Statement Of Wanda K. Mohr, Ph.D., Rn, Faan,
Regarding The "One Hour" Rule
Presented On Behalf Of The Advocates Coalition For The Appropriate Use
Of Restraints
To The Centers For Medicare And Medicaid Services
October 29, 2002
Good morning. My name is Wanda Mohr and I am a professor
of psychiatric mental health nursing at Rutgers University College of
Nursing in New
Jersey. I have extensive clinical experience in the care of psychiatric
patients and have conducted research and published widely on the use
of
restraints in psychiatric settings. I teach advanced practice psychiatric
nurses and direct the program that graduates advanced practice nurses
with prescriptive privileges. More importantly I have the experience
of
living with a mother who had a chronic and persistent mental illness
and I have seen first hand how restraints are used and misused.
My remarks are provided on behalf of the Advocates Coalition
for The Appropriate Use of Restraints. The Coalition is comprised eight
national organizations concerned with preventing death and serious injury
resulting from restraint and seclusion use. The organizations include:
The Arc of the United States, the Bazelon Center for Mental Health Law,
The National Association of Protection and Advocacy Systems, The National
Alliance for the Mentally Ill, The Federation of Families for Children's
Mental Health, Children and Adults with Attention Deficit/Hyperactivity
Disorder, The International Association of Psychosocial Rehabilitation
Services and The National Mental Health Association. The Coalition is
dedicated to improving the quality and appropriateness of treatment for
persons with mental illness, children with serious emotional disturbance,
and persons with mental retardation and other developmental disabilities.
The interim final CMS conditions of participation concerning
restraints and seclusion represented a major step forward in patient care
within institutional settings. This is not the time to dismantle that
progress by possibly eliminating or weakening the one-hour rule.
There is no question that physical restraint of some sort must be employed
at times for reasons of safety. Restraints are security measures and by
no means benign procedures. The large number of children and adults who
have died or been injured proximal to their use - an under-inclusive number
due to the fact that most institutions still are not required to report
these data -- provides stark evidence of this fact. In the past 18 months
I have consulted on 3 cases of children. Two died proximal to being restrained;
one sustained a spinal cord injury. They were all under the age of 14.
The last to die was 11 year old Tanner Wilson, whose parents gave me permission
through their attorney to identify. According to the well-known forensic
pathologist, Ronald O'Halloren, Tanner died unnecessarily as a result
of asphyxia secondary to intense pressure on his chest during a restraint.
According to witnesses, Tanner cried repeatedly "Help me, I can't
breathe" as he struggled. No one paid attention. One might well ask
how these therapeutic misadventures occurred in institutions that were
acting in loco parentis and were responsible for the health and safety
of these youngsters. These are only three. I get calls about many more.
In several cases of death that I have reviewed, staff
members observed that children struggled intensely. Such struggle represents
a natural response to the subjective feeling of being unable to breathe.
As their struggles intensify, staff members met such resistance by increasing
the pressure of their hold until patients stopped resisting. The reports
note that when a patient ceased struggling, staff assumed that they had
"calmed down" or that they were "playing possum."
Restrained individuals were either left alone and observed ostensibly
every 15 minutes or by video camera, or staff members intensified holds
for extended periods when they struggled. Too often the observed calm
indicated that they were in respiratory arrest or that they had died.
Subsequent resuscitation was ineffective. These tragedies underscore the
necessity of careful application of restraint procedures and ongoing monitoring
and assessment of patients by well-educated and well-trained personnel.
Several factors should be stressed in considering the
use of restraints and the necessity for professional assessment of patients
in restraints within one hour. Perhaps the most important concerns the
complexity of the current state of psychiatric care and the resulting
vulnerability of persons in psychiatric systems. Persons with psychiatric
illnesses do not only have a physiologically based brain disorder. They
are often otherwise chronically ill. Rates of sudden death are reported
to be higher among recipients of mental health services as compared to
the general population for a number of reasons, including general neglect
of health, increased rates of damaging personal habits such as smoking,
alcohol and other substance abuse, and poor diet. Moreover, the medications
prescribed for these individuals can also cause serious medical side effects,
including lethal cardiac arrhythmias. In one of the cases which I mentioned,
the 11 year old child was receiving four psychoactive medications, all
of which could potentially have precipitated a cardiac arrhythmia. Consumers
may have pre-existing conditions, which may or may not have been previously
identified that could contribute to injury or death. Moreover, excited
delirium, a state of altered consciousness, and intense agitated states
have been identified historically as associated with lethal outcomes for
patients, often due to powerful surges of adrenaline during intense struggle
with staff and against restraints. Position and immobilization clearly
play a role in injury and death due to asphyxia or aspiration, as do blows
to the chest, electrolyte imbalances, thrombosis, and other effects of
medications - such as delirium. Aspiration is a condition that occurs
when a person chokes on a piece of food or vomit. Electrolyte imbalances
mean that the salts and minerals that sustain body functions become disproportionate,
again a condition that can be lethal. Thrombosis, clots in the veins,
happens when persons are left in one position too long, such as when they
are involuntarily restrained for hours at a time.
Finally, factors associated with the environment itself,
such as inadequate staffing ratios and lack of staff training are undoubtedly
implicated with injury and death. In the case of the same child who was
taking 4 psychoactive medications, the staffing ratio was 9 boys between
the ages of 8 and 12 to one staff member. The staff member was a psychiatric
technician who was also responsible for passing medications. Many registered
nurses are unaware of the serious side effects of the medications taken
by people with psychiatric illnesses. It is undoubtedly safe to assume
that persons with a high school education or less would not be aware of
the potential lethality of medications, particularly when one is taking
several of them and becomes intensely agitated. No research has yet been
conducted to determine what factors, under what conditions, and in what
combinations lead to injury and death, but until such research is done,
it is both prudent and humane that every safeguard be in place to assure
patient safety. The one-hour rule is not an arbitrary or capricious requirement.
Rather, it is one advocated by those who are aware of the multifactoral
causes of injury and death associated with a restraint.
CMS' analysis of the one-hour rule itself (which was published
in the Federal Register on October 2, 2002) makes a compelling argument
supporting the critical need for the rule. Based on my perspective as
a teacher, researcher, and consultant, I strongly with agree with the
agency's conclusions. Among the important points CMS makes in this analysis
are the following:
Often patients are medically complex, with concomitant
medical and psychiatric symptoms and conditions. When staff must resort
to restraint or seclusion to protect the patient or others, it is essential
to examine: (1) The immediate situation, that is whether the patient has
been injured by the intervention; (2) the patient's reaction to the intervention;
(3) the patient's overall medical and psychiatric condition; and (4) whether
the behavior may stem from a condition that can be remedied quickly. Such
a determination is a medical decision that requires the integration of
many pieces of information, and therefore; merits a physician's or other
LIP's attention.
Moreover, when issuing the one-hour rule, CMS correctly rejected the
option of permitting a staff member to perform a patient assessment through
telephone consultation with a physician or other LIP. The reasoning for
this decision is quite sound; CMS stated that:
Given the complexity of the patient population, we did not select
this option. Physicians and LIPs are extensively trained in assessment
of symptoms and behaviors, in physical examination and formulation of
diagnoses and resulting treatment strategies. Staff who are onsite may
have widely disparate assessment skills. Some hospitals may staff patient
care areas with licensed practical nurses or other available staff. We
are not persuaded that these staff members have the physical and psychiatric
assessment skills that correspond to the medical complexity of a patient
in crisis. Accordingly, we opted not to permit patient assessment through
telephone consultation.
I am equally unpersuaded. I have worked on many psychiatric units, in
both public and private facilities. In too many instances they are staffed
with individuals who have inadequate specialized education. Licensed practical
nurses, registered nurses without advanced training, and other non-LIPs,
should not be making independent assessments in critical situations. One
might ask why they would want to be put into such a situation of liability
where they are clearly out of the scope of their practice and abilities.
One would not see persons without advanced preparation assessing patients
in an intensive care unit or a cardiac care unit. Our compromised psychiatric
patients and those individuals with mental retardation and challenges
deserve no less.
Another important point is that permitting hospital staff who are not
physicians or LIPs to solicit a verbal order from physician or LIP permits
only the viewpoint of that other staffer to be presented. In such a case,
the physician or LIP is not able to interact with the patient and make
an objective determination and assessment. Allowing aides, technicians
and nurses, who may be the ones involved in initiating the restraint or
seclusion, or who may be associated with or under the supervision of staff
who were involved in that decision, creates a potential conflict regarding
the assessment process. Underscoring this is a study that I conducted
two years ago on the debriefing process following restraint of individuals
on a unit serving seriously emotionally disturbed youngsters. This study
demonstrated that in many cases children did not know why they were restrained
and that what they perceived as the reasons for the restraint, differed
from the staff member's report.
Other facts should be taken into account. I have done extensive research
on how professional publications such as textbooks for advanced professionals,
as well as undergraduate nursing texts, deal with the issue of restraints.
Few consider the proper approach to actually implement restraint procedures
in light of potential adverse effects associated with their use. Only
two provide a general description of the structure and process by which
restraints should be conducted and include precautions regarding select
high risk factors. An examination of psychiatric texts, substance abuse
and chemical dependency, and psychiatric mental health nursing texts shows
that although restraint is a topic of discussion as an intervention for
violent behavior, it is discussed in very general terms. Only my own text
and The Sadocks' Comprehensive Textbook of Psychiatry specifically discuss
the dangers inherent in restraint use or even allude to the fact that
they may cause injury, death, or trauma. This oversight on the part of
educators represents a failure to communicate the serious nature of restraint
use and it is one that has yet to be corrected in curricula. It has been
discussed in current scholarly journal articles, but I can assure you
that practitioners do not generally spend their free time at home reading
scholarly material. It is disquieting that our health care providers who
carry out these procedures and are responsible for monitoring restrained
individuals have not had this information as part of their curricula.
Implementing regulations that require persons in restraints or seclusion
to be seen and evaluated within an hour by a professional with the necessary
education and experience to assess their overall medical and psychiatric
condition is absolutely essential to their wellbeing. It also puts people
on notice that restraints are not to be taken lightly and that they are
serious measures with consequences.
There are those who would argue that the one-hour rule is economically
burdensome. Given the potential lethality of restraints, such an argument
diminishes the humanity and worth of vulnerable individuals with psychiatric
disorders. It diminishes the persons who would pose such an argument even
more. What are reasonable standards for the appropriate employment of
restraint, including specific inclusion and exclusion criteria and their
monitoring? What is the necessary cost/benefit ratio, including the potential
for death, in equating the benefits to be derived from the use of restrictive
interventions, the failure to properly assess, and the use of unskilled
personnel? In other words, are the costs of providing appropriate personnel
and care to these vulnerable individuals so unacceptable in our society
that we are willing to continue putting them at risk for death? These
questions demand answers. But the answer does not include a retreat from
the progress we have made to assure that persons remain safe in institutions
that have a mandate to provide for their safety and well being.
Thank you very much for the opportunity to provide comments on this critical
public health issue.
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