Depressed self-referral to ED

[jana82]

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.

[MunoRN, RN]

It's certainly not unheard of for a patient to present to the ED with suicidal thoughts, and then to decide to leave prior to being evaluated for a legal hold. No legal hold=no legal hold. Our legal option is to notify the police and request a welfare check, it is then up to their legal processes to determine if the patient can be subjected to an involuntary evaluation.

Even the the patient was deemed high risk, the methods described would still be pretty questionable at best.

[elkpark]

Detaining due to being incompetent to make the decision to leave can't be based solely on having had some drinks anywhere in the US

I'm not talking about "having had some drinks," and I'm not suggesting a blanket policy that anyone who has any EtOH in her/his system lacks capacity -- I'm talking (hypothetically) about acutely intoxicated. Show me some documentation that there is some legal obstacle to a physician determining that someone acutely intoxicated lacks capacity to make a decision to leave a healthcare facility AMA.

[odaat]

Well that probably most effectively nixed any chance she'll reach out for help ever again. That's all I have to say about that. I really hate how we don't treat and then horribly treat mental illness.

My thoughts exactly 😕

[Farawyn]

What elkpark said.

I do agree the restraints were over dramatic.

[BellionRN]

Those restraints sound like hobbles. Not something we use.

Did she run out screaming or did she calmly express her desire to leave & provide a reason why? Did she express this desire to you or just try to sneak away?

[KelRN215, BSN, RN]

The patient was competent and not on a hold. If she chooses to leave, she chooses to leave. Restraining her was wrong.

[Anna Flaxis, BSN, RN]

For anyone presenting with suicidal ideation, a risk assessment using a standardized scale should be performed at triage. This will help determine what appropriate suicide precautions should be implemented as outlined by policy, such as removing personal property, placement in a safe room, Q15 minute checks, face to face continuous observation, seclusion, etc. Risk level can change over the course of the patient's stay in the ED, so a person who initially presents as a low risk could be upgraded to a higher level of risk if warranted, and vice versa- so long as you are using a standardized tool and are in compliance with state laws and facility policies.

Laws vary from state to state, but in my state, we are allowed to prevent a person from leaving the ED prior to the formal psychiatric evaluation at the physician's discretion.

As has been discussed, restraints/seclusion are last resorts and are not indicated for the cooperative patient. However, removal of personal belongings and placement in a safe room (with the door open and unlocked) may be appropriate for a person who presents a moderate risk as evidenced by attempting to leave prior to evaluation. Should the person meet the criteria as a flight risk, it may be appropriate to close the door so long as you are following proper policy and procedure.

In the end, much of this is dependent upon the laws in your state and on your facility's policies. I would highly recommend that you familiarize yourself with these.

[Guest219794]

Way over violation of patient bill of rights, maybe even false in prison containment....... I mean without emergent mental health warrant......not impressed

I am not sure it's a violation at all. Basically, once somebody identifies themselves as potentially suicidal, things change legally until it can be determined that the person is safe. Having gone in on her own volition doesn't really change that dynamic.

[Anna Flaxis, BSN, RN]

^ That. Once you've said the magic words, you can't un-say them.

[jana82]

She didn't have a plan, though.

[Anna Flaxis, BSN, RN]

She didn't have a plan, though.

Whether or not the person has a plan is only one piece of the overall risk assessment. Risk assessment tools intended for use by ED staff are not a substitute for an evaluation by a qualified mental health professional. They are only intended to give ED staff a road map for determining the level of precautions to implement during the patient's stay in the ED. It is not in the ED nurse's scope of practice to determine that the patient is low risk because they don't have a plan and then allow that patient to leave. It is the ED physician that is ultimately responsible for that decision, and again, laws vary from place to place, but where I am, the patient can lawfully be prevented from leaving the ED prior to the evaluation by the qualified mental health provider.

You really need to avoid relying on your own subjective discretion here, but rather, be familiar with the laws and policies that guide practice in your particular facility.

The day you allow someone to walk out because you determined they were low risk, then get a phone call from their parent/sister/child that they were found dead having jumped off a bridge, your defense that "she didn't have a plan" will be of no consolation.

Trust me. I've been around for a minute.

[blah_blah_blah]

I work in a psych ER (and I'm new, only 7 weeks in and this is my first nursing job, so take my input with a grain of salt) but when someone comes in voicing suicidal ideation, they get brought back to the psych ER (a locked unit) ASAP, like within 5 minutes of them showing up. This is so they don't leave and potentially harm themselves. However, if they SELF REPORT then leave without being seen, I don't think we go after them. If the cops, crisis services, etc. bring them in on specific paperwork, they CANNOT leave until they have been evaluated and are usually brought right in through the ambulance door and directly to the psych ER. Ankle restraints seem like overkill on a cooperative patient. I know other hospitals in the area that don't have psych services don't restrain a cooperative patient until they're transferred to us, I think they just put them on a one on one observation, but I'm not sure.