JCAHO issues revised restraint standards
JCAHO issues revised restraint standards
Follow the strictest rules, expert says
Last month, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released a set of revisions to its restraint and seclusion standards that are designed "to restrict the uses of restraints and seclusion to emergency situations in which there is imminent risk that the individual may physically harm himself or others."
While some experts expected that the Joint Commission’s revisions would bring its standards in line with the Health Care Financing Administration’s (HCFA) 1999 Condition of Participation on restraint and seclusion, some differences remain, most notably with regard to HCFA’s now-infamous "one-hour rule," which dictates that a patient placed in restraints must be evaluated in person within one hour by a physician or other licensed independent practitioner. The Joint Commission’s standard is less strict, requiring a licensed independent practitioner to evaluate an adult patient within four hours, and within two hours for patients 17 or younger.
In addition, the Joint Commission stipulates that:
• Individuals who continue in restraints or seclusion must be re-evaluated in person by a licensed independent practitioner every eight hours for individuals ages 18 and older, and every four hours for individuals ages 17 and younger.
• The licensed independent practitioner must conduct an in-person evaluation of the individual within 24 hours of the initiation of restraints or seclusion if the individual is no longer in restraints or seclusion when an original verbal order expires.
Interestingly, in a press release announcing the revised standards, Joint Commission president Dennis S. O’Leary, MD, said, "Despite the distinctive safeguards in our standards, we recognize that HCFA may still determine that the one-hour’ rule must be enforced for hospitals participating in Medicare. If this occurs, the Joint Commission has agreed to work with HCFA to enforce this requirement for hospitals seeking deemed status."
Michelle Camicia, RN, MS, CRRN, clinical manager at California Pacific Medical Center in San Francisco, notes that while HCFA hasn’t changed its policy regarding the one-hour rule, the rule so far hasn’t been enforced. Even so, she recommends that facilities adopt HCFA’s stricter standard to avoid trouble down the line. "I see where HCFA’s going, and I don’t think they’re going to change," she says. "So in my organization, we’re going to proceed with HCFA’s most stringent rules, as the law dictates."
The Joint Commission standards, which place special emphasis on staff education, also include the following requirements:
• continuous monitoring of individuals in restraints;
• careful assessment of an individual in restraints or seclusion every 15 minutes;
• efforts to contact family members when restraints or seclusion are applied if the individual has requested that they be so advised;
• a debriefing to occur within 24 hours of the use of restraints, including the individual, his or her family (if appropriate), and staff;
• establishment and communication of behavioral criteria that will lead to discontinuation of restraints or seclusion (staff are expected to work with the individual to help him or her meet the criteria);
• establishment and communication of the organization’s philosophy on the restricted use of restraints and seclusion to all staff who have direct care responsibilities.
The JCAHO standards, scheduled to take effect Jan. 1, 2001, are on the Internet at www.jcaho.org/ standard/restraint/restraint_stds.html.
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