| JCAHO Provides NAMI With Helpful Clarification; NAMI Remains Gravely Concerned With Certain Draft Restraint And Seclusion Standards |
NOVEMBER 22 REMAINS THE DEADLINE FOR COMMENT
On November 10, received at NAMI on November 15, JCAHO provided NAMI with a helpful clarification. Attached after this introduction is "JCAHO Statement Relative to the 11/9/99 NAMI E-News." Though the statement provides very helpful clarification of JCAHO intent and purpose, the draft standards for field review contain major problems for consumers and families seeking national protection against the abuse of restraint and seclusion.
SOME GOOD NEWS
First the good news from NAMI's perspective. Though NAMI continues to advocate that psychiatric hospitals should be held to the more specialized and detailed Comprehensive Accreditation Manual for Behavioral Health standards while JCAHO continues to use the more generalized and non-specialized Comprehensive Accreditation Manual for Hospitals standards for psychiatric hospitals, JCAHO has clarified and emphasized that the restraint and seclusion (R/S) standards under consideration would apply to both sets of standards. This is good news.
In our E-News, NAMI and other national advocacy groups missed proposed standard TX 3.12, that deaths would have to be reported to external agencies as required by applicable law and regulation. NAMI apologizes for this oversight and previous misstatement.
In a slightly good news category, JCAHO's draft standards for field comment would prohibit audio and video monitoring as a substitute for continuous face-to-face monitoring of persons in R/S. This is really good news. However, the attached clarification goes on to state that JCAHO is asking for instances where such video monitoring may be appropriate. NAMI is opposed to any video or audio monitoring as a substitute for actual face-to-face monitoring.
JCAHO has also provided helpful clarification and details regarding information which should be placed in the clinical/medical record. The items proposed are very helpful and important. However, NAMI believes that there are gaps in such items. Specifically, the record should clearly state who ordered the R/S, when was the treating physician contacted, and what did the treating physician decide? Related, but different, NAMI advocates mandatory de-briefing for both staff and person (and where appropriate, the family) involved in each R/S incident. Thus, these de-briefings and their content should also be documented in the clinical/medical record.
NOW, SOME MAJOR PROBLEMS CONTINUE
The attached JCAHO clarification is helpful. But, there remain major public policy differences between NAMI and JCAHO.
In the NAMI E-News, NAMI asked how the legal agent of the national government and its Health Care Financing Administration (HCFA), which administers both Medicare and Medicaid, through the "deemed status" arrangement, could issue R/S standards which are less protective of patients than HCFA final regulations? The JCAHO response is silent on this question.
The three major issues NAMI continues to have with the draft JCAHO standards are the use of non-professional personnel determined by the facility to be "qualified and trained," the delays permitted before a face-to-face assessment is made, and the timeframes in which people may continue to be placed in R/S. The attached JCAHO clarification better explains these proposals, but NAMI continues to disagree with these proposals.
NAMI currently advocates the state of Pennsylvania state psychiatric hospital experience, namely, that within 30 minutes within the initiation of R/S, and on the hour thereafter, a physician performs a face-to-face evaluation of the patient to determine the continued need for the R/S. New York state psychiatric hospitals currently use a 30 minute evaluation rule.
HCFA final regulations (refer to NAMI E-News #00-04 of July 9, 1999) require a physician or licensed independent practitioner recognized by the state to complete a face-to-face evaluation of the patient within an hour of the initiation of R/S. The maximum time period for the use of R/S would be 4 hours for adults, 2 hours for children ages 9-17, and one hour for children under the age of 9 years. To reorder or repeat the order for R/S, another face-to-face evaluation by the physician and licensed independent practitioner would be required. Hospitals object to the HCFA requirement and have convinced JCAHO though its field draft proposals to use a lesser standard for who does the evaluation, when a face-to-face may be done, and for how long the R/S may be applied.
In its comments to HCFA on their interim final rules (refer to NAMI E-News #00-22 of August 11, 1999), NAMI did support waivers and flexibility in applying the one hour rule for facilities in rural and medically underserved areas as officially designated by the U.S. Public Health Service. The attached JCAHO clarifications emphasize the need for flexible standards in rural areas, medically underserved areas in cities, and residential settings. JCAHO does not say whom determines where these facilities are, thus facilities would probably have the ability to self-designate themselves as being located in these areas.
It is these areas in particular - who orders the R/S, when must the face-to-face evaluation be made, and for how long the R/S stays in effect - that NAMI has the greatest concerns with the JCAHO proposals. The nation has final HCFA regulations on these areas. And yet JCAHO says that they must propose standards which are less than the national government's regulations.
JCAHO allows individuals who are not licensed independent practitioners to be involved in the use of R/S. Such non-licensed persons have to be "qualified and trained." Other times these persons are called "competent and trained." Examples of knowledge and skills these persons should posses are listed in the attached clarification. These are helpful and useful skills to have.
HCFA requires a face-to-face evaluation of the patient by a physician or licensed independent professional within one hour. JCAHO requires that a licensed independent professional be contacted within an hour and that a face-to-face evaluation be made "promptly." JCAHO seeks recommendations for what timeframe "promptly" should be. Before this prompt evaluation is undertaken, a "qualified and trained" person recognized by the facility does the face-to-face evaluation.
JCAHO and HCFA both allow R/S to be imposed for 4 hours for adults, 2 hours for children ages 9-17, and one hour for children under the age of 9 years. JCAHO encourages early release from such R/S whenever possible. The initial order can be used again to reapply the R/S after an early release; however, this initial order may only last for the 4-2-1 hour periods. A new order would be required and a new face-to-face evaluation would be required. Thus, "prompt" first face-to-face evaluation could take up to 3 hours and 55 minutes. Further, under "certain circumstances" defined by the facility, non-licensed independent practitioners who are "qualified and trained" have the authority to renew the orders for another 4-2-1 hour periods. Thus, the total time between face-to-face evaluations by a licensed independent practitioner would be 8-4-2 hours, not 4-2-1 hours. Such proposal undermines and contradicts the HCFA final regulation and NAMI opposes such extended time periods and use of non-licensed independent practitioners.
Further, JCAHO acknowledges in the attached clarification that "experience suggests that injuries and death related to the use of restraint and seclusion are most likely to occur within the first hour of their initiation." HCFA requires a face-to-face evaluation by a physician or licensed independent professional within an hour. JCAHO acknowledges that the first hour is fundamental to possible life and death situations. And yet, JCAHO allows non-licensed independent professionals to keep people in R/S for 8 hour periods with only one professional examination.
These are the major JCAHO draft proposals to which NAMI objects - we want professionals making judgements after face-to-face evaluations within an hour and for very limited periods of time, only in response to emergency safety situations.
There is one other concern, raised to NAMI by one of its founding members and former JCAHO PTAC member, Max Schneier, J.D. That concern is that these particular proposed draft standards do not apply in emergency rooms. JCAHO states that all persons in hospital emergency rooms would be protected by "slightly different set of R/S standards." Max characterizes this "slightly different" as a "particularly misleading sentence." Max reminds us of the general hospital R/S standards - that independent licensed practitioners or R.N.s order R/S, that within 12 hours a written or verbal order is obtained from a licensed independent practitioner, and that R/S may last longer than 24 hours if the licensed independent practitioner believes that such R/S is clinically justified.
JCAHO STATEMENT RELATIVE TO THE 11/9/99 NAMI E-NEWS
The Joint Commission appreciates the opportunity to clarify a number of issues identified by NAMI in its 11/9/99 E-NEWS regarding the Joint Commission's draft restraint and seclusion standards for behavioral health care. These issues have brought to our attention the need to provide greater clarity in the draft standards, as we further revise them based on the field review. However, we would like to clarify the Joint Commission intent for some of the draft standards immediately to assist people who are responding to the field review.
Having the right standards for restraint and seclusion is critical to the safety and quality of behavioral health care. The Joint Commission's goals in setting standards for restraint and seclusion are that:
While there is general agreement on these goals, there has been considerable controversy about how to achieve them. The draft standards sent out for review and comment are an initial effort to gather information needed to resolve some of these controversies. Therefore, the Joint Commission seek comments from people who review the draft standards. We would like to know:
Your comments can be sent to the Joint Commission Department of Standards at One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181. Questions can be directed to Amy Wilson (630)792-5876 or Shelby Dunster (630)792-5893.
ISSUE: SURVEYABILITY UNDER THE CAMH AND THE CAMBHC.
The Joint Commission surveys freestanding psychiatric hospitals and behavioral health units in general hospitals using the standards in the Comprehensive Accreditation Manual for Hospitals. Other settings providing behavioral health services are surveyed using the standards in the Comprehensive Accreditation Manual for Behavioral Health Care. However, the final standards for restraint and seclusion will appear in both Manuals, assuring that the same requirements for restraint and seclusion are in place for individuals receiving hospital-based and non-hospital based behavioral health care services.
ISSUE: CREDENTIALS OF STAFF WHO CAN INITIATE AND PLACE PERSONS IN RESTRAINT AND SECLUSION.
Under the draft standards, restraint and seclusion are emergency interventions to be used only when there is an imminent risk of an individual harming him/herself, staff, or others, and when other interventions are not effective (standards TX.3.4 and TX.3.4.1). It would be ideal if a licensed independent practitioner (for example, a physician) were immediately available in every such an emergency to order restraint or seclusion. But because these are emergencies, sometimes other staff have to initiate the restraint before an order is written, in order to prevent harm to the individual or others. In this situation, the draft standards allow other authorized staff to place the person in restraint or seclusion, if so allowed by the organization (standard TX.3.4.3). However, in order to protect the patient from harm, draft standard TX.3.2 would require that "only competent, trained staff are involved in the use of restraint and seclusion." Therefore, the organization would have to train and assess the competency of all staff (whether or not they are licensed independent practitioners) who are authorized to be involved in the use of restraint and seclusion. According to standard TX.3.2, some examples of knowledge and skills these authorized individuals would need to possess through the training include: 1) an understanding of how their own behavior can affect the behavior of the persons being served; 2) competence in the use of de-escalation, mediation, and other non-physical intervention techniques that can avert the need for restraint or seclusion; 3) the safe use of restraint and seclusion, including physical holding techniques; and 4) recognizing and appropriately responding to signs of physical distress in individuals who are restrained or secluded.
When a licensed independent practitioner is not the person who initiates the restraint or seclusion, the draft standards require that a licensed independent practitioner be contacted within one hour after the restraint or seclusion begins (standard TX.3.4.3). The purpose of this call is to inform the licensed independent practitioner of the restraint or seclusion episode and secure a verbal order that is documented in the individual's clinical/medical record. The verbal order would be replaced by an order personally written by a licensed independent practitioner at the time of the face-to-face evaluation by the practitioner.
ISSUE: FACE-TO-FACE EVALUATION BY A LICENSED INDEPENDENT PRACTITIONER.
The draft standards require that a licensed independent practitioner evaluate the individual "promptly" after the initiation of restraint or seclusion (standard TX.3.4.4). The word "promptly" in this draft is only a placeholder. Through the field review, the Joint Commission is seeking opinions about what timeframe(s) for such an evaluation should be substituted in the standard for the word "promptly," and why. The HCFA rule sets the timeframe at one hour. However, we have been told that there are some situations and settings (for example, rural areas, medically underserved areas in cities, and residential settings) in which it may be impossible to have a licensed independent practitioner physically present within one hour. Therefore, we are especially interested in learning about possible solutions to this dilemma. Based on the field review research, should the Joint Commission ultimately adopt a timeframe that differs from HCFA's requirement, the Joint Commission still would hold organizations that are subject to the HCFA regulations to whichever standard or regulation has the shorter timeframe.
Experience suggests that injuries and death related to the use of restraint or seclusion are most likely to occur within the first hour of their initiation. Consequently, even a one-hour timeframe requirement for a face-to-face evaluation of an individual by a licensed independent practitioner may not always address this safety concern. Therefore, draft standard TX.3.6 requires that whether or not a licensed independent practitioner is available, a qualified, trained individual is to immediately assess the person in restraint or seclusion for signs of injury, nutrition/hydration, circulation and range of motion in extremities, vital signs, hygiene and elimination, physical and psychological status and comfort, and readiness for release from restraint or seclusion. This assessment would be repeated at 15 minute intervals. The Joint Commission is seeking information related to the specific knowledge, skills, and credentials of the "qualified, trained" staff person who (in the absence of a licensed independent practitioner) could conduct this face-to-face evaluation. For example, if you were to recommend that this evaluation be done by a registered nurse, how might settings such as residential treatment centers, most of which do not have registered nurses 24 hours per day, comply?
ISSUE: INFORMATION TO BE PLACED IN THE CLINICAL/MEDICAL RECORD.
Joint Commission draft standard TX.3.10 addresses documentation of the use of restraint and seclusion. The draft standard would require that each episode of restraint and seclusion be documented in the individual's clinical/medical record.
The draft standard would also require that the organization collect information for each restraint or seclusion episode with respect to the staff involved; the shift in which the incident occurred; the duration of the restraint or seclusion use; time, day of week, and type of restraint used; and any injuries that occur as a result of restraint use. These data are then to be used to find and implement practices that would reduce the need for restraint or seclusion and improve the safety of their use (standard TX.3.11).
ISSUE: TIME-LIMITED ORDERS FOR INITIAL AND CONTINUED USE OF RESTRAINT/SECLUSION
The Joint Commission draft standards would require that each order for the use of restraint or seclusion be limited to four hours for adults, two hours for children ages 9-17, and one hour for children under age 9 (standard TX.3.5). Although orders can be written for these maximum time periods, the standards encourage early release from restraint or seclusion whenever possible.
Orders would only be valid for these maximum 4 or 2 or 1 hour intervals (depending on the individual's age) and would expire when that time-limit is reached, regardless of when the order is secured. For example, an adult is restrained at 12:00 pm. An order is secured at 12:10 pm. The order expires at 4:00 pm (four hours after the initiation of restraint, not 4:10 pm, four hours after the order was secured).
The draft standards would also allow the same order to be used to reapply restraint or seclusion after an early release, if the individual begins to again exhibit behavior that puts him/her or others at imminent risk of harm. However, this reapplication of restraints is limited to the time remaining in the original order. That is, the original expiration time of the order still applies. For example, an adult is restrained at 12:00 pm. An order is secured at 12:10 pm. The order is limited to 4 hours from the initiation of restraint, expiring at 4:00 pm. The individual is released at 2:00 pm -- an "early" release because the individual no longer appeared to be at risk of harming others. At 2:15 pm the individual again exhibits dangerous behavior that meets the criteria for the use of restraint. The individual may be placed in restraint without securing a new order, but can only remain in restraint until the original order expires at 4:00 pm. At 4:00 pm, the individual has a face-to-face reevaluation and is either released from restraint, or a new order is written.
Once the initial order has expired (i.e., at 4 or 2 or 1 hours, depending on the individual's age) a face-to-face reevaluation would be required, and a new order is written if the restraint or seclusion is to be continued (standard TX.3.7). This face-to-face evaluation and new order must be repeated no less than every 4 or 2 or 1 hours (depending on the individual's age) for as long as restraint or seclusion is necessary.
The draft standards require that these 4 or 2 or 1 hour orders (depending on the age of the individual) be based on a face-to-face evaluation (standard TX.3.7). These face-to-face evaluations are to be done by a licensed independent practitioner, but, under certain circumstances, could be done by another "qualified, trained" individual. Specifically, after a face-to-face evaluation by a licensed independent practitioner, a "qualified, trained" individual could be authorized by the licensed independent practitioner's order to renew the order once for an additional 4 or 2 or 1 hours (depending on the individual's age). After this renewal expires, a new order must again be issued based on a face-to-face evaluation by a licensed independent practitioner. Thus, even if a "qualified, trained" individual is authorized by the licensed independent practitioner to renew an order for one time, the total time between face-to-face evaluations by a licensed independent practitioner can never exceed 8 or 4 or 2 hours (depending on the individual's age). And, the order itself must be rewritten or renewed no less often than every 4 or 2 or 1 hours (depending on the individual's age).
The Joint Commission would like to learn whether this contemplated authorization of a "qualified, trained" individual to renew a restraint or seclusion order on a one-time basis is appropriate, and, if that were to be the final standard, what knowledge, skills, and credentials such an individual should have.
ISSUE: VIDEO MONITORING.
The Joint Commission's draft standards would not allow audio and video monitoring as a substitute for continuous face-to-face monitoring by an assigned staff member of an individual in restraint or seclusion (TX.3.6). The HCFA regulations do permit audio and video monitoring in lieu of face-to-face monitoring under some circumstances. In the draft standards field review, the Joint Commission is requesting opinion from the field about whether there are instances in which audio and video monitoring in lieu of face-to-face monitoring might be appropriate.
ISSUE: VERBAL VERSUS WRITTEN ORDERS.
The Joint Commission draft standards do not differentiate between verbal and written orders with respect to timeframes -- that is, whether written or verbal orders are required, the 4 or 2 or 1 hours (depending on the individual's age) time-limits apply (TX.3.5). The standards would require that a verbal order be secured from a licensed independent practitioner within one hour of the initiation of the restraint or seclusion (standard TX.3.4.3). A written order would subsequently be obtained at the time of the licensed independent practitioner's initial face-to-face evaluation, which must occur "promptly." (As explained above, a specific timeframe will replace the word "promptly"in the final standard.)
ISSUE: APPLICABILITY OF RESTRAINT AND SECLUSION STANDARDS.
The introduction to the draft standards indicates that the standards would not apply to "individuals who are in the emergency department for the purposes of assessment, stabilization, or treatment, even if awaiting transfer to a psychiatric hospital or psychiatric unit" or to "individuals awaiting transfer from a non-psychiatric bed to a psychiatric bed or psychiatric unit after receiving medical or surgical care." This does not mean that no standards for restraint and seclusion apply in those settings, or that restraint or seclusion could be freely or automatically used. Rather, it means that a slightly different set of restraint and seclusion standards would apply. These other standards, which are already in the accreditation manual, apply to the use of restraint or seclusion in all medical/surgical settings. Therefore, individuals in the emergency department or on a medical/surgical inpatient unit who have behavioral health conditions and require restraint or seclusion because of an imminent risk of harm would not be treated differently from non-behavioral health patients; rather, they would be treated the same, with the same requirements for ordering restraint or seclusion, for its safe use, for monitoring the individual, and for removing the individual from restraint or seclusion as soon as possible.
ISSUE: EXTERNAL REPORTING OF DEATHS.
Draft standard TX.3.12 would require that the organization have a policy that addresses "reporting of injuries and deaths to the organization's leadership and to the appropriate external agencies consistent with applicable law and regulation." This policy, therefore, would encompass the required reporting of such instances to HCFA.
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