Behavioural Management in Emergency, need ideas...

[NO50FRANNY]

Thought I would ask my fellow experienced ED nurses about good tricks both medical and nursing when dealing with patients who have complex psychiatric/intellectual/social issues that occasionally overlap with obvious behavioural problems. I exhausted all my usual techniques tonight and was wondering if the smart AN people could give me some ideas. We have all dealt with this kind of patient at one time or another.

Nightmare pt.-no fixed abode, intellectually impaired with an IQ tested around 50. Profound prejudicial childhood, foster care, emotional and protracted physical abuse both from parents and foster carers. Very sad. Diagnosed with ADHD, BPD. Mother with significant substance abuse problems. Pt. will get drunk, overdose on paracetamol (LOTS) and present, generally requiring NAC infusion. Presentations escalating and largely behavioural. Given our duty of care and pts' limited capacity to understand the more complex consequences of his actions was recently reluctantly admitted under mental health briefly given potential for significant risk of self harm, unfortunately re-enforcing his behaviour. Presentations continue on essentially a second-daily basis.

The patient plays the usual games. Attention seeking, absconding, lying, manipulating. Shift started when he was on his 16 hour bag and he kept fidgeting with his IV to make the machine alarm, after doing several other things to try and get my attention (has terrible access). I usually do one of two things with patients who play games, I either do everything they ask and give them nowhere to go, or shut them down completely. Unfortunately what he wanted were things that I couldn't do which I highly suspected he knew. I turned his drip off. He cracked the you know whats because he couldn't play with me and absconded, twice. We know he is pushing for admission and that his suicidal ideation is chronic and largely unlikely but he batters his poor body. I made the suggestion about addressing his behaviour with mechanical restraints which was met with the usual obstruction but we don't do it often enough in my opinion. There just aren't any negative consequences to anything he is doing (that he can rationalise). Years ago we had a similar pt. who would do almost precisely the same thing, she would save money from her pension while in hospital and had exhausted her welcome in many facilities. On about her thousandth presentation, our consultant gave her no drugs and put her in restraints until she was reviewed by psych, and the next time, we did the same thing. She never presented again.

I am curious about other facilities and how they deal with pts such as this. I just feel as if we are not helping by all this positive re-enforcement and someone needs to have the guts to give some negative consequences to this behaviour. I'm out of ideas. Don't get me wrong, I am not a fan of restraining people but I can't think of any other way with this poor soul. I do the best I can but I just couldn't win tonight.

[NO50FRANNY]

By the way, I forget that paracetamol is called acetaminophen in the US. He usually ingests in excess of 100 grams or 50 odd tablets.

[Altra, BSN, RN]

Wow, this is a handful, NO50FRANNY.

In most US states, the repeated self-harm with that much acetaminophen would have produced an involuntary psychiatric commitment. And if his IQ (and therefore ability to care for self) has been documented as being that low and he is dependent on mother's care but she has documented substance abuse issues and is homeless ... that situation may also have produced some court action to have him declared a ward of the state.

In the short term, in my experience, someone who had ingested that much acetaminophen would be restrained if necessary to complete the medical treatment necessary to attempt to minimize liver damage. And if he has done this repeatedly, it's not going to be long before his hepatic dysfunction will impair his overall functioning to such an extent that he will require institutional care.

Very sad.

I guess I'm saying that the short-term answer in the ED would be restraints where I have worked ... but I realize that is highly dependent on local laws and practices.

[NO50FRANNY]

Thank you so, so much for your response Altra, He is a ward of the state to an extent, his financial beneficiary is the "adult" guardian (government carer) so his parents have no influence whatsoever in his care, he is 20 years old. But given that his issues are largely behavioural he is not under an involuntary treatment order, other than acutely. The problem with this particular patient is his ability to manipulate services. He doesn't behave violently, and conservative management for his repeated escapes is usually mandated from a reluctance to enforce mechanical rather than pharmacological restraint given the behavioural nature. Institutional care is almost non-existent for this patient because he has capacity. His mother provides intermediate accomodation which he utilises when it suits him. The suckful thing is he is looking for safe placement with other agendas. Attention, care and somewhere safe but he has capacity to be provided with this outside of a hospital setting. The biggest issue I can detect is that Psych reasonably believes that he can be managed in the community and that the current carry on is a push for something that will ultimately not benefit him. Thank you for agreeing, mechanical restraints in this particular situation were a reasonable option. The issue is that given the behavioural nature of his actions, they don't want to put him on a permanent involuntary treatment order permanently because it is exactly what he wants for the wrong reasons, and won't help.

[sapphire18]

A person with an IQ of 50 is considered "competent"?? I don't see a contraindication for mechanical restraints, if he is playing around with Tylenol OD treatment...such a dangerous thing if not treated quickly. Even if it's behavioral (it's for their safety; not determined by WHY they're creating possible harm to themselves or others). Did he have a 1:1 sitter?

[NO50FRANNY]

A person with an IQ of 50 is considered "competent"?? I don't see a contraindication for mechanical restraints, if he is playing around with Tylenol OD treatment...such a dangerous thing if not treated quickly. Even if it's behavioral (it's for their safety; not determined by WHY they're creating possible harm to themselves or others). Did he have a 1:1 sitter?

Not competent as such, he is under the care of a government agent who acts as guardian, controls his finances and so on, but he functions at a level deemed too high for institutional care so far. He didn't have a sitter, just in a highly visual area- he absconded in front of me both times, and unfortunately is a big boy so I couldn't physically restrain him and he knows how to hide from security- he also knows that as soon as he is "off campus" they will not detain him. I almost managed to talk him down both times but alas. Even with duress alarm they weren't quick enough to catch him. I totally agree that he needed restraints but the culture in our department for some reason leans toward chemical restraint rather than mechanical. Sapphire do you guys use mechanical restraints often?

[sapphire18]

We use them if they are trying to hurt themselves or others ("behavioral") or for tube/line safety ("medical/surgical"). So yes, I see medical/surgical restraints quite often as I mainly work ICU. If, for example, someone pulled out his IV and he was getting mucomyst for a Tylenol OD, no one would protest putting the pt in medical/surgical restraints. Of course, we would still need to have the Dr. sign the order as soon as possible. Behavioral restraints, on the other hand, are most definitely used as a last resort, and I've never seen them being used without some type of chemical restraint as well, to try to allow the pt out of the mechanical restraints as soon as possible. These are for the aggressive/violent patient and/or one that is trying to escape and is under involuntary commitment. These are used often in the ED usually on the psych patients. Suicidal patients also always get a 1:1 sitter- no exceptions.