Applying Standards for use of Physical Restraint and Seclusion
Regulations and practice standards for the use of physical restraint and seclusion have been changing since 1998. The terms restraint and seclusion will be used interchangeably unless indicated. Providers now face more legal and financial accountability for injury from restraints. In 2008 the Center for Medicare and Medicaid Services (CMS) designated severe injury from restraint as medical error. Workforce turnover is higher in restraint-using facilities, which is another reason for creating work and treatment environments that actively reduce the need for restraint. Some patients will still require restraint, like actively psychotic and dangerous patients. However, federal legislation and standards for psychiatric facilities have increased patient protection from unnecessary restraint, in particular for children, youth, and the elderly. In the school setting, there have been similar regulations at the state level.
Recent Regulations and Changes of Standards
Physical restraint has been an essential part in reducing safety risks in violent and self-harming patients who are in psychiatric care. Restraints can be human (such as a therapeutic or protective hold), can use mechanical devices (e.g., wrist restraint, jacket vest, or papoose), or consist of sedating drugs. Restraint has not only been used for reducing imminent risk for harm to self or others but also for control, convenience, and retaliation. For an overview of changes in laws and regulations in regard to restraint and seclusion, see also Luna (2001). In 1987, the Nursing Home Reform Act was passed. Since then, freedom from unwarranted restraint has been one of the rights monitored in the oversight of care facilities for the elderly and mentally disabled adult. However, there was no federal or state monitoring of serious injury and death (p. 590) as a result of restraint, especially in psychiatric inpatient or residential treatment. In 1998, the Hartford Courant released a five-part investigative report. It documented the alarming number of restraint-related deaths that occurred in psychiatric treatment facilities across the United States (Weiss, Megan, Blint, & Altimari, 1998). The newspaper conducted a 50-state survey in mental health facilities, mental retardation facilities, and group homes and documented at least 142 deaths during the preceding decade, mostly through asphyxiation. This contributed to Congress passing the Children’s Health Act in October 1999, which legislated restrictions in the use of restraint in residential treatment and all psychiatric facilities that received federal or state funds like Medicaid (Children’s Health Act, 2000). In children and adolescents, only personal restraint is permitted, and only in emergency situations to ensure the immediate physical safety of the resident or others. Both the use of chemical and mechanical restraint is prohibited. Use of restraint in correctional and educational settings, including schools, wilderness camps, or prisons, has not been regulated on the federal level. State laws have been passed that regulated school district use of restraints. Most school districts now have a restraint policy, which typically stipulates that restraint is used only if there is imminent danger to self or others, alternative and less restrictive containment has been tried but failed, staff is trained in safe restraint, and a physician has ordered the use of mechanical, medication, or physical restraint. Most school districts post those on their Web sites, like the Cambridge Public School District.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issues practice standards for health and psychiatric care facilities. In 1999, JCAHO issued restrictive and protective guidelines in regard to restraint and seclusion of patients of all ages. Implementation and documentation of compliance with JCAHO standards is necessary for all accredited organizations, thus leading to changes in practice.
In 2001, the Centers for Medicare & Medicaid Services (CMS) released their interim final rule regarding restraint and seclusion (Interim Final Rule, 2001). This regulation applies to patients under the age of 21 years who receive inpatient or residential psychiatric treatment. In contrast, JCAHO standards apply to any accredited medical setting in which emotional or behavioral problems require use of restraint, and they apply to patients of all ages.
Injury and death from restraint has been included in a list of “Never Events” by CMS (Substance Abuse and Mental Health Administration, 2011). CMS and most insurers are no longer going to pay treatments related to serious disability acquired during hospitalizations. One of the 28 “Never Events” is related to use of restraint or bedrails. Institutions also risk increased liability premiums and exclusion from insurances with such events.
What follows is a summary of the CMS standards in regard to restraint (Interim Final Rule, 2001). Exempt conditions of physical containment are also discussed.
• The restraint and seclusion policy of a facility must be posted. Upon admission to a facility, the patient’s guardian must review the policy and indicate consent by signature.
• Restraint and seclusion can only be used to ensure the patient’s safety or the safety of others during an emergency safety situation. Imminent danger must be present.
• Restraint must end when the emergency safety situation is over.
• The least restrictive intervention should be used. Only a licensed independent practitioner (LIP; i.e., physician, nurse practitioner, or physician assistant, depending on state law) may give the order for carrying out restraint or seclusion.
A LIP must perform a face-to-face evaluation of the patient no more than 1 hour after the restraint or seclusion is initiated. Ongoing monitoring of physical and psychological condition is required and must be documented. After removal from restraint, immediate examination by an LIP is required. The patient’s (p. 591) legal guardian must be notified of the situation that led to the use of restraint or seclusion as soon as possible. Two debriefing sessions must be conducted after the use of restraint or seclusion. One of them is between the patient and the staff involved, and one is only for the staff involved.
• All deaths have to be reported to the regional CMS office.
• All staff must have appropriate training in the use of nonphysical interventions, the safe use of restraint, identification of factors that lead to emergency situations, and CPR. Documentation of each staff member’s training must be maintained and available for review by a state survey agency.
The following holding situations are not regarded as physical restraint or requiring a physician order:
• Briefly holding without undue force a patient for the purpose of comforting him or her.
• Holding a patient’s hand or arm to safely escort him or her.
JCAHO Definitions and Standards
The JCAHO’s regulation regarding restraint for behavioral health reasons applies whether the patient is in a behavioral health care (psychiatric hospital or residential treatment) or a general hospital setting. For example, if a patient on a postsurgical unit is restrained because he or she tries to assault another patient, the behavioral health standard applies (TX.7.1 – TX.7.4, JCAHO, 2002).
A second set of regulations applies to restraint or seclusion used for medical/surgical care reasons. That restraint aims at directly supporting medical healing, such as preventing a patient from trying to walk on an injured leg or preventing the removal of an IV or feeding tube. (TX.7.5, JCAHO, 2002). I will not elaborate on the medical/surgical care standards as they are primarily relevant for nurses and physicians. Furthermore, there are more detailed standards regarding the medical assessment of patients during the process of restraint which are also not reviewed. See Orhon (2002) for a review of restraint standards from a nursing perspective. Orhon (2002) also compares JCAHO and CMS standards from a general perspective.
• Restraint is defined as the direct application of physical force to a person, with or without the individual’s permission, with the purpose of restricting freedom of movement (JCAHO, 2002).
• Seclusion is defined as the involuntary confinement of a person in a locked room. It is less restrictive than physical restraints because it allows an individual to move about.
• Patients in restraint and/or seclusion require continuous personal monitoring through observation and have to be assessed every 15 minutes for injury, health, psychological status, and readiness for the restraint or seclusion to be discontinued. A patient in a physical hold must have a second staff person observe the patient.
• The time limitations for an order for restraint or seclusion are as follows: 4 hours for patients 18 years and older, 2 hours for children 9 to 17 years, and 1 hour for children under 9 years.
• The JCAHO also requires prompt notification of the patient’s family or guardian when restraint or seclusion is initiated. Extended episodes of restraint or seclusion (more than 12 hours) or multiple episodes (two or more in 24 hours) require notification of the organization’s clinical leadership.
• The JCAHO’s standard for long-term care and assisted living in adults includes the right to a restraint-free environment. Past deaths in long-term care during or after restraint were associated with mechanical and chemical restraints, used for long periods of time and without monitoring of patients’ well-being (United States General Accounting Office, 1999). The restraint standards aim at increasing dignity and independence in the long-term care population.
(p. 592) Exceptions to the Applicability of the Behavioral Health Care Restraint and Seclusion Standards
The JCAHO standards for restraint and seclusion (2002) do not apply to the following:
• The use of restraint associated with acute and postoperative medical or surgical care
• Holding or physically redirecting a child, without the child’s permission, for 30 minutes or less—staff involved in holding has to be trained in physical restraint and seclusion.
• Time-out, which consists of removing a child from the immediate environment and restricting him or her to an unlocked quiet room for 30 minutes or less in order to regain self-control. The child or adolescent may not be physically prevented from leaving the time-out area. These restrictions have to be consistent with the unit’s rules and the patient’s treatment plan.
• To forensic restrictions and restrictions imposed by correction authorities for security purposes. However, use of restraint in the clinical care of a patient under forensic or correction restrictions is not surveyed under these standards.
• The use of protective equipment such as helmets
• Physical escorts—the use of restraint with patients who are severely developmentally delayed and receive treatment through formal behavior management programs that target intractable, severely self-injurious, or injurious behaviors
Comparing CMS and JCAHO Standards
CMS requires continuous in-person monitoring only when patients are concurrently in restraint, whereas JCAHO requires continuous monitoring. The CMS rule of face-to-face evaluation by an LIP within 1 hour of initiation of restraint or seclusion is more stringent than the JCAHO rule of within 4 hours. However, the JCAHO requires organizations to comply with the CMS rule because organizations must meet federal and state regulations in order to meet JCAHO’s requirements.
Compared to the CMS standards, the JCAHO standards are more specific, also in defining situations exempt from restraint and seclusion standards. This writer is not qualified to give legal advice about which standards may take precedent and a qualified attorney should be consulted if more clarification is needed. Furthermore, the reviewed CMS and JCAHO standards were current as of July 2011, but changes should be monitored as they are announced by CMS and JCAHO.
The JCAHO “Standard TX 7.1.2—Staff Training and Competence” (2002) outlined requirements for competence and training of staff who conduct seclusion or restraint. These standards also comply with CMS standards. Direct care staff should be trained in and understand the following:
• The underlying causes of threatening behaviors exhibited by the patients they serve
• Aggressive behavior that is related to a patient’s medical condition and not related to his or her emotional condition, for example, threatening behavior that may result from delirium in fevers or from hypoglycemia
• How their own behaviors can affect the behaviors of the patients they serve
• The use of de-escalation, mediation, self-protection, and techniques, such as time-out
• Recognize signs of physical distress in patients who are being held, restrained, or secluded
• Competence in the safe use of restraint, including physical holding techniques, take-down procedures, and the application and removal of mechanical restraints
Staff-initiated physical contact is the most frequent precursor to patient restraint. Direct care staff must be able to de-escalate potentially aggressive patients without touch, as well as apply physical control strategies safely. (p. 593) Both JCAHO and CMS require training documentation.
Clinical Application of Restraint and Seclusion
The reviewed seclusion and restraint standards have been mandated to protect patients’ physical and mental integrity. However, effective reduction of restraint also depends on correct diagnosis and treatment of a patient’s condition as it contributes to aggression against self or/and others. Luiselli, Bastien, and Putnam (1998) identified contextual variables associated with restraint and seclusion on a child and adolescent psychiatric inpatient unit. They found that staff-initiated physical contact often (34% of instances) precipitated restraint or seclusion and occurred in the context of patients refusing to leave or enter the quiet room. They recommended the use of closed-door seclusion time-out to reduce the avoidance and repeated leaving which precipitated the restraints. Another finding was that mechanical restraints occurred for long periods of time, in the absence of clear release criteria. Luiselli et al. point out that “contingent procedures such as time-out and physical holding are most effective when they are of brief duration and include a differential release criterion. These guidelines ensure that the person who receives time-out learns to end the procedure rapidly by ceasing negative behaviors and achieving a more relaxed state” (p. 153). Luiselli et al. recommended that occurrence of restraint can be reduced through identification of patient-specific triggers. CMS and the JCAHO recommended that to be part of direct care staff competence. However, Luiselli et al. emphasize linking diagnosis to treatment in a formal treatment plan, to assess the nature, contexts, and consequences of challenging behaviors, and to identify how restraint can reduce aggression under specific circumstances. A behavioral assessment is one way to determine a patient’s condition as it contributes to injurious behavior, which lends itself well to determine the effectiveness of restraint procedures. The use of restraints in the treatment of retractable, self-injurious behaviors in the developmentally delayed is exempt from JCAHO’s restraint and seclusion standards. However, even there, an individualized treatment plan is ethically imperative, in that restraints should be used effectively to reduce the future need for restraints. Fisher, Piazza, Bowman, Hanley, and Adelinis (1997) describe the effective use of restraint fading to control injurious and self-injurious behaviors in such a manner in three profoundly mentally retarded individuals.
References and Readings
Children’s Health Act, Public Law No. 106-310, § 3207, 114 Stat. 1178 (2000).Find this resource:
Fisher, W. W., Piazza, C. C., Bowman, L., Hanley, G., & Adelinis, J. D. (1997). Direct and collateral effects of restraints and restraint fading. Journal of Applied Behavior Analysis, 30(1), 105–120.Find this resource:
Interim Final Rule, Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services to Individuals Under Age 21, 42 C.F.R. § 441 and 483. (2001). Retrieved March 2003, from www.access.gpo.gov/su_docs/aces/aces140.html
Joint Commission on Accreditation of Healthcare Organizations. (2002). Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Author.Find this resource:
Luiselli, J., Bastien, J., & Putnam, R. (1998). Behavioral assessment and analysis of mechanical restraint utilization on a psychiatric, child and adolescent inpatient setting. Behavioral Interventions, 13(3), 147–155.Find this resource:
Luna, J. (2001). Limiting the use of physical restraint and seclusion in psychiatric residential treatment facilities for patients under 21. Retrieved March 2003, from University of Houston, Law Center Web site. www.law.uh.edu/healthlawperspectives/Mental/010829Limiting.html
Orhon, A. J. (2002). Of human bondage: Alternatives to restraint. Retrieved March 5, 2003 from Nurses Learning Network Web Site 184.108.40.206/nurse/courses/nurseweek/nw0187/c1/index.htm
Substance Abuse and Mental Health Services Administration (SAMSHA). (2011). The business case for preventing and reducing restraint and seclusion use. HHS Publication No. (SMA) (p. 594) 11-4632. Rockville, MD: Substance Abuse and Mental Health Services Administration.Find this resource:
US General Accounting Office. (1999, September). Mental health: Improper restraint or seclusion use places people at risk. Retrieved March 2003, from www.gao.gov/archive/1999/he99176.pdf
Weiss, E., Megan, K., Blint, D., & Altimari, D. (1998, October 11–15). Deadly restraint: An investigative report. The Hartford Courant.Find this resource: