The One-Hour Rule Controversy: Experts Disagree on Who Should Evaluate Patients after They Have Been Secluded or Restrained
Levin-Epstein, Michael, Behavioral Healthcare
Late last year, the Centers for Medicare and Medicaid Services (CMS) issued final rules to prevent patient injuries and deaths from the improper use of seclusion and restraint techniques in healthcare facilities, as well as ban their use as a punitive measure. (1) The final rules, effective since January 8, also strengthen staff training requirements. In promulgating the regulations, CMS Acting Administrator Leslie Norwalk said the agency will hold facilities responsible for the appropriate use of seclusion and restraint techniques.
The final rules are controversial, especially the "one-hour" rule, which requires a face-to-face patient evaluation by a physician or independent licensed practitioner within one hour of implementing seclusion and restraint practices. While the interim rules required a physician to conduct the evaluation, the final rules permit other staff members, such as nurses, to conduct the evaluation and issue restraint and seclusion orders, in accordance with hospital rules and state laws.
Mark Covall, executive director of the National Association of Psychiatric Health Systems (NAPHS), says his association always has supported the concept that a physician needs to be responsible for ordering seclusion and restraint practices, but he says there are practical advantages in allowing other staff members to perform the one-hour evaluations. For example, he says RNs usually are more available and more familiar with a specific patient's condition than physicians.
Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, disagrees. He believes the interim rules issued in 1999, with their stricter interpretation of the one-hour rule, offered patients more protection. "In our view, hospitals should have a physician see a restrained patient within an hour," he says. "Restraint or seclusion is our 'code blue.' There are significant physical and psychological risks involved."
Bernstein says CMS caved to industry complaints that requiring a physician to see a secluded or restrained patient within an hour was too burdensome. He believes it's important to have a physician involved to determine whether a medical condition is underlying the behavior that prompted the use of seclusion and restraint practices. He acknowledges that there could be situations in which having a physician readily available for an evaluation could be difficult, such as in a rural area in the middle of a snow storm, but he says that national policy should not be based on extraordinary exceptions.
At a time when mental health advocates have been working with the Substance Abuse and Mental Health Services Administration (SAMHSA) to further reduce the use of seclusion and restraint practices, the CMS final rules are a marked departure from the reforms taking place nationwide, Bernstein asserts. …