Depressed self-referral to ED

elkpark · Oct 30, 2015

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

Really? So, confused and demented individuals are allowed to just wander around the hospital at will, smack the staff, get into whatever dangerous trouble they can find, and elope into the street? Pull their ETs and GTs out in the ICU? I find that hard to believe.

Tenebrae, BSN, RN · Oct 30, 2015

This reminds me of how ALL psych pts in my state are handcuffed when being transported to an outside facility.

What the heck?

Thats appalling

jana82 · 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.

Well, here are the details - good, bad, otherwise. Pt entered ED complaining of feeling depressed to receptionist. She sat in lobby (90 seconds maybe?) before being taken back to first stop to sign treatment consent, wristband, etc.. Then she was brought back to actual room. She was placed in the second room right across from station. This room is a regular treatment room with two large sliding glass doors with a curtain pulled all the way open facade. The first nurse who attended her was ending her shift. Anticipating taking over after her shift, I entered the room, with MD. I think this is the first time pt admitted sucidal ideation, and mentioned drinking. Blood draw occured within 30 min. BAL came back 0.00. Pt hadn't been medically cleared yet; all hell broke loose on unit; (fully clothed) pt walked out of her room and attempted to leave; and she was stopped at lobby threshold. I came upon the scene. I stayed with pt while MD was asked if she could leave on her own. He said no. We escorted her to seclusion and that is when pt stripped as ordered, as I described earlier. I was correct in my understanding that she was going to remain in seclusion, but the restraints had been ordered on the presumption that she was going back/staying in the treatment room she was in before. Not so, however, and the restraints came off later. Quite possibly within 15 minutes. (I said less than or equal to 20, but that's also including application and removal which takes a few minutes) I was surprised by the resrtraints - as was pt, but I would've found having to strip completely naked more unsetling, as I feel she did. I thought maybe her shoes should have been taken from the start, but it ended up being more than that. Pt had to wait 2 1/2 hours for eval - which by that time, things had settled down. Eval took 1/2 hour - 45 min. Pt would have likely ended up waiting the 45 min to hour it took for discharge without clothes if I hadn't took them to her as soon as she was cleared by psych evaluator. It had been over three hours that pt hadn't had any clothes. But she was moved to treatment for eval and was able to cover up then. Actually, I pt's shoes weren't in the bag with her clothes, but I got them to her on her way out. I don't know how pt's evaluation went (presumably well) and curtains were shut at that time, but pt always seemed calm and pleasant whenever in my pesence. I had a chance to talk to her in seclusion, but she was mostly quiet and very soft-spoken. It was a first for me.

Dogen · Oct 30, 2015

We escorted her to seclusion and that is when pt stripped as ordered, as I described earlier. I was correct in my understanding that she was going to remain in seclusion, but the restraints had been ordered on the presumption that she was going back/staying in the treatment room she was in before.

This is not okay. Taking her clothes is SOP - humiliating, but necessary for everyone's safety - but once she's on a hold the facility is required to hold her in the least restrictive way possible. Putting restraints on her while staff figures stuff out is not okay. Putting her in a treatment room with restraints also would not have been okay. Either by CMS rules or common human decency. If you have to run short staffed in order to have someone sit with her, without restraints, then that's what you do.

I would've found having to strip completely naked more unsetling, as I feel she did.

Maybe, but you did both, which compounds whatever embarrassment and shame she's feeling.

It had been over three hours that pt hadn't had any clothes. But she was moved to treatment for eval and was able to cover up then.

This makes it sound like the patient was stark naked for three hours, which is horrifying. Was she given a gown? Scrubs?

emmy27 · Oct 30, 2015

Having a patient who reports SI/HI undress and gown, securing their belongings, and placing them in view of a safety sitter or nurse immediately has been standard procedure everywhere I've ever worked. We also draw blood and obtain urine asap and order the standard labs for medical clearance as a standing protocol even before the MD sees them, so that if the provider orders a psych hold, the process towards medical clearance is already underway and we can start trying to find them appropriate placement sooner. The docs round on these patients quickly to to make a determination as to whether they can remain voluntary or need a hold, but it's not in our scope as nurses to make that call. And while it's true that being disheveled is a potential sign of mental illness, being well-dressed is not inversely evidence that someone is not genuinely a danger to themselves or others.

The ankle restraints would be inappropriate and are unjustifiable, but so is leaving a patient who expressed SI upon arrival alone with their belongings. It sounds like there were a lot of bad calls in this scenario.

When you've come across a patient who OD'd *in the ER* on heroin they had hidden on their person, had a homicidal patient elope in street clothes with a knife, or seen someone attempt to hang themselves in a bathroom, you will understand why undressing and gowning SI/HI patients is a common policy. It's in everyone's best interest to be as kind and understanding as possible while helping people get undressed and gowned, but it's also in everybody's best interest to make sure they aren't left alone with the means of killing themselves or someone else.

NutmeggeRN, BSN · Oct 30, 2015

Totally off topic but what does GCU mean?

imma guess BSN at a school whose initials are GCU?

SleeepyRN · Oct 30, 2015

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.

I can't... I don't.... I mean, I have no words to this....my vocabulary fails me at the moment. How horrid.

In this decade. In this country. She went to get help. Yet was humiliated, imprisoned, and suddenly set "free"....all leading to no help for this poor girl.

Whispera, MSN, RN · Oct 30, 2015

she was kept naked???

PhoenixDevil · Oct 30, 2015

GCU = Grand Canyon University in the Phoenix, AZ area.

Anna Flaxis, BSN, RN · Oct 31, 2015

This story does not add up. Something is really fishy here.

K+MgSO4, BSN · Oct 31, 2015

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

You are in Australia? Yes you can restrain someone who is not under the MHA. Its about reason and context. This lady didnt need it but the hypoxic pt who is actively bleeding, cannot be considered competent so I could shackle him.

l1234567 · Oct 31, 2015

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

Actually it's not. varies state to state (if you are in Aus). Where I am, you can restrain if you have a medical order, and some Registered Nurses (equivalent to BSN in America) are allowed to 'Nurse Initiate' and then report on it later. So it is not illegal at all, it seems like something they may teach you at uni, but in real life is very different.