Safety with dangerous pts

PeakRN · May 15, 2018

I'm a bit confused at the situation. If patients are cleared and awaiting transfer then why are they being admitted rather than staying in the ED? Unless you are licensed as a psych facility you can't bill for psych ICD-10 codes and the subsequent admission. It also sounds like they are being admitted into a less safe environment, which beyond the obvious safety issues may be a legal issue. Even when we transfer psych patients we need to be reasonably certain that the patient is safe during transfer and at the receiving facility (not all psych facilities have the same resources either, our patients that are physically aggressive despite medications may need to be admitted to the state hospital instead of a private facility).

We do have security and PD in house 24/7. Patients who require a sitter but are not violent may (in the ED or the house) may have a tech as their 1:1. Patients that are violent will have security at the bedside. All patients who have a medical need for admission and need restraints are admitted to the ICU due to the increased risk from the restraints.

If patients are on a legal hold then they need PD/SO/Prison guards/et cetera with them at all times. Our house PD officer can watch patients for short periods of time while the custodial officer uses the bathroom but otherwise we do not provide any watch services for these patients. PD will often drop of psych patients who don't have any legal issues, in these cases PD does not stay with them.

3peas · May 16, 2018

I'm a bit confused at the situation. If patients are cleared and awaiting transfer then why are they being admitted rather than staying in the ED? Unless you are licensed as a psych facility you can't bill for psych ICD-10 codes and the subsequent admission. It also sounds like they are being admitted into a less safe environment, which beyond the obvious safety issues may be a legal issue. Even when we transfer psych patients we need to be reasonably certain that the patient is safe during transfer and at the receiving facility (not all psych facilities have the same resources either, our patients that are physically aggressive despite medications may need to be admitted to the state hospital instead of a private facility).
We do have security and PD in house 24/7. Patients who require a sitter but are not violent may (in the ED or the house) may have a tech as their 1:1. Patients that are violent will have security at the bedside. All patients who have a medical need for admission and need restraints are admitted to the ICU due to the increased risk from the restraints.
If patients are on a legal hold then they need PD/SO/Prison guards/et cetera with them at all times. Our house PD officer can watch patients for short periods of time while the custodial officer uses the bathroom but otherwise we do not provide any watch services for these patients. PD will often drop of psych patients who don't have any legal issues, in these cases PD does not stay with them.

Normally these pt's have medical issues that need to be taken care before a private psychiatric facility will accept. Attempted suicide-if they were injured those need to be addressed. If an acute psychosis pt has any medical issues (hypertension, diabetes, etc) then they can transfer. Psych pt's are traditionally placed in ICU due to lower ratios. Most of the time you can't have a patient in restraints 24 hours prior to transfer.

I'm a former ICU nurse turned psych nurse. Depending on diagnosis psych patients don't like being confined to a bed or a room. Most are addicted to nicotine and want to smoke and want many other substances. My heart aches for these patients and the staff that care for them. There needs to be more training in this area.

PeakRN · May 16, 2018

Normally these pt's have medical issues that need to be taken care before a private psychiatric facility will accept. Attempted suicide-if they were injured those need to be addressed. If an acute psychosis pt has any medical issues (hypertension, diabetes, etc) then they can transfer. Psych pt's are traditionally placed in ICU due to lower ratios. Most of the time you can't have a patient in restraints 24 hours prior to transfer.
I'm a former ICU nurse turned psych nurse. Depending on diagnosis psych patients don't like being confined to a bed or a room. Most are addicted to nicotine and want to smoke and want many other substances. My heart aches for these patients and the staff that care for them. There needs to be more training in this area.

The vast majority of psych admits are medically stable on arrival (or perhaps just need to detox from drugs or alcohol). We admit less than 5% of our psych patients to the hospital for medical problems. Chronic hypertension or diabetes are not something that we can admit for, the insurance will end up not paying and there is no reason that a chronic disease state cannot be managed at a psych facility. If they are in hypertensive crisis or have an acute diabetic problem like DKA then we will admit. Basically if we could have discharged them home barring the psych complaint then we cannot admit them to the hospital for those same problems.

More than training we need a different approach to psychiatric care. We stabilize them on antipsychotics in psych hospitals and then immediately discharge them without any real way to make sure they make it to outpatient appointments or continue their medications. We set these patients up for a cycle of failure.

JKL33 · May 16, 2018

Normally these pt's have medical issues that need to be taken care before a private psychiatric facility will accept. Attempted suicide-if they were injured those need to be addressed. If an acute psychosis pt has any medical issues (hypertension, diabetes, etc) then they can transfer. Psych pt's are traditionally placed in ICU due to lower ratios. Most of the time you can't have a patient in restraints 24 hours prior to transfer.
I'm a former ICU nurse turned psych nurse. Depending on diagnosis psych patients don't like being confined to a bed or a room. Most are addicted to nicotine and want to smoke and want many other substances. My heart aches for these patients and the staff that care for them. There needs to be more training in this area.

The OP has clarified to say that these are patients who are already medically cleared. That means there is no admitable medical dx.

Peak - they aren't admitting the patient (i.e. no inpatient admission). They are placing them in an obs bed that happens to be in the ICU. But...I'm not really sure how they are even getting away with that when they aren't observing them for the purposes of deciding what additional care they might need. But, who knows. It already sounds like people who are not at all versed in these issues are the ones making decisions.

CTtoRN, ADN, BSN, RN · May 16, 2018

You need medication orders for patient behavior. Benadryl 50mg, Ativan 2mg, Haldol 10mg or geodon IM injections or perhaps IM Zyprexa would benefit you greatly. The solution is you need psych drugs or withdrawal medications to treat these people and you need protocols.

riverlands · May 16, 2018

Ditto to SobreRN another reason I enjoy corrections!! I feel safer than I did in acute care

allnurses Guide · May 16, 2018

Hi all!
I come from a critical access icu and er. We live in a big college town and get a fair amount of dangerously combative pts and psych pts. Our icu is the only observation unit so all the psych holds are admitted there. We generally only have two small female nurses and a female aide. They admit pts that require 8 people to take them down and send them to us. I'm working on a safety initiative and trying to find out what works for other hospitals in regards to safety with these pts. Do you staff a police officer at bedside? I know a lot are brought in by the police here. I would like to hear the way you deal with these dangerous situations.

I am a bit confused - Are you saying that college towns have more dangerously combative and psych patients than towns without colleges nearby? I have been working with the acute psych population for 17 years and they are as a rule rarely dangerous. In fact as another poster said here most patient escalations are cause by staff interacting improperly with these patients. Proper training in verbal de-escalation works wonders as does a nice cocktail of haldol, Ativan and benedryl. You patients should have these orders before they come to you. When the police drop off a patient under arrest they need to stay until the patient is medicated. IF your hospital is accepting these patients then they need to staff accordingly. If you are a union hospital take this to your rep. IF not learn everything you can about how to work with psych patients. Take CEUs, CPI, MAB, etc. less that 1% of psych patients are dangerous once you understand how to work with them.

Hppy

Neats, BSN · May 16, 2018

I would speak to your management about this issue, here are some tips to assist you now and in the future.

1. Have good verbal skills if you do not know what those are just observe a good bartender or waitress or some correctional/peace officers. They can come back with some snappy reply that is political correct, can diffuse a situation, have the ability to redirect from an increasing sticky situation. This art is called verbal judo/verbal tactical skills. It has gotten me out of a lot of situations and we usually end up laughing at something and when I walk away the inmates usually say thank you Mrs XXX.

2. Be aware of your surroundings. It is like what you are taught in your CPR class first assess the scene. Before you go into the room pause at the door and just look around the room real quick to see what you are stepping into. Same with when a patient approaches you, have what is known as situational awareness. This means you know what is going on in your surrounds. I sit with my back against the wall all the time, my family pointed this out to me because I want to see what is going on. There are times my husband and I will sit side by side when we travel because we both want to know what is going on in our surrounds. We also are aware of where our exists are.

3. You must document everything in detail. It shows what the situation is, what happened and may help to improve your working situation.

4. This is one of those situations where if you are union I would go to your shop steward and let them know about this situation, management has not provided any correction and now you want union involvement, it is even cause for negotiation at the union table.

Good Luck to you.

Hazelgirl_06 · May 18, 2018

The OP has clarified to say that these are patients who are already medically cleared. That means there is no admitable medical dx.
Peak - they aren't admitting the patient (i.e. no inpatient admission). They are placing them in an obs bed that happens to be in the ICU. But...I'm not really sure how they are even getting away with that when they aren't observing them for the purposes of deciding what additional care they might need. But, who knows. It already sounds like people who are not at all versed in these issues are the ones making decisions.

They do not have medical issues but straight psych. They are under a hold until they can find a bed in a psych facility. If they can't in six hours, they are admitted under observation in the icu whether they be safe or dangerous. There is a huge push to get them out of the er. So they stay with us until a bed is open.

Hazelgirl_06 · May 18, 2018

You need medication orders for patient behavior. Benadryl 50mg, Ativan 2mg, Haldol 10mg or geodon IM injections or perhaps IM Zyprexa would benefit you greatly. The solution is you need psych drugs or withdrawal medications to treat these people and you need protocols.

If they are combative and dangerous it is impossible to give. We have to wait for police to come which take a while which in that time someone could get hurt

FolksBtrippin, BSN, RN · May 20, 2018

1. Pts who are medically and are awaiting a psych bed placement
2. They expect us to hit a button and wait until the cops show up which could be a while and in that time we could get injured
3. We have one security guard responsible for the whole hospital and is only there half the night. As for sitters it's only if we can find a unit to float someone to help. If not we have to deal with it.

This is very unsafe. Combative pts should not be on a unit where they have access to medically fragile people. You need to get them out of there. And you don't have nearly enough staff. You don't even have enough staff to deal with one of these patients.

You need at least one locked seclusion room, a designated restraint bed and people assigned to cover psych emergency code situations. You also need standing orders for ativan, and thorazine or haldol.

Can you get these pts to another unit? If there are charges I suppose you could have the police officer stay until a bed is found. And communicate better with your local pd because they should bring combative psych pts somewhere else if at all possible.

FolksBtrippin, BSN, RN · May 20, 2018

If they are combative and dangerous it is impossible to give. We have to wait for police to come which take a while which in that time someone could get hurt

You have this backwards. You must give combative and dangerous patients IM drugs. That is necessary to prevent staff and patient harm.

If you don't have enough staff to force the drug, you call a psych code and get the staff running to force the drug. You can't just let a psychotic patient kill and maim others or self.