Cutting Clothes: ED SI/HI pt

SarahMaria, MSN, RN · Feb 28, 2020

If a patient with SI/HI came to my facility, we would administer I'm medications as this patient is a danger to himself and others. Once the patient was manageable, then I would have him/her change into the proper attire. I don't think I would cut off his/her clothing.

Orion81RN · Feb 28, 2020

I'm curious as to why you had to take his clothes. I've been in a handful of behavioral health facilities, including in the hospital, and it was never required. Just curious.

EDNURSE20, BSN · Feb 28, 2020

I was thinking the same as above. What was the reason for them changing out of there clothes. Was really that urgent you had to cut there clothes? Forcing people into hospital gowns, without good reason, is outdated way of doing things.

trytounderstand · Feb 28, 2020

Why was it necessary to cut his clothes off in the first place? Was he injured or covered in something that was potentially dangerous to himself or others? Did he have weapons or drugs? Was it more a fact of control on who's part?

Would it not have been better to get him calmed down and in a more agreeable mood first?

There may have been a reason that no one was aware of that he didn't want to part with his clothing. Not only from the standpoint of not wanting to be stripped down in front of people. But those may have been his only clothes and he had a fear of losing them. He may have a past of being abused or assaulted and in his state at the time he could not give up the one thing he was in control of.

As long as there was no physical reason...injury, substances on the clothes that could be harmful to him or someone else, illness that required immediate surgery if the patient said No it was No. The first thing to get under control would have been make sure everyone was safe first. So instead of administering something to help calm he the decision was made to cuff him to a bed, hold him down forcefully and cut of his possible only set of clothing.

FolksBtrippin, BSN, RN · Feb 28, 2020

On 2/18/2020 at 1:58 PM, bigldiesel said:
Hello,
ED RN here. Had an SI/HI pt in police custody. Pt refused to change into the required behavioral health attire; was verbally aggressive, threatening staff and officers that had pt in custody, if we attempted to remove pt's clothes.
In short, after every deescalation tactic and accomodations offered, I cut off the pt's clothes. Pt was cuffed to the stretcher and physically restrained by two officers and an ED tech.
Do you think its appropiate to cut pts' clothes off in this situation?
With the principles of "least restrictive measures" of restraints, "pt safety", and "minimal/least-invaisive force necessary" what are your thoughts on this? How would /have you handle/handled this situation? (Chemical restraints etc.?)

No, I don't think it was appropriate.

Policies need to change around how we handle patients in psychiatric crisis in the emergency room.

We cause a lot of trauma, which subsequently becomes a serious barrier to care.

JKL33 · Feb 28, 2020

No I have never needed to do that.

2 hours ago, FolksBtrippin said:
Policies need to change around how we handle patients in psychiatric crisis in the emergency room.

Do you have any specific ideas about this? I've thought about it a lot over time and haven't had any great epiphanies yet.

4 hours ago, trytounderstand said:
Did he have weapons or drugs?

How do you plan to ascertain this info, and what is your proposal for maintaining the safety of patient and others?

5 hours ago, Orion81RN said:
I'm curious as to why you had to take his clothes. I've been in a handful of behavioral health facilities, including in the hospital, and it was never required. Just curious.

I've never worked in an ED where it wasn't the policy in this situation.

Waiting for Retirement · Feb 28, 2020

On 2/18/2020 at 1:58 PM, bigldiesel said:
Hello,
ED RN here. Had an SI/HI pt in police custody. Pt refused to change into the required behavioral health attire; was verbally aggressive, threatening staff and officers that had pt in custody, if we attempted to remove pt's clothes.
In short, after every deescalation tactic and accomodations offered, I cut off the pt's clothes. Pt was cuffed to the stretcher and physically restrained by two officers and an ED tech.
Do you think its appropiate to cut pts' clothes off in this situation?
With the principles of "least restrictive measures" of restraints, "pt safety", and "minimal/least-invaisive force necessary" what are your thoughts on this? How would /have you handle/handled this situation? (Chemical restraints etc.?)

Are you by any chance a student and giving us a scenario you are supposed to be offering your input on, and asking our opinions to help clarify your own? This sounds like one of those classwork/homework questions students in my facility kick around.

trytounderstand · Feb 28, 2020

38 minutes ago, JKL33 said:
How do you plan to ascertain this info, and what is your proposal for maintaining the safety of patient and others?

I suppose it would be a case by case scenario. If you are in an ed with open bays where this patient could have reached other patients and staff, then restraints would be necessary until the patient could be sedated and calmed down. But why did the patient have to be stripped of what little bit of dignity he had left. Unless he was bleeding or injured then his clothes should have been left until he was calmed down. If he was in an ed where you have a room the officers could have stayed in the room until he was under control. The other patients and staff have to be protected but at the same time there was no need to cause anymore unnecessary trauma on an already traumatized person.

JKL33 · Feb 28, 2020

2 minutes ago, trytounderstand said:
Unless he was bleeding or injured then his clothes should have been left until he was calmed down.

What happens when remaining "calm" (or at least cooperative) only extends up to the point that it is time for the assessment to actually proceed? We can sit in "neutral" territory indefinitely (that is, no one's dignity being further violated but also no progress related to the legal obligation of evaluating the patient).

In other words, when "calm" is dependent upon no one doing anything then a solution has not been reached.

5 minutes ago, trytounderstand said:
If he was in an ed where you have a room the officers could have stayed in the room until he was under control.

You need a minimum of 2:1 officers/security/etc. Are you able to duplicate those resources to dozen+ patients at the same time?

Also, how do you propose to get him under control? Restrict your answer to the previously-mentioned likelihood that remaining under control may simply be a stand-off: I am calm as long as you do absolutely nothing and do not require anything of me.

trytounderstand · Feb 28, 2020

5 minutes ago, JKL33 said:
Also, how do you propose to get him under control? Restrict your answer to the previously-mentioned likelihood that remaining under control may simply be a stand-off: I am calm as long as you do absolutely nothing and do not require anything of me.

If he is cuffed and restrained then sedated or given medication to calm him, he would be under control. While he is still under the effect of the medication is the time to explain that if he doesn't stop and allow the assessment to proceed this is what is going to happen. I am sure there are instances where it is necessary to proceed as what was described, but in this scenario there was no mention of an injury to the patient. It was just he didn't want to change to the hospital attire. He should have been given a chance rather than held down, stripped in front of others and further trauma added to whatever else is going on inside his head.

JKL33 · Feb 28, 2020

2 minutes ago, trytounderstand said:
He should have been given a chance rather than held down, stripped in front of others and further trauma added to whatever else is going on inside his head.

I absolutely agree with you. All I can do is take the words of the OP at face value, though, which were:

On 2/18/2020 at 1:58 PM, bigldiesel said:
after every deescalation tactic and accomodations offered [...]

I personally have had enough experiences where I did not believe the situations were proceeding in a respectful manner that I am sensitive to the whole issue. There is no excuse for unnecessary exacerbation of the situation and I would never defend that. However, at some point we go with the situation as reported by the OP. It isn't impossible; stand-offs are fairly frequent and could go on indefinitely which affects many other patients. Compromises sound great but then you have to accept that compromises sound great until dozens of different staff members are allowed to individually make compromises in many different situations based on nothing more than what they think "seems" reasonable. And those compromises are reasonable right up until they turn out to have been the wrong choice.