when a restraint-or-seclusion evaluation of
a violent or self-destructive patient is conducted.
The new regulations do not ban the use of restraint or seclusion. However,
they prohibit use of restraint or seclusion when it is “imposed as a
means of coercion, discipline, convenience, or retaliation by
The regulation defines restraints as “any manual method, physical or
mechanical device, material, or equipment that immobilizes or reduces the
ability of a patient to move his or her arms, legs, body, or head freely; or a
drug or medication when it is used as a restriction to manage the patients'
behavior or restrict the patient's freedom of movement and is not a standard
treatment or dosage for the patient's condition.”