Kaiser Report Provides Empirical Foundation for Addressing Health Care Needs of the Uninsured

Health care workers who employ physical restraints and seclusion when treating patients must undergo new, more rigorous training to ensure the appropriateness of the treatment and to protect patients' rights, according to much-awaited final rules on use of seclusion and restraint issued by the Centers for Medicare and Medicaid Services (CMS). The new rules limit episodes of physical restraint or seclusion to four hours for adults, two hours for children and adolescents ages nine to 17, and one hour for children under age nine. Previously there were no limitations.

The rules, which were published in the December 8, 2006, Federal Register, apply to all hospitals participating in the Medicare and Medicaid programs, including short-term, psychiatric, rehabilitation, long-term, children's, and alcohol and drug treatment facilities. The rules were issued seven years after a five-member committee was created by CMS to study deaths of patients undergoing restraint and seclusion. National attention was focused on this issue by a series of articles published in 1998 in the Hartford Courant, which revealed that 142 U.S. patients died between 1988 and 1998 as a result of being restrained.

In response to more than 4,000 public comments received on the 1999 interim final rules, the final regulations strengthen the staff training standard. Staff who carry out these practices must be trained and able to demonstrate competency in the application of restraints and in implementation of seclusion, monitoring, assessment, and provision of care for a patient in restraint or seclusion. Staff must be trained to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion; to use nonphysical intervention skills; to choose the least restrictive intervention on the basis of an individualized assessment of the patient's medical or behavioral status; to recognize and respond to signs of physical and psychological distress, such as positional asphyxia; to identify behavioral changes that indicate that restraint or seclusion is no longer necessary; to monitor the physical and psychological well-being of the patient, including respiratory and circulatory status, skin integrity, and vital signs; and to use first-aid and cardiopulmonary resuscitation.

The rules also expand the category of practitioners who may conduct patient evaluations during an episode of restraint or seclusion. CMS currently requires that a face-to-face evaluation be conducted within an hour of a patient's being restrained or secluded. Before the new regulations, these actions had to be reviewed within that hour by a physician or "other licensed independent practitioner." The new rules expand that list to include a trained registered nurse (R.N.) or a physician assistant (P.A.). However, when an R.N. or P.A. conducts the one-hour-rule evaluation, the new rules require that a physician or other licensed independent practitioner be consulted as soon as possible. Hospitals are required to document in a patient's record the situation for which the practice was needed, any attempts to use less restrictive methods, and the patient's response to the intervention.

Stricter standards now apply for reporting a death associated with the use of restraint and seclusion. Not only must a facility report a death that occurs while a patient is in restraint or seclusion, it must also report any death known to the hospital that occurs within one week after physical or chemical restraint or seclusion when it is reasonable to assume that use of these practices contributed to the death. Deaths must be reported by telephone to the CMS regional office no later than the close of business on the next business day following knowledge of a death.

The full text of "Medicare and Medicaid Programs: Hospital Conditions of Participation: Patients' Rights, Final Rule" is available on the Government Printing Office Web site at www.gpoaccess.gov/fr/index.html.

Nominations SAMHSA Science to Service Awards: The Substance Abuse and Mental Health Services Administration (SAMHSA) is seeking applications for its Science to Service Awards, a new national program that will recognize community-based organizations and coalitions that have shown exemplary implementation of evidence-based mental health and substance abuse interventions. A maximum of three awards will be made in each of four categories: treatment of mental illness and recovery support services, mental health promotion, substance abuse prevention, and treatment of substance abuse and recovery support services. Eligible organizations must have successfully implemented a recognized evidence-based intervention. Both public- and private-sector organizations, including community-based organizations and coalitions, are eligible to compete. Complete information is available on the SAMHSA Web site at www.samhsa.gov/spotlights/sciencetoservice.pdf. The application deadline is February 28, 2007.

New approach for SAMHSA antistigma campaign: The Substance Abuse and Mental Health Services Administration (SAMHSA), in partnership with the Ad Council, has launched a national awareness public service advertising campaign designed to decrease negative attitudes about mental illness. The designers decided that instead of telling people why they shouldn't discriminate against people with mental illnesses, the campaign would show friends how they can be supportive of those who have disclosed that they are having a mental health problem. Created pro bono by Grey Worldwide, the campaign aims to reach 18- to 25-year-olds. The television and radio spots feature a voiceover by actor Liev Schreiber and illustrate how friendship is the key to recovery. The campaign also includes print and interactive advertising that directs people to a new Web site, www.whatadifference.samhsa.gov, to learn more about mental health and what they can do to play a role in their friend's recovery. An impetus for the campaign was a recent Porter Novelli survey showing that only one-quarter of young adults believe that a person with a mental illness can eventually recover and slightly more than half (54 percent) of those who know someone with a mental illness believe that treatment can help people with mental illnesses lead normal lives.