Revisions seek to reduce restraints and seclusion

Not as bad as expected

The Joint Commission on Accreditation of Healthcare Organizations has released major revisions to its standards that seek to reduce the use of restraints and seclusion. The revisions are intended to provide greater assurance of safety and protection of individuals when placed in restraint or seclusion for reasons related to psychiatric disorders or substance abuse. While more elaborate than the previous requirements, the revised guidelines are not as strict as the original proposal.

The revised standards restrict use of restraints and seclusion to emergency situations in which there is imminent risk that the individual may harm himself or others. Even then, restraints are to be used only as a last resort.

"These standards underscore the importance of applying great care in using interventions that can harm or even kill patients," says Dennis O’Leary, MD, president of the Joint Commission. "This need is especially compelling in this vulnerable patient population."

In addition to limiting the reasons for restraining or secluding an individual, the standards place special emphasis on staff education. For example, staff must demonstrate an understanding of the factors that influence behavior and may result in the need for restraints and seclusion. The standards also place specific time limits on the length of an order for restraints or seclusion and require that only a licensed independent practitioner issue such an order.

The strengthened focus on staff training and education seeks to enhance staff skills in monitoring and evaluating patients and to promote effective communication between the staff and the responsible physician or other licensed independent practitioner, O’Leary says.

The Joint Commission expects staff education to enhance patient safety in these ways:

• Staff are trained and competent to minimize the use of restraints and seclusion and in their safe use.

• All individuals placed in restraints or seclusion, regardless of age, must have an order for restraints and seclusion issued by a licensed independent practitioner within one hour of the initiation of the restraints or seclusion.

• The length of the initial and any subsequent order for restraints and seclusion cannot exceed a range of one hour for children under age 9 to four hours for adults.

• Upon expiration of an order for restraints or seclusion, a new order — either written or verbal — must be issued by a licensed independent practitioner within a range of every one hour for children under age 9 to every four hours for adults.

• An individual must be evaluated in person by a licensed independent practitioner within four hours of the initiation of restraints or seclusion for adults ages 18 and older, and within two hours for individuals ages 17 and younger.

• Individuals who continue in restraints or seclusion must be reevaluated, 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.

When the new restraint guidelines for behavioral health care were first proposed in 1999, many risk managers feared they could be a burden and expose the organization to several types of increased risk. Leilani Kicklighter, RN, ARM, MBA, DASHRM, assistant administrator for safety and risk management at North Broward Hospital District and a past president of the American Society for Healthcare Risk Management in Chicago, says the final version is less onerous.

The standards 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 or seclusion. Staff also are to be taught to recognize signs of physical distress in an individual who is being held, restrained, or secluded.

New standards, requirements

The standards also include the following new requirements:

• continuous monitoring of individuals in restraints;

• a 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, within 24 hours of the use of restraints, among 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.

A subset of the standards — those related to criteria for the use of restraints or seclusion, initial and subsequent evaluation, time-limited orders, periodic assessment, and continuous monitoring — will apply also in nonpsychiatric settings in which restraints or seclusion are used for reasons related to psychiatric disorders or substance abuse.

The new requirements, posted on the Joint Commission Web site at http://www.jcaho.org/ trkhco_frm.html, become effective January 2001.

Phone call makes compliance easier

In the proposed version in 1999, Kicklighter was disturbed by a key provision requiring a "licensed independent practitioner" to authorize the restraint or seclusion and then monitor the patient frequently, at least every eight hours.

The Joint Commission defines that person as "Any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges (these individuals may be referred to by other terms, such as independent care provider’). In many behavioral health organizations, licensed independent practitioners include physicians, psychologists, and social workers."

If the periodic assessment must be made by a physician in most cases, Kicklighter says that would have been a problem for some facilities that do not have access to physicians or social workers around the clock. But in the final version, the Joint Commission says the practitioner can approve the continuation of restraints by phone instead of seeing the patient in person.

"That still might mean that a qualified professional will have to be awakened in the middle of the night, but they won’t have to put their trousers on and come to the hospital in the middle of the night," she says. "That’s an improvement over what we feared a few months back. A phone call doesn’t seem nearly as difficult as bringing someone in all the time."

A potential conflict exists between the new standards and the restraint guidelines from the federal Health Care Financing Administration (HCFA). The interim final rule set forth by HCFA in July 1999 provides for a one-hour time frame for the initial in-person evaluation by a licensed independent practitioner of an individual placed in restraints.

However, "the Joint Commission believes that its revised standards provide for an equal or greater level of protection and safety for these individuals," according to information released by the Joint Commission. In addition, significant emphasis has been placed on the health care organization’s provision of qualified, capable staff who are trained to defuse emergency situations safely and quickly.

"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," O’Leary says. "If this occurs, the Joint Commission has agreed to work with HCFA to enforce this requirement for hospitals seeking deemed status."