December 1st, 2013

EIP rules still an issue in Vermont

Ever since Tropical Storm Irene hit in 2011 and the Vermont State Hospital was destroyed, the state has been in the process of revising its mental health rules.

The legislature passed a bill last year creating a decentralized system and various stakeholders have been working with the state’s Department of Mental Health on the new regulations and are in agreement on most rules, but are still trying to navigate an issue with Emergency Involuntary Procedure or EIP rules.

Hospital officials and advocates for patients with mental illness are debating whether the Vermont regulations should continue to require a psychiatrist to do a face-to-face assessment of a patient within an hour of use of force on that patient or if nurses or other hospital staff should be allowed to do this assessment. Force is used if a patient is at risk of serious harm to themselves or others.

“The change is necessary because the old rules used at Vermont State Hospital are almost 30 years old and needed updating to meet Vermont’s decision to use private hospitals for some of the people who would be in the former state hospital if it still existed,” says Paul Dupre, Vermont’s mental health commissioner.

The department has been hosting open forums to get opinions on the rules from as many people as possible, he says. Advocates want the rule to continue to allow only psychiatrists to assess patients while hospital officials are pushing to include trained nurses in the rule.

“The bottom line is that if more people who are less qualified, less trained, have less authority and are paid less than physicians are allowed to order these procedures and do the one hour assessment, it will be easier to implement these procedures and their use will increase…contrary to our legislation,” says A.J. Ruben, supervising attorney at Disability Rights Vermont, by email.

He says allowing other staffers to do the assessment does “not bring the variety of important factors that physicians bring to the decision of whether or not to take someone’s liberty away and to the process of evaluating the use of force and impact on the patient at the one-hour assessment as a physician does.”

Jeff McKee, Psy.D., director of psychiatric services at Rutland Regional Medical Center in Rutland, Vermont, says by email that the Centers for Medicare & Medicaid Services has determined there is no evidence to suggest that an assessment in these situations by a doctor over a trained nurse is superior.

“At [Rutland], we have experience working under both systems and have concluded that nurses conducting the face-to-face assessment are equal in quality to an M.D.-only assessment,” he says. “Moreover, there is a strong belief among our staff that nursing assessments represent a superior quality of care when the attending M.D. is an on-call physician who has little or no direct knowledge of the patient.”

The Department of Mental Health presented a proposal to the Legislative Committee on Administrative Rules in early November that allows a specially trained nurse to do the face-to-face assessment.

McKee says Rutland Regional Medical Center is in support of adoption of the proposed rule and expects other hospitals to back it.

By Rivkela Brodsky

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