Depressed self-referral to ED

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Just curious how other hospitals might have handled the situation. Early 40's female pt self-referred to ED complaining of feeling depressed and suicidal ideation - no plan, however. It was a little surreal because pt appeared well-put-together - very calm and composed. However, pt admitted to drinking earlier. Pt attempted to leave before her psych eval could be conducted, saying she felt better and had changed her mind. At that point, pt was re-directed to a locked room, her clothing, underwear were taken, ankle to ankle restraints applied. She ended up being discharged after her eval. Didn't know what other hospital policies might be in similar situation.

Specializes in Behavioral Health.
Like I said before, it was surreal because of how calm she was otherwise... I tried to help initiate her disrobing by taking her shoes off, myself and casually complimenting her on her bare feet as I did.

It's not that uncommon in either depressed patients or those with severe anxiety (which often drives depression and SI). They become so internally preoccupied - with their fears, doubts, self-talk, etc - that they present as somewhat flat.

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It's not that uncommon in either depressed patients or those with severe anxiety (which often drives depression and SI). They become so internally preoccupied - with their fears, doubts, self-talk, etc - that they present as somewhat flat.

Or it's not uncommon that they are at peace because they have finally made a decision to kill themselves, after agonizing over the decision for a long time ...

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Again, I'm struggling to see the disconnect here. If the physician has determined that the patient presents a danger to themselves and requests a mental status exam by a QMHP, they certainly *can* prevent the patient from leaving prior to said mental status exam.

I believe the disconnect lies in weather or not an RN can implement a hold. While we do not specifically implement a hold we will stall a pt long enough for a physician to evaluate and decide. Sometimes that means repeatedly telling a pt to wait one minute as they are walking out the door, while someone runs and grabs the physician.

As a side note what I hate is when a physician tells me," well they are kinda a hold. They shouldn't leave. But we don't have to dress them down and make them stay"

Ok mr/mrs md, but if they want to leave I'm going to show them where the door is.

Md says," no they can't leave"

Then I guess you better put a hold order in. I won't be assaulting/kidnapping anyone tonight.

BSN GCU 2014.

Sent from my iPhone using allnurses

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^^^ And this is why the ED RN is NOT the QMHP that makes the call. This is why we have standardized screening tools to assist us in determining the level of precautions to take. This is why the RN does not get to say "Oh, well they don't have a plan, so it's okay to just let them walk out." The responsibility of that decision lies with the physician and the QMHP.

Edited to add: AZQuik, we posted at the same time. I don't disagree with you. I don't think I ever said an RN could implement a hold.

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Specializes in ER, progressive care.

Restraints on a psych patient in a locked room? That's a recipe for a disaster. Unless the patient was violent and needed temporary restraining and there was someone who had eyes on that patient at all times, restraints are a big no-no.

If the patient had a legal psych hold in place then they weren't allowed to leave until they had a psych eval. We would call the local PD or security if the patient tried to leave. If they had no legal hold, then you can't hold them - we would also notify the local PD and request a welfare check.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

My mentor and one of the most adored people in my life killed herself a week after I last saw her. She had a successful medical practice and was very well put together. She smiled and engaged with me, looked like a recent haircut, too. It will be 20 years next year and I am still so raw inside-- and I was not that aunt of hers who was a Navy Nurse from the days of the crustiest of crusties who was devastated, but maybe this is why I think the patient's grooming habits are a rather useless benchmark. Sorry if I sound like I am taking it personally I guess I am.

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Specializes in ER.
I am only a student but this goes against anything I have learned or participated in on the wards. The restraint sounds extremely unethical and unecessary. I could never see this being done in any of the wards I have worked on simply because she was merely asking for help/support and was not threatening by any means. I would assume the locked door is enough (maybe even too much) of a restraint. I do understand that she needs to be assessed after confessing her suicidal thoughts before leaving, but is there a more practical way it could have been done?

May I ask why all of her clothes were removed?

Clothes are removed and patients are placed in paper scrubs, usually helps describe them when they elope. It may sounds unethical but I have worked in a busy ER for 7 years were we hold these patients. When they decide they no longer want to wait they change their mind about being suicidal. I have known two patients to elope after saying they were no longer suicidal. One purposely ran onto and interstate and came back as a level 1 trauma the other jump from an over path to on coming traffic. Now you tell me what's the better option. After that you can bet you and the hospital will be grilled by CMS and asked about your protocols for providing safety for these patients. And I bet she became a little combative when she realized she couldn't leave and had to be placed in restraints.

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Specializes in ER.
I believe the disconnect lies in weather or not an RN can implement a hold. While we do not specifically implement a hold we will stall a pt long enough for a physician to evaluate and decide. Sometimes that means repeatedly telling a pt to wait one minute as they are walking out the door, while someone runs and grabs the physician.

As a side note what I hate is when a physician tells me," well they are kinda a hold. They shouldn't leave. But we don't have to dress them down and make them stay"

Ok mr/mrs md, but if they want to leave I'm going to show them where the door is.

Md says," no they can't leave"

Then I guess you better put a hold order in. I won't be assaulting/kidnapping anyone tonight.

BSN GCU 2014.

Sent from my iPhone using allnurses

This all depends on the state and county you are in. In Dallas county a nurse can call a police office and request an Apoww( apprehension by police without a warrant) and some counties outside of Dallas they utilize different methods. When I worked in cali it was called a 5150. So if a nurse or doctor feels the patient is a treat they can contact the police and the police will talk with the patient and determine if they need to be held. Usually these are a 24 hour hold or until evaluation by a physician. For suicidal ideation she would have be a hold.

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Yeah the restraints sound a little much, but at the end of the day both patient and staff were safe.

I only wish I had some legal backing in cases like this. I have had to discharge 2 attempted suicide cases in the last 2 weeks because I cannot make them stay and get a psych assessment. There is no law to let myself or a doctor hold a patient against their will, and all the police would do is lock them up. Which is definitely not a solution.

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Specializes in Critical Care.
Yeah the restraints sound a little much, but at the end of the day both patient and staff were safe.

I only wish I had some legal backing in cases like this. I have had to discharge 2 attempted suicide cases in the last 2 weeks because I cannot make them stay and get a psych assessment. There is no law to let myself or a doctor hold a patient against their will, and all the police would do is lock them up. Which is definitely not a solution.

Generally the police don't lock people up for that, on what charge would they be locking them up?

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What state was this? She wasn't even combative? Restraining is a last resort.

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Specializes in Psych.

In a room with as many dangerous items removed or a "soft" room with a sitter providing continuous observation, Q 15 min documentation, with nurse assessment at minimum Q 1 hour (if restraints were on).

Restraints are a violation of human rights and if the patient had borderline or attention seeking behaviors, that was some serious validation. If no order was placed for restraints and if she was not continuously monitored while in restraints (behavioral laws are different than medical laws when it comes to what we can do as health care providers), everyone involved can have serious charges filed against them. Including loss of license.

Usually a nurse can place a patient in restraints and the doctor has to visualize and assess them within an hour. Behavioral health you have to REALLY justify as to why a person needs to be restrained. Even having a person in a seclusion room can be considered a restraint.

Sounds like your doctors need education or their license to practice suspended.

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