Circular Letter: DHCQ 08-07-495

TO: Hospital Administrators, Directors of Emergency Services, Directors of Mental Health Services

FROM: Paul Dreyer, Ph.D., Director

DATE: July 8, 2008

SUBJECT: Forced Removal of Clothing of Patients in Hospital Emergency Departments

This letter is intended to provide hospitals with guidance regarding the forced removal of clothing of individuals presenting in the hospital emergency department (ED) setting, and in particular those who present with psychiatric difficulties or behavioral problems.

Representatives from the Department of Public Health and the Department of Mental Health, together with hospital ED professionals and mental health advocates from throughout the Commonwealth, have been meeting regularly to discuss the issues that confront people with behavioral health disorders in the ED setting. As a result of these discussions, the Department is providing all acute care hospitals with the guidelines below to ensure that the rights of each patient and the need of hospitals to ensure the safety of their staff and patients are maintained.

The Department anticipates that all acute care hospitals will review their current policies and practices in regard to forced removal of clothing to ensure compliance with applicable state and federal regulations and statutes. The Department's hospital surveyors will reference the hospital policy when reviewing complaints alleging the violation of patients' rights arising from forced removal of clothing. The surveyors may also refer to the policy during routine hospital surveys.

  1. Policies regarding clothing removal should apply equally to all patients seeking treatment in the emergency department. Hospitals should rescind any policies regarding clothing removal or pat downs that apply solely to patients seeking psychiatric treatment or who have psychiatric histories.
  2. All hospital policies regarding clothing removal should recognize the right of patients to refuse to remove their clothing as well as the need by the clinician to request the removal of clothing if appropriate to conduct a medical screening examination. This right should be included in any materials or communications presented to patients that enumerate their rights. Patients need not be verbally informed of this right prior to a request for the removal of clothing, but must be informed of this right in the event of a refusal by the patient. All clothing should be returned to the patient as soon as is reasonable.
  3. It is well recognized that removal of clothing may be necessary to enable a medical screening examination for the identification of an emergency medical condition. Another reason to request the removal of clothing is to protect self or others against potentially harmful substances or weapons that might be hidden on a patient's person. Forced removal of clothing is a form of physical restraint, and as such, all appropriate alternatives to this action should be used before restraint is applied. Therefore, compelling clinical information indicating imminent risk to self or others is necessary to support forced removal of clothing

Should you have any questions about this matter, or a specific event, please contact Lillian Jette at the Division of Health Care Quality at 617-753-8204.