Crisis Unit: To lock or not to lock??

[Meraki]

That is the question. I apologize for the length of the post but I need your experience and expertise and want to make the situation as clear as possible.

I work on a 15 bed adolescent acute care, crisis and assessment unit (average stay 10-14 days). Our hospital does not have any kind of Psych Emerg or Step Down unit, all psych admissions come directly to us (voluntary, involuntary and incompetent). We have been up until now a secure unit, locked 24 hours a day. There is discussion about changing that and becoming an unlocked unit for 12 hours during the day and locked for 12 hours overnight. I have been asked to oversee the transition.

I understand the pro's of unlocking the door but have some major concerns as well. My concerns are:

1) Increased anxieties for parents who are often terrified their child may attempt or attempt again (we often refer to the locked door as a way to reassure them)

2) Needing to more closely monitor/supervise/guard the patients to ensure they have not left the unit resulting in them feeling a decreased sense of freedom, privacy and feelings of taking responsibility for themselves (ie If I have to always follow them to make sure they do go to their room or the bathroom when they say that's where they are going, and not out the door)

3) Increased physical restraints / physical redirection of dragging kids back onto the unit if they leave without permission.

4) Increased anxiety for staff who are concerned that their patients may AWOL and harm themselves

5) A decrease in programming / 1:1 time as staff will need to spend their time being more vigilant and will not have the 'luxury' of knowing their other patients are still on the unit if they are busy.

My other concern is that the lay out of our unit means that the doors are not visible from the nursing station. Our unit is a U shape. the nursing station is at the bottom curve of the U and the two doors at either top of the sticks of the U. They will be putting in a camera at the entrances with a video monito in the office but unless someone is specifically monitoring th video there is no way of knowing is someone has come in or out (there is no alarm or sound if someone opens the door). All of our staff, including the nurse in charge have a patient assignment so there is no one to sit and watch the camera. We do not have techs or aids or the like to help with door or camera monitoring.

I am very interested from hearing from anyone who works on an unlocked unit...are my concerns valid? how do you deal with these issues?

And if anyone has worked on a unit that has made the transition from locked to unlocked...please tell me how it went.

Also if anyone has links to any articles that discuss the issue, either pros or cons or both...I would appreciate receiving that as well.

Thank you in advance

Jenn

[suzanne4, RN]

Check first with the the county or who ever places non-voluntary patients there. I thought that one of the requirements was that the unit be locked 24/7. That may change right away what your unit wishes to do.

[rn/writer, RN]

Check also with insurance companies and HMOs. What the higher ups at your facility might not have considered is that they could well be muddying the waters as far as criteria goes. If your kiddies can be on an unlocked unit for 12 hours at a time, I'll bet it won't be long until someone says, "Why can't they just be treated on an outpatient or partial hospital basis?"

I used to work on a unit very similar to yours except the nurses station was next to the main door. I can't imagine what we would have had to deal with if those doors had been unlocked. Sheesh. We had kids who tried to escape even with them locked.

Sometimes people who have no business being on the unit (non-custodial parents, bf or gf, patients from other units) try to get in. That can be almost as problematic.

Why in the world is your facility even willing to consider such an unsafe idea??? It can't be to save money as you'd probably need to increase staff for the sake of vigilance. And I shudder to think of what kind of payout there would be with even one bad outcome following an escaped kiddo.

You guys might also want to ask the hospital's insurer about the liability issue. I'll bet they won't be crazy about the idea.

Honestly, I just don't see any plusses for a change like this.

Good luck,

Miranda F.

[lovinghands]

In the early 90's, I worked on an unlocked adolescent unit for chemical dependency kids. It was a treatment center not a hospital setting located on a large campus in a small rural community. It was a headache and a major liability issue that was soon resolved by locking down the unit shortly after I left. Kids occasionally walked away, items were hidden outside & occasionally we would have an unexpected visitor come through our door that was located a few doors down from the office.

I could not imagine this setup on an acute psychiatric unit. I don't see any benefit in exposing children to potential harm. I shudder to think of the terrible things that could happen. Please keep us posted.

[MandyInMS]

Sounds like an accident WAITING to happen...unless they want to hire one on one staffing to assure no one goes AWOL , they need to leave the unit locked..for the safety of the pts , staff , liability issues of the unit...I would NOT assume responsibility in an unsecure unit.

[Meraki]

well....things have progressed quicker than I expected. They unlocked the door yesterday!

They were open to having guidelines in place...ie situations in which the door needs to be locked.

I guess we'll wait and see how it goes!

I think the USA has mostly locked units, here in Canada it's about 50/50, over in the UK about 90% of their units are unlocked...so I guess it can work... although my anxiety is sky high!

Thanks for the responses

[CharlieRN]

I'm onboard with everyone else.

I can't see how an acute care, general psych unit can be maintained safely with unlocked doors. The only justification would be if there were an extensive list of conditions which would cause an immediate lock down. See the prior posts for ideas as to what those are.

Any patient who has thoughts of running away.

Any suicidal patient.

Any substance abuser who is not 100% committed to treatment.

Any patient who has a problematic non custodial parent or an abuser who is not jailed.

Any pt who is incompetent to maintain their own saftey.

If you lock down for any listed condition, then sure call it an "unlocked unit" if they want to but it will not actually be unlocked very often.

At least in the US, nursing licensure is all about maintaining a safe environment, so it is very reasonable to refuse to take responsiblity for an unlocked unit if you do not believe it is safe. Not to say that might not cost your job, but at least you don't get sued.

[Balder_LPN, LPN]

Update, PLEASE!