Depressed self-referral to ED

Dogen · Oct 30, 2015

In my ER she would have been placed in a psych pod, which is a locked hallway but the rooms are open, and she would have been asked to change into scrubs. A staff member - either an RN or a security guard - is always in the hallway, monitoring the pod. She wouldn't have been allowed to leave, but we also would have put her in the pod right away and informed her that she was on a safety hold until she could be evaluated by a physician. We would never have hobbled her, even if it meant putting staff at the open door to keep her there. CMS requires that we use the least restrictive alternative:

All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.

If this woman was not an immediate danger - and SI has never qualified in any MH setting where I've ever worked - then restraints were a violation of her rights.

The ED, generally speaking, is not the best place for any psych patient. They're not designed to treat people who are walkie talkies, scared, confused, and possibly disorganized. Every psych area of every ED I've ever seen has felt distinctly institutional, like a prison. Also, ED nurses are not generally trained to handle our patients. I float to the ED sometimes and the nurses there frequently make a point of telling me they're uncomfortable with psych patients. I tell them it's okay, I'm uncomfortable with active trauma patients. But really, it's just another in a long list of things wrong with how we treat mental illness.

Whisper · Oct 30, 2015

The treatment seems incredulous to me. Totally over the top, but maybe thats a difference between the US and UK. We have enough trouble trying to restrain violent patients, and the rings we have to jump through to arrange that let alon a co operative patient.

If this had happened in the UK the news papers would have been full of it, and very nurse would have yet more DOL training to attend.

AbstracRN, BSN, CNA, RN · Oct 30, 2015

Totally off topic but what does GCU mean?

Long Term Care Columnist / Guide · Oct 30, 2015

Here's how it went down when I was a suicidal patient exactly one year ago.

I had a plan, the only question in my mind was which way to go---the pills or the gun. I called my psychiatrist only because I was scared, and of course he told me to go to the ER. When I got there they were waiting for me, and they put me in the safe room with my husband by my side. I was asked to get into a gown but they didn't object to my keeping my pants on underneath, although I was patted down, wanded, and my things gone through before hubby was allowed to hold them for me. The attending psychiatrist came in to see me, and made the decision to admit me to the psychiatric facility in the next town over. In the meantime there was a security guard at the nurses station to watch me and the staff checked in frequently as well.

After about six hours in the safe room, secure transport arrived and I was taken to the facility. I was NOT restrained, although it felt like it because I was in the back of what had once been a police cruiser, with the cage and the doors that don't unlock from the inside. That was the worst part of the experience, but the transport team was very nice and talked me down when I nearly panicked (I am really claustrophobic). Basically, I was treated with dignity throughout the entire day, and I think knowing that the staff wasn't judging me or trying to make me feel like crap kept me calm. I was in a very dark place at that time and if someone had put restraints on me or locked me in a cold room, I'd probably have bolted the instant I had a chance, and gone home and committed suicide.

I hope everything turned out all right for the patient in the OP. The road to recovery from an episode like that is a long one, and sometimes people don't make it back.

Anna Flaxis, BSN, RN · Oct 30, 2015

"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."
I very strongly disagree. OP, you need to ask yourself in this situation, "Was this right? Did this harm my patient?"
Then take action, whether it's a policy issue or a provider issue.

I'm having a hard time understanding what exactly you strongly disagree with.

Anna Flaxis, BSN, RN · Oct 30, 2015

Im not advocating her treatment one way or the other. I did think/have stated that I thought it may have been a bit overboard but that's a all. I agree the restraints didn't seem necessary, but they didn't stay on that long either, and I think it was partly due to lack of understanding if she was going to stay in that room or if it would be locked.
She was considered higher risk at the point we took her clothes. That is what I actually found most unsettling/not necessarily necessary...Again there was some confusion on her underwear, she should have been able to keep that I think. But she had to stay that way for quite a while - up until she was allowed to leave. I felt bad for that.

Am I understanding that you felt more unsettled about the patient being asked to dress down than you did about her being hobbled?

Anna Flaxis, BSN, RN · Oct 30, 2015

Viva, I am sorry for what you went through, but I am glad you felt that you were treated with dignity during your experience.

When I ask a patient to dress down, I always explain that it is for their safety, that I will secure their belongings in a safe place, and that their belongings will be returned to them as soon as possible.

When I have to place a patient in a safe room, I always explain to them that they are not locked in, the door will remain open, and that they are in a safe place.

I have received sincere thanks from the patients and their loved ones on more than one occasion.

Long Term Care Columnist / Guide · Oct 30, 2015

Also, if a person wants to kill themselves they're going to do it regardless of any inpatient treatment. People like this are put on pills that are supposed to make you happy because you're so stoned from them. Psychiatric medication is powerful stuff. And it's even more interesting that these types of drugs are what people usually do wind up ODing on and actually catching the bus.

This is an unfortunate misconception that just won't go away. I take five psychiatric medications every day, some of them twice a day, and they make me neither "happy" nor stoned. They do, however, keep my moods in check and allow me to have something of a normal life. I can all too easily imagine where I'd be if I didn't have them.

twinmommy+2, ADN, BSN, MSN · Oct 30, 2015

I work in a VA ER, and we see psych every single day, self reported and not. Here are some precautions taken and rational:

-Taken behind locked doors and not allowed to leave until cleared by psych: because even those who take back what they reported lie. Patients lie. They want out of the constant radar of people viewing them which is understandable but safety first.

-ALL belongings removed: patients hide things in their clothing, bags, such as drugs, alcohol, and weapons. My first duty toward patient and staff safety after them coming back is removing their belongings. Does it feel bad, yes it does. Look up on youtube how many weapons patients can stash on their person.

-blood and urine on all suicidal, drunk/intoxicated. ETOH level should be checked because it is a depressant and can make suicidal symptoms much worse. Do they have a high TSH? That could produce symptoms of depression.

-Patients do not leave the ER unless they are below 0.08 (legal limit) or released to sober person who can be responsible for their care: This is independent of the psych eval. If their eval is done and they are still over the legal limit, the above applies. CYA

-no going out to smoke even with escort: We just don't have the staff to go chasing someone down who decided to elope after going to smoke. We have had people commit suicide in the past after going to smoke so the above was implemented.

We do not place anyone in restraints unless they are a harm to themselves or us. In the OP's post, that is the only thing that I can see wrong here besides the nurse not knowing what the ETOH is. Having a psych patient on your team is something that should be continually on the back of your mind, even if they LOOK like they are well put together. Those are only outward appearances, very superficial and may not reflect what is going on in her mind. Many alcoholic depressed people function daily dressed to the nines.

twinmommy+2, ADN, BSN, MSN · Oct 30, 2015

Here is that youtube video on the guns in clothing

jadelpn, LPN, EMT-B · Oct 30, 2015

Most standardized assessments for suicide risk include the least restrictive means. I have seen a lot of 1:1 observations in busy ED's until evaluations, however, in order to (at least in my state) hold someone in the fashion you describe OP, they have to be sectioned. And people can not be sectioned for vague depressed/suicide thoughts.

Any number of depressed people will make suicidal references. People who are actively suicidal usually do have plans. You need to know and understand your specific policies, as you are held liable for NOT following them. However, the suicidiality of a patient is up to the psych evaluator.

Suicide risk/depression knows no status. Therefore, that this patient was well dressed with a fancy pedicure has no bearing on the assessment. Taking someone's clothes...ALL their clothes on a patient who I certainly would want to know if there was a hold put on them--is also a "restraint" of sorts.

Never the less, if your policy is that one is mechanically/physically restrained regardless, then there is a protocol for that. Meaning an MD has to evaluate, order, the patient needs to then be on constant observation. YOU are liable for a patient who is mechanically restrained behind a locked door. In my 30 years, I have never, ever seen/participated in this. YES, we restrain with soft/or even leather restraints IF the patient is acting out. YES there are locked rooms. But never the 2 together. And no, it doesn't matter that is was less than 20 minutes. Thank goodness it was not 2 hours.

The nurse needs to check CSM's q 15 minutes, you can only keep restraints on until such time as a patient no longer poses a risk....lots of things, and all facility based, and needs to be documented clearly. "Patient calm and cooperative. 2 point restraints applied to bl ankles......." Try explaining that it was because the ED was chaotic, so you applied mechanical restraints?! Hopefully, you documented the heck out of this. Even then, you will have a really hard time justifying any of it, and hopefully, the MD did their due diligence.

Again, may be facility based and my state but we can NOT have a standing order for restraints. The MD has to be present, order them after evaluation. And there's got to be a risk. And a locked room with no clothes or no means certainly is not a huge risk. Especially with a cooperative patient.

And if the patient wants to leave and there has not been an evaluation, AND there has not been a section done (AND again, the MD has to actually lay eyes on the patient to do this) it is holding someone against their will. This could be one heck of a lawsuit if the paperwork/documentation was not done to the letter.

With this type of practice, protect yourself. Get malpractice insurance. Good for any nurse but there is so much wrong with this. And if you are going to continue in the ED, remember, your own personal judgments need to stay at the door. People are not always what they appear to be.

Tenebrae, BSN, RN · Oct 30, 2015

Absolutely illegal here to restrain/seclude a patient who is not under the mental health act.