APA and five other health-related organizations fired off a joint letter last month to the Health Care Financing Administration (HCFA) urging the agency to reconsider the requirement that physicians or licensed independent practitioners see patients within one hour of initiating seclusion or restraint.

The five associations who cosigned the strongly worded letter were the American Medical Association, American Hospital Association, American Nurses Association, Federation of American Health Systems, and National Association of Psychiatric Health Systems.

"The use of seclusion and restraint is a medical decision, and its appropriateness varies from one patient to another," stated the professional organizations in the letter. It may not be clinically necessary to require a face-to-face evaluation within an hour of application of seclusion or restraints.

The six organizations recommended amending the language to allow evaluations to be performed "by the appropriate professional over the phone in consultation with a registered nurse unless it is believed that a face-to-face evaluation is necessary."

HCFA officials were urged to consider the joint recommendations before issuing the final rules on seclusion and restraint anticipated to be released in the spring. The interim rules were established July 2 as new hospital conditions of participation in Medicare/Medicaid to emphasize patients’ rights to safe and humane treatment, according to Nicholas Meyers, deputy director for congressional relations in APA’s Division of Government Relations.

Meanwhile, HCFA drafted guidelines interpreting the interim final rules on seclusion and restraint for federal and state employees charged with monitoring Medicaid and Medicare facilities’ compliance. HCFA asked APA among other groups to comment.

Meyers told Psychiatric News, "We believe the guidelines are flawed. There are numerous discrepancies with the interim final rules that put facilities at risk for noncompliance."

For example, the guidelines use the term "chemical restraint," but the rules do not. Mirin, who signed the January 11 letter to HCFA official Josephine Simmons, said the term is pejorative and inaccurate and recommended it be deleted.

Mirin also said the guideline’s interpretation of the use of physical restraints is more vague than what the rules specify. The guidelines refer to "holding a patient and restricting his movement." In contrast, the regulations refer to "any manual method or physical or mechanical device that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body," according to the comment letter.

Mirin questioned, "Would a surveyor conclude from the guidelines that holding an arm of a patient to redirect his or her path or to prevent [patients] from striking themselves or other patients constitutes a physical restraint and apply the standard?"

Because some patients have advanced directives refusing seclusion or restraint and/or psychotropic medications, Mirin asked HCFA to clarify what options hospitals have to treat a very aggressive and/or psychotic patient and their obligations in discharging the patient, according to the letter.

Mirin also urged HCFA to amend the language in the guidelines allowing the use of seclusion or restraint in emergency situations to ensure the physical safety of the patient to include "the safety of other patients and staff."

APA’s medical director also recommended that the guidelines allow a limited timeout or seclusion for patients whose disruptive behavior infringes on the rights of other patients but would not be considered an emergency.

Mirin also stated APA’s opposition to the one-hour evaluation requirement, in particular, its application even in the event that the patient was released prior to the evaluation. Moreover, APA asked HCFA to clarify whether additional evaluations are required for each subsequent use of restraint or seclusion within a short period of time, according to the letter.