National Alliance on Mental Illness
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The National Regulation of Restraint Use in HCFA Funded Treatment Facilities: Some Questions and Answers

Chris Marshall
For Immediate Release
6 May 99

  1. Question: Why is there a need for such legislation? Answer: The Hartford Courant October 1998 series documented 142 deaths in psychiatric treatment facilities. Since that publication, NAMI has gathered stories from its 208,000 consumer and family members. Not only are serious injuries and psychological harm continuing, we have documented 5 deaths in 5 months; four of these deaths by restraints have been children, the youngest being a nine year old, 53 pound boy, killed by restraint in a residential treatment facility. NAMI’s "Cries of Anguish" report is available for your review. The Center for Risk Analysis at Harvard University estimates that there are between 50 and 150 deaths a year resulting from restraints.

  2. Question: Isn't Accreditation by the Joint Commission on Accreditation Of Hospitals Adequate? Answer: JCAHO, whose governing board is controlled physicians and hospitals, is attempting to improve its accountability for reducing death and serious injuries in JCAHO accredited facilities. But this is an industry dominated private entity which is striving to improve while keeping all information confidential and not available to the public. Further, JCAHO does not investigate individual complaints and mostly conducts their site visits on a pre-announced 3 year cycle.

    Many of the deaths are in JCAHO facilities. Gloria Huntley was reported in the Hartford Courant. Having been kept in restraints for 558 hours during her last two months of life, she died the day after JCAHO awarded her hospital accreditation with commendation. 60 Minutes II on April 21, 1999 reported the death of 16 year old Tristan Sovern in a JCAHO accredited with commendation facility. He was placed in restraint for leaving a group therapy session. He was placed in four-point restraint and had a mouth covering applied. Even though this JCAHO accredited facility had no written policy on the use of mouth coverings, 85-to-90% of persons placed in restraints are routinely applied mouth coverings. Many of the horror stories in NAMI's "Cries of Anguish" have occurred in JCAHO accredited facilities.

  3. Question: Aren't these clinical decisions involving physician judgment? Answer: yes they are. NAMI advocates that restraints only be used to respond to emergency safety situations as determined by a face-to-face evaluation by a physician. All that we are asking is that the authorization of a restraint actually be a clinical decision made by the clinician with the clinician accountable for the decision. The April 21 60 Minutes II show documented that frequently the decision to use restraint against someone is made by non-clinicians.

  4. Question: What Are Some Best Practices Which Exist in the Nation? Answer: Refer to the enclosed Behavioral Healthcare Tomorrow article, "Death by Restraint." Best practices include physician authorization after a face-to-face evaluation on the hour; staff training competencies in de-escalation techniques, alternatives to restraints, and safe application of restraints; staff and consumer de-briefing sessions the day following the use of restraints; trauma counseling after the use of restraint; data monitoring systems; mandatory reporting of deaths and serious injuries to state level legal entities which can investigate circumstances; and family and consumer monitoring groups.

  5. Won't Violence and Assaults Go Up As Restraints Are Decreased? Answer: There are no evidence-based studies documenting that violence and assaults go up when restraint and seclusion go down. On the contrary, actual multi-year data monitoring used by the Pennsylvania Office of Mental Health and Substance Abuse Services in all units of all state psychiatric hospitals demonstrate the opposite: when restraint and seclusion use decline, violence and assaults decline. Enclosed is the Pennsylvania data.

    Pennsylvania combines a number of the best practices identified in question 4. Further information is available from Charlie Curie, Deputy Secretary for Mental Health, or Dr. Steven Karp, Chief Medical Officer, Pennsylvania OMHSA, at 717-787-6443 or Mary Ellen Rehrman, Director of Public Policy, NAMI- Pennsylvania.

  6. Question: Won't Family and Consumer Monitoring Groups Interfere in Clinical Decision-Making and Fail to Follow Privacy and Confidentiality? Answer: No. Family and citizen monitoring groups currently operate in five state mental health systems - Delaware, Massachusetts, New Hampshire, Oklahoma, and Pennsylvania. They are trained private citizens who posses hospital identification, are not authorized to see clinical records, may not interfere with any activities including clinical activities, and sign confidentiality agreements as part of their monitoring protocol.

  7. Question: What Is It That NAMI Wants? Answer: NAMI wants a single national standard on the use of restraint for all Health Care Financing Administration (HCFA) financed treatment facilities. HCFA finances the Medicare and Medicaid programs. The proposed standard is that restraint should only used for emergency safety situations, may be initiated in an emergency by a R.N., but must be authorized within 30 minutes by a physician following a face-to-face examination and must be re-authorized on on the hour following a face-to-face evaluation by a physician. NAMI also supports the mandatory reporting of deaths and serious injuries resulting from restraints to a legal authority within the state. Ideally, NAMI would also like to see family and consumer monitoring groups in all facilities. Facilities where deaths and patterns of serious injuries occur should be publicly reported.

For these reasons, NAMI supports national legislation such as S. 736 by Senator Joseph Lieberman (CT), S. 750 by Senator Chris Dodd (CT), and H.R. 1313 by Representatives Diana DeGette (CO), Pete Stark (CA), and Rosa DeLauro (CT).

Further Information: E. Clarke Ross, D.P.A.
Deputy Executive Director for Public Policy