From The Carlat Psychiatry Blog, ,

Daniel Carlat, MD

On Friday (April 3), the Massachusetts Department of Mental Health (DMH) issued an emergency expansion of what psychiatric nurse practitioners are allowed to do on psychiatric inpatient units. (For the DMH bulletin click here, and for the accompanying official order from the Department of Public Health, click here.)

For the duration of the COVID related state of emergency, NPs can now:

–Assess whether a patient is competent to sign in voluntarily to the hospital (called a Section 10/11 or “conditional voluntary”)

–Assess whether a patient may need to be admitted involuntarily because of danger to self or others (called a Section 12, or a 3 day hold, or in many states, a “pink slip”)

–Order emergency restraints for patients who become violent to self or others

–Examine a patient within 1 hour of the restraint

For those of us living and breathing (now a through a face mask) inpatient psychiatry, these arcane sounding authorities are crucial to the operation of a unit. Until yesterday, Massachusetts regulators required that only psychiatrists could sign off on these specialized assessments and forms. For many years, nursing groups and many doctors have been lobbying DMH to allow nurses these privileges, because there is really no clinical justification for the restriction. NPs are already acknowledged to have great competency in psychiatric care and are allowed to admit, evaluate, and medicate psychiatric patients—almost independently (the state requires some supervision by psychiatrists). We trust NPs with the most complicated clinical tasks—but signing a pink slip? No, that’s the doctor’s job.

These archaic regulations have meant that hospitals have had to recruit and pay top dollar to psychiatrists so that they can hang around the facility just in case these situations come up. The COVID pandemic has forced DMH’s hand, because if the attending psychiatrists become ill, hospitals would be forced either to have NPs take over these duties, or, if this were not allowed, they would have to shut down.

This new announcement is an implementation of Governor Baker’s shrewd emergency order on March 27 in which he temporarily authorized NPs in all specialties to practice without physician supervision (https://www.mass.gov/news/baker-polito-administration-announces-travel-guidelines-and-new-health-care-resources-to).

The silver lining of the COVID pandemic is that it forces us to scrutinize business-as-usual health care practices. Many of the old rules and regulations have been temporarily relaxed, such as these NP rules, as well as HIPAA rules that had made telehealth difficult to implement. Those of us who have long chafed under these and other regs are hoping and praying that when the state of emergency is over, a state of enlightenment will dawn.