Withdrawn: 28 CFR Parts 35 and 36, Nondiscrimination on the Basis of Disability by State and Local Governments and Places of Public Accommodation; Equipment and Furniture (ANPRM)

A. Medical equipment and furniture

Without accessible medical examination tables, dental chairs, radiological diagnostic equipment, scales, and rehabilitation equipment, individuals with disabilities do not have an equal opportunity to receive medical care. Individuals with disabilities may be less likely to get routine preventative medical care than people without disabilities because of barriers to accessing that care. The Department has entered into settlement agreements with several medical care providers that have required the medical care provider to purchase accessible equipment and furniture for its facilities, including at least one accessible examination table in each medical department and additional accessible examination tables, radiologic equipment, scales, beds, and lifting devices, as needed. These settlement agreements are available to the public at www.ada.gov. The Department has also issued technical assistance on this issue. See Access to Medical Care for Individuals with Mobility Disabilities, on May 17, 2010.

The health care reform law, the Patient Protection and Affordable Care Act, added a new Section 510 to the Rehabilitation Act of 1973. Section 510 directs the Access Board to promulgate regulatory standards setting forth the minimum technical criteria for medical diagnostic equipment used in (or in conjunction with) physician's offices, clinics, emergency rooms, hospitals, and other medical settings. The standards shall ensure that such equipment is accessible to, and usable by, individuals with accessibility needs, and shall allow independent entry to, use of, and exit from the equipment or furniture by such individuals to the maximum extent possible. The Access Board has announced that it will draft new design standards for medical diagnostic equipment to satisfy this requirement. As an Access Board member, the Department will work closely with the Board in the development of these design standards. The Department will not issue a final rule on medical equipment until the Access Board has completed its medical diagnostic equipment standards. When the standards are completed, the Department will have the option to adopt them for ADA implementation and, if it does so, will, at that time, develop specific scoping requirements to establish the required number of accessible diagnostic elements for specific facility types. In addition, the Department may propose regulations to ensure the accessibility of medical equipment that is used for treatment, rehabilitative or other purposes.

i. Medical examination and treatment tables and chairs

Healthcare providers use examination and treatment tables and chairs for many different types of medical and dental examinations and treatments. Examples of specialty areas using examination or treatment tables or chairs include ophthalmology, optometry, podiatry, oncology, physical therapy, chiropractic, rehabilitation medicine, urology, and obstetrics and gynecology. If a person with a disability cannot get onto an examination table or chair and is thus not examined (as occurs, for example, with some women with disabilities who cannot access ob-gyn tables) or is examined in a wheelchair, any examination that does occur likely will be less thorough than it would have been on an examination table, and the medical provider may miss important medical information.

The Department has received complaints and learned in the course of its enforcement efforts that medical and dental examination tables and chairs often are too high to be accessible, lack stabilization elements, and do not have adequate clear floor space nearby to permit access. Although Section 510 of the Rehabilitation Act does not specifically address tables and chairs used solely for treatment purposes, the Department anticipates that such treatment equipment would be subject to similar accessibility requirements, such as adjustable heights.

ii. Accessible scales

Medical providers often do not weigh individuals who use wheelchairs because they do not have an accessible scale, even though that information is a routine part of medical examinations and is important to the patient´s health and medical care. Patient weight can serve as a health indicator for many conditions, including depression, diabetes, cancer, cardiovascular disease, high blood pressure, and pregnancy. Correct patient weight is crucial to correctly prescribing medicine. Scales should be accessible to individuals who use wheelchairs or have other mobility disabilities that would impede the use of step-on scales.

Several different types of scales offer different means of accommodating patients with mobility disabilities while also affording flexibility to medical providers. Wheelchair scales are currently available as stand-alone devices or as equipment that is integrated into other medical equipment. Stand-alone wheelchair scales include wall-mounted stationary (folding or not folding), platform (in ground), and portable platform (folding or not folding).

iii. Radiological Diagnostic equipment

Some types of radiological diagnostic equipment, such as Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), and X-rays, including Computerized Axial Tomography (CAT) scans and mammography, are difficult to access for individuals with disabilities because of the height, shape, or configuration of the equipment. The Department has reached settlements with medical offices and hospitals providing diagnostic services because patients with mobility disabilities could not access medical diagnostic equipment. Some individuals with disabilities had difficulty transferring from wheelchairs onto scanning tables and were denied staff assistance or not provided access to medical equipment and furniture, such as gurneys or lifts, to facilitate the transfer to the diagnostic equipment and furniture. Different types of diagnostic equipment and furniture pose different challenges. For example, MRIs typically require individuals with disabilities to climb onto an MRI table and remain on the table while it is moved into and out of a scanning tube, a process that can take one to two hours. Mammograms may be inaccessible to individuals with mobility disabilities who cannot stand for the duration of the examination.

iv. Lifts

Medical providers may need lifts to transfer some patients with mobility disabilities safely to examination or treatment tables or chairs or to gurneys or hospital beds. The kind of assistance needed will depend on a patient´s disability. Using lifts may provide more security for a patient than being lifted by medical staff and may reduce the risk of injury to medical staff. Concerns about lifting injuries have given rise to proposed legislation at the federal and state levels designed to increase safety for patients and medical staff. See, e.g., Nurse and Health Care Worker Protection Act of 2009 (S. 1788); Recognizing the Need for Safe Patient Handling and Movement (H.Res. 510). There are several different types of patient lifts available now on the market, including free-standing, ceiling-mounted, and sling lifts. The use of lifts by medical and dental providers may improve accessibility to medical and dental examination and treatments.

v. Infusion pumps

Infusion pumps infuse fluids such as chemotherapy drugs, pain medications, or nutrients into the circulatory system in a controlled manner. Several kinds of infusion pumps, including Patient Controlled Analgesia pumps, are available. Problems can arise with infusion pumps when there are errors in dosing rate or fluid volume. Infusion pumps often rely on patients controlling settings on difficult-to-reach buttons or flat screens that may not be accessible to individuals with disabilities. Integrated alarms may not be audible to individuals with hearing disabilities.

vi. Rehabilitation Equipment

Medical providers offering rehabilitative services must make those services equally available to individuals with disabilities. Rehabilitation and exercise equipment and furniture, including balance equipment, cardiopulmonary equipment, exercise pulleys and stretching equipment, resistance equipment, and general exercise equipment, should be available to individuals with disabilities requiring such rehabilitative treatment on an equal basis with other patients. For example, individuals with hearing impairments or blindness or low vision might require equipment or furniture to permit their full participation in cardiopulmonary rehabilitative services.

vii. Ancillary equipment

Ancillary equipment is equipment used with other medical equipment, such as examination tables or chairs or MRIs, and adapted to or adjustable for use by individuals with disabilities. Ancillary equipment includes items such as positioning straps or cushions; protective padding; adjustable, padded leg supports for gynecological examinations; and additional supports, rails, or bars needed to ensure the safety and comfort of patients with disabilities. Sliding boards or sheets and gait belts may assist in transfers of patients with disabilities to and from examination or treatment tables and chairs. Individuals with mobility disabilities may require air mattresses and cushions, stools, or other pressure relief equipment to aid in the avoidance or treatment of pressure sores. Accessible call buttons and telephones can address communication difficulties for patients with mobility or other types of disabilities.

viii. Hospital beds and gurneys

Hospital beds and gurneys can be inaccessible to individuals with mobility disabilities. Medical care and long-term care facilities do not always provide accessible beds in the patient and resident sleeping rooms required to be accessible. In order to permit transfers by individuals with mobility disabilities, including those using wheelchairs, accessible height-adjustable beds would allow persons using wheelchairs and other mobility devices to transfer in and out of bed as independently as possible. Gurneys used to transport patients from place to place in a medical facility or used in certain diagnostic procedures may need to meet the same height requirements. Hospital bed control devices, for raising and lowering the bed and for other functions, as well as call buttons, also should be accessible to patients with disabilities.

ix. Medical Equipment Questions

To assist the Department to develop appropriate requirements for medical equipment and furniture, we are seeking information that will inform the rulemaking process. With respect to medical equipment, for each type of medical equipment it would be helpful to know details about the accessible features and if particular types of equipment with accessible features are currently available. The Department is seeking the following information:

Question 1. The Department is considering adopting the Access Board's standards for medical diagnostic equipment. What other types of medical equipment and furniture should the Department include in its proposed regulation? What modifications to other types of medical equipment and furniture, including equipment and furniture used for treatment or other non-diagnostic purposes, such as hospital beds, should be included in the Department's proposed regulations?

Question 2. The Access Board is expected to promulgate design standards for medical and dental diagnostic tables and chairs. Are there tables or chairs used for medical, dental, ophthalmology, or optometry treatments, which are not typically used for diagnostic purposes, that would pose unique accessibility challenges? What modified features would make these tables or chairs accessible? What features would enhance patient stability and facilitate correct positioning?

Question 3. What types of lifts are the safest, most efficient, and most cost effective in transferring patients with disabilities in different medical or dental settings? Should the use of lifts or staff to lift patients be considered a substitute for providing independent access to medical equipment?

Question 4. If a hospital or medical provider uses staff to lift patients onto and off of medical equipment and furniture, should it be excused from the requirement of having lifts in any or all situations? What types of training programs are available to provide information to staff on lifting and transferring patients with disabilities? Are there any particular situations where lifting by staff should not be allowed?

Question 5. What features, such as low bed heights, can best enhance the accessibility of hospital beds and gurneys? Are these features available on products currently available?

Question 6. What technologies are currently available to increase the accessibility of infusion pumps? What types of infusion pumps are partially or fully operated by patients in the normal course of treatment?

Question 7. What are the greatest difficulties facing individuals with disabilities in accessing rehabilitative and exercise equipment and furniture in a therapeutic setting? What equipment and furniture most effectively permits accessibility for different types of rehabilitative needs? Can different types of equipment meet different access needs of, for example, people with low-vision who need access to visual displays on equipment? Are there differences between exercise equipment in therapeutic settings and exercise equipment in non-therapeutic settings (e.g., gym or fitness center)? What exercise equipment or machines are available to meet the needs of individuals with mobility impairments?

Question 8. What types of ancillary equipment are most effective in different types of medical or dental examination or treatment settings?

Question 9. Is there a need for separate standards for bariatric medical equipment and furniture in the Department's equipment and furniture regulation? If so, what equipment and furniture are necessary to address the needs of patients with disabilities who are obese?

x. Scoping and Triggering Events for Medical Equipment and Furniture

If the Department proposes a rule recommending regulations requiring accessible medical equipment and furniture, it should provide guidance on the appropriate amount of different types of medical equipment and furniture that must be accessible. In making this determination, the Department might consider the size of a medical practice or the patient population and other factors. For example, in a doctor's office with two exam rooms, one accessible examination table might be a reasonable number of accessible examination tables. However, in a hospital with multiple medical departments, a reasonable number might include at least one accessible examination table in each department. Radiologic and other diagnostic equipment is highly specialized and a reasonable number of accessible diagnostic equipment in a radiology department might be one of each type of diagnostic equipment.

The Department is considering proposing that entities have eighteen months from the date of the publication of a rule to come into compliance with medical equipment and furniture requirements. The timeframes for replacing different types of medical equipment and furniture may vary widely. The very high cost of some radiological and diagnostic equipment, such as MRI machines and CAT scans, which often leads medical providers to lease rather than buy them, might require a later effective date.

Question 10. What are the key criteria for scoping in different types of medical settings? What are appropriate scoping requirements for each of the types of medical equipment and furniture discussed above?

Question 11. How could medical providers time replacement or modification of equipment and furniture to ensure that individuals with disabilities receive equal access to healthcare without undue delay? What types of triggering events are appropriate for different types of medical equipment and furniture? Should the Department require the purchase rather than the replacement of some accessible equipment and furniture at a certain point? Should the replacement of inaccessible medical equipment or furniture be triggered only by the end of the useful life of the equipment or furniture?