Charles K. Devitt, M.D., F.A.P.A.

When you take the King’s shilling, you get the King’s bailiff.
Anglo-Saxon proverb, c. 1066

August marks the third anniversary of the Health Care Financing Administration’s new regulations governing seclusion and restraint procedures in acute care hospitals (HCFA, 1999). These regulations were precipitated by reports of patients’ deaths during such procedures. These requirements for participation with Medicaid and Medicare included a provision known as the “One-Hour Rule.” This is not a psychoanalytic precept. Hospitalized patients who are restrained or secluded must be seen within one hour of the procedure’s initiation by a “licensed independent practitioner,” which in most instances is a physician. The best face on this requirement was that it would assure these procedures were: initiated for therapeutic reasons, performed competently, kept medically safe and directed to the child’s treatment goals. Today, the “One-Hour Rule” doesn’t seem as unnecessary and aversive as we feared when the regulations were suddenly released three years ago.

Seclusion, and particularly restraint, are brief events, lasting a mean of fewer than 15 minutes. Most are over by the time a physician who is not physically present on the unit arrives, so the direct evaluation of purpose, performance, and safety are moot. The nurse who has initiated the procedure is the individual who ensures those elements immediately. Documentation takes longer than the procedure itself. So is the “One-Hour Rule” completely unnecessary? The debriefing by the psychiatrist would be valuable if these procedures were rare and psychiatrists plentiful. Neither is true. Even though many facilities have reduced the frequency of these procedures (Petti, 2002), the aggression or self-injury necessitating restraint or seclusion remains a criterion for admission and continuing stay in hospitals. Per diems do not permit full-time psychiatrists on each unit, even if there were enough to staff them. Many of us are on the units just half of any workday, and are at offgrounds clinics, pediatric hospitals or academic assignments the remainder. The “One-Hour Rule” often requires the physician to interrupt the care of several patients with no discernable benefit for the index patient.

The aversive aspects of this requirement include the obvious (such as the interruptions to other duties, leisure and even sleep) and the insidious. Now, some hospitals will not accept patients they expect will need a number of seclusions or restraints. These patients are said to be “not appropriate for the milieu.” Difficulty complying with the rule and heightened concern over “the numbers” of procedures are cited privately to explain the occasional rejection of those most in need of acute care; acceptance of such children might come from a facility that is a remote distance from the family, or none at all. The rule actually may be a factor in the increase of procedures at some facilities. Since a small number of patients account for the majority of such procedures, the magical appearance of the doctor may be inadvertently reinforcing. The doctor evaluating the patient is often not a psychiatrist. Some hospitals have had to contract with family practice residency programs or large pediatric groups to meet the requirement. Then there is not even an imagined treatment benefit for the patient or staff. Budgeted amounts to pay for coverage range in Virginia from $11,000 to $90,000. There is, however, no current procedural terminology (CPT) code to pay for this physician service, seen as a prototypal unfunded mandate. It is demoralizing when the art therapist is “let go” to pay for a service with no redeeming value. Are regular or asneeded psychotropic medications overused to sedate children who have been very aggressive? Each of us asks himself that question. Add the rule and the numbers to earlier pressures to raise the doses and classes of medications with a particular child. What are the effects on recruitment to our subspecialty when residents are paged out of seminars and sessions repeatedly to perform redundant functions? Finally, what are the practical and personal implications for psychiatrists in rural areas where all live an hour away from the hospital? Even with immediate response, they have an appreciable noncompliance rate to the time parameters. The Medicaid surveyor and senior administrative staff at just such a facility dealt with the issue as the proverbial “elephant in the room that nobody mentioned,” but the medical staff continues to bear the tension of discovery.

AACAP’s Clinical Affairs Department mobilized a response to the crisis following the report of deaths associated with these procedures. Importantly, it emphasized prevention of aggression as the larger issue in which concerns about restraint and seclusion are embedded (AACAP, 2001; Masters, 2002). It was encouraging that HCFA (now, CMS-Center for Medicare and Medicade Services) regulations for seclusion and restraint in residential treatment contained ideas and terminology from AACAP’s input (HCFA, 2001). The “One- Hour Rule” is not an element in the regulations governing the free-standing residential facilities. Using the logic that a restraint is a restraint whether it occurs in acute care or residential treatment, there is a strong case to be made for the elimination of the “One- Hour Rule” from regulations governing the use of these procedures in hospitals. Some strategies to pursue this were previously suggested (Masters KJ, 2002) and will be discussed at the upcoming Annual Meeting in October.

Dr. Devitt is Medical Director of The Barry Robinson Center, a residential treatment and community-based services center of the Children’s Hospital in Norfolk, VA. He is also co-chair of the AACAP’s Hospitalization Committee.

American Academy of Child and Adolescent Psychiatry (2001), Practice Parameter for the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions with Special Reference to Seclusion and Restraint. J Am Acad Child Adolesc Psychiatry 40: 1356-1358

HCFA (1999), Hospital Condition of Participation in Medicare and Medicaid. Federal Register 64, 127, Friday, August 2.

HCFA (2001)

Masters KJ (2002), Preventing and Managing Aggressive Behavior in Child and Adolescent Psychiatric Facilities, AACAP News 3: 110.

Petti, TA (2002) Seclusion and Restraint: A Paradigm Shift for the Millenium, AACAP News 1: 24, 27.