Cutting Clothes: ED SI/HI pt

[bigldiesel]

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.?)

[LibraNurse27, BSN, RN]

My hospital does have a psychiatric emergency room, and as long as the patient is not having any medical symptoms they can skip the general ED. I wish more psych emergency rooms did exist, it’s a great resource.

[FolksBtrippin, BSN, RN]

11 hours ago, JKL33 said:

I have no issue with that to the extent that nothing about the clothing can be used to harm self/others or to conceal dangerous items.

You check for dangerous items and you use a 1 to 1 for whatever you can't control. You never force a patient to disrobe ever.

11 hours ago, JKL33 said:

How would this work logistically?

I don't think it's correct to to compare the care delivered in a space that takes all comers of every age and diagnosis to that of a highly controlled space where concepts like "accepting (or not accepting) the patient for admission" and the words "not appropriate for our milieu" exist. The ED "milieu" is neither better equipped nor more appropriate. Complaints about the attempts of extremely-strained safety nets to handle these patients as best they can and calls for trained psych nurses are a little bit below the belt given the facts of the actual situation.

Perhaps psychiatric hospitals and facilities should be required to operate psychiatric emergency departments? That seems a little more logical than deciding that the general ED should be staffed with psych RNs (how many?)

Interesting that you found my suggestion below the belt, it was not intended to be offensive. Psych nurses are experienced with the population.

Maybe that is why you chose to make the comments you made about about the milieu, which are certainly offensive and uncalled for. You don't know what you don't know about psych nursing.

[JKL33]

3 hours ago, FolksBtrippin said:

You check for dangerous items and you use a 1 to 1 for whatever you can't control. You never force a patient to disrobe ever.

Why are you acting this way? You quoted me agreeing with something and then posted that ^ in response.

3 hours ago, FolksBtrippin said:

Interesting that you found my suggestion below the belt, it was not intended to be offensive. Psych nurses are experienced with the population.

I would apologize if I thought I misunderstood, but I don't think I did and your subsequent responses also don't suggest that you intended your comments to be helpful for improving the situation we're talking about.

What is your idea for practical implementation of the above idea? You either actually have one (or at the very least a vision of the way you wish things could be) or you aren't trying to help anyone.

3 hours ago, FolksBtrippin said:

Maybe that is why you chose to make the comments you made about about the milieu, which are certainly offensive and uncalled for. You don't know what you don't know about psych nursing.

I wrote what I do know and it was not incorrect. My comments about the milieu were not unfair, you came here to tell others what they are doing wrong and to suggest that psych RNs staff a general ED while at the same time what we are faced with is difficulty obtaining definitive (I.e. specialty) care for the patient. My problem isn't actually with the inpatient psych end of things; they have plenty of their own difficulties and lack of resources. My problem is with you coming here to criticize everyone given the situation in which we all find ourselves; you have come here with a decidedly different tone than just about everyone else who has participated so far. If this is indeed that important to you then give us some real suggestions.

[FolksBtrippin, BSN, RN]

3 hours ago, JKL33 said:

Why are you acting this way? You quoted me agreeing with something and then posted that ^ in response.

That was a real suggestion. Which you requested. It was in response to your assertion that you have no problem with not forcibly disrobing someone "as long as"... I'm saying no. Just make it a never event. Get adequate 1 to 1 staff. It should never happen.

Quote

I would apologize if I thought I misunderstood, but I don't think I did and your subsequent responses also don't suggest that you intended your comments to be helpful for improving the situation we're talking about.

What is your idea for practical implementation of the above idea? You either actually have one (or at the very least a vision of the way you wish things could be) or you aren't trying to help anyone.

I have suggested the policy change that no patient be forcibly disrobed under any circumstance. Your questions about implementation and logistics are not appropriate for this forum. How many psych nurses? That would depend on the size of your ED of course. Whether it should be a separate psych ED, also would be about resources and population density and all sorts of things that are site specific.

Quote

I wrote what I do know and it was not incorrect. My comments about the milieu were not unfair, you came here to tell others what they are doing wrong and to suggest that psych RNs staff a general ED while at the same time what we are faced with is difficulty obtaining definitive (I.e. specialty) care for the patient. My problem isn't actually with the inpatient psych end of things; they have plenty of their own difficulties and lack of resources. My problem is with you coming here to criticize everyone given the situation in which we all find ourselves; you have come here with a decidedly different tone than just about everyone else who has participated so far. If this is indeed that important to you then give us some real suggestions.

I did give real suggestions. Your statements about using words like milieu are extremely rude and also very ignorant. You should apologize for that, regardless of whether you think my suggestions were helpful or not. You were absolutely hitting below the belt, which isn what you accused me of doing. Wrongly.

And I came here to answer the OPs question, which is specifically what I did.

[speedynurse, ADN, BSN, RN, EMT-P]

I have never done that, no. I always try to have the patient change into one of the SI gowns (no ties for ligature risks) but honestly, if they refuse to, then I never ever force it. I feel like that just escalates the issues and places the rest of the staff in danger. If I feel there is a weapon risk, then enlist the help of the police.

[hppygr8ful, ASN, RN, EMT-I]

Since the OP has not come back I believe like many others who are looking for people to sign off on their actions. They disappear when the opinions offered don't support their actions.

I've worked in mental health for 20 years and Psych patients have rights (Even in the ER/ED). One of those rights is to keep and wear their own clothing. When a patient comes to us direct from the street we check their clothing and body Then return their clothing to them. Two staff are always present. If they are unable to comply due to behavior or psychosis we medicate them so they will be able to comply. We do not force them as this is a violation of patient's rights. We keep them in an observation room with staff until they are able to comply.

I also agree that ED/ERs should have nurses trained in using psychiatric interventions. This does not mean you have to have a lot of psych nurses. Just that nurses in the ED should be cross trained. Also training in Trauma Informed care and open communication would be very helpful.

Hppy

[bigldiesel]

Thanks. There's some good feedback here.. Some clarifying points:

1) All SI/HI and OD, patients change into safe attire. This is policy at the systemic level and prevents ligature and/or further TI.

2) Staffing is an issue and 1:1 obs aren't correctly observed, 1 sitter can have 4 "1:1s." I wish there were "Psych ED's" as a resource, both medical and psych patients would receive a higher quality of care in the healthcare system.

3) As stated every de-escalation attempt was made, for this (AO4, highly aggressive, non-compliant) pt, so the question is chemical restraint vs Shears for clothing removal. I agree with the posts above and will choose chemical restraint as a last resort. (Context: 5 other patients, consisting of 1 ICU, 2 IMC, 2 medical, needed care and no providers were available for chemical restraint orders.)

4) Proposal or discussion of evidence-based "principles" for rationales behind clinical action isn't "student homework"; it was my attempt to discuss best practice. Failure to do so ends up with circular rhetoric and no conclusions.

Thank you.

[JKL33]

57 minutes ago, FolksBtrippin said:

Just make it a never event. Get adequate 1 to 1 staff. It should never happen.

I am not opposed to the idea that if something is inherently/absolutely wrong then it should never be an option and yes, no matter what some other way must be found. I guess one of my concerns is that it isn't just the clothing. None of the interventions utilized in the worst scenarios are great. Physical restraint, chemical restraint, etc.--all of these are traumatic. They each individually have major potential for injuring someone's sense of dignity. Yet every option for handling a situation can't be taken away. These interventions are not absent from the spaces where specially-trained psych nurses are in charge, either.

I am not sure to whom you're suggesting "get adequate 1:1 staff." The staff nurses here discussing how to handle situations IRL/IRT are not in charge of that. That's what I mean, it would be like me telling psych to "get an appropriate bed for this patient, then, if you don't have one, because this patient needs it." I would not go into your spaces and give you a directive like that because it is not helpful.

1 hour ago, FolksBtrippin said:

Your questions about implementation and logistics are not appropriate for this forum. How many psych nurses? That would depend on the size of your ED of course. Whether it should be a separate psych ED, also would be about resources and population density and all sorts of things that are site specific.

The questions are appropriate if someone purports to be participating here with helpful intent. How should I know if you or someone else reading this may have been involved in implementing the suggestion you made about staffing the general ED with psych nurses? Maybe someone else has some experience with this even if you don't. But you're the one who made the suggestion as if it were as simple as pie so it isn't unreasonable for me to have thought you might know something more about the matter.

1 hour ago, FolksBtrippin said:

Your statements about using words like milieu are extremely rude and also very ignorant.

We are asking for definitive, specialized help **for the patient** from the ED, one of the worst places possible to try to maintain a therapeutic environment for patients who need psychiatric care. You are here criticizing us when we are not set up to provide the kind of care that can be provided elsewhere and you want to retain the right to say, "sorry, can't help you." No I will not apologize. I can't even begin to fathom how you think you are the offended party.

[JKL33]

42 minutes ago, bigldiesel said:

As stated every de-escalation attempt was made, for this (AO4, highly aggressive, non-compliant) pt, so the question is chemical restraint vs Shears for clothing removal. I agree with the posts above and will choose chemical restraint as a last resort. (Context: 5 other patients, consisting of 1 ICU, 2 IMC, 2 medical, needed care and no providers were available for chemical restraint orders.)

This is where, as an RN, you need to call for some accountability from other quarters rather than feeling forced to actions that, well, are probably towards the top of the list as far as being offensive, traumatic and least likely to facilitate any sort of therapeutic relationship with the patient.

It's okay to do that; to start calling the responsible people and saying, "nope, this is beyond the pale, get some more help."

Good luck ~

[Tenebrae, BSN, RN]

On 2/29/2020 at 12:07 PM, JKL33 said:

Ideally we could keep everyone safe while maintaining very flexible policies. It doesn't usually play out that way given the numbers, the range of potential situations, the resources, etc.

Its not necessarily about flexible policies, its sometimes about realising the limitations of the policy and trying to work with the patient top find a way foward.

For example, we have a policy on acute impatients, that patients are not allowed access to their cell phone chargers on the ward. Sounds obvious right. Except in the last three months we've had several attempted hangings and one of those sucessful where the patients had used bag straps. No ones proposed banning bag straps

Like I said, just because its policy doesnt mean it makes clinical sense or is the best way forward

[JKL33]

Agree. ^

[MunoRN, RN]

7 hours ago, bigldiesel said:

Thanks. There's some good feedback here.. Some clarifying points:

1) All SI/HI and OD, patients change into safe attire. This is policy at the systemic level and prevents ligature and/or further TI.

2) Staffing is an issue and 1:1 obs aren't correctly observed, 1 sitter can have 4 "1:1s." I wish there were "Psych ED's" as a resource, both medical and psych patients would receive a higher quality of care in the healthcare system.

3) As stated every de-escalation attempt was made, for this (AO4, highly aggressive, non-compliant) pt, so the question is chemical restraint vs Shears for clothing removal. I agree with the posts above and will choose chemical restraint as a last resort. (Context: 5 other patients, consisting of 1 ICU, 2 IMC, 2 medical, needed care and no providers were available for chemical restraint orders.)

4) Proposal or discussion of evidence-based "principles" for rationales behind clinical action isn't "student homework"; it was my attempt to discuss best practice. Failure to do so ends up with circular rhetoric and no conclusions.

Thank you.

I assume you're referring to "All SI/HI and OD patients" that have already been evaluated and placed under a legal hold by someone legally prescribed to do so, since what you describe isn't broadly legal as applied to all of these patients. Although even then there are limitations even under a legal psychiatric hold. Facility policy does not override legal limitations.

I'm not familiar with what "TI" is, looking it up as a medical abbreviation returned "time intercourse".