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.

[Tenebrae, BSN, RN]

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.

Actually we just prefer to let them run free in the grounds

/endsarcasm

ICU, they can use partial restraint eg one hand for an intubated patient who is at risk of pulling out tubes. The ratio is also 1:1 for an intubated patient, so the nurse is "right there"

Demented/delirious patients get a watch, someone who is with them constantly to ensure they dont pull out vital bits and bobs until such a time that the bits and bobs are removed, or their delirium passes and their risk to themselves dramatically decreases.

A patient who is expressing suicidal ideation can not be secluded or restrained unless they are under the mental health act (similar to your pysch hold). This is only used when a person demonstrates clear mental unwellness eg bipolar crisis, psychosis etc or the psychiatrist feels that there is a clear danger to the patient or someone else.

We will use seclusion but only as a last resort and only if the patient has been committed under the mental health act

Four point restraints are only used if its a matter of life or death, eg the paracetamol overdose who has ingested a fatal amount of paracetamol and is refusing to allow the treatement and only then would be used as until the patient calms down and stops threatening to rip their IV line out

Its the system, its not perfect but it sure as heck beats putting a vulnerable compliant patient into four point restraints and into seclusion.

[Tenebrae, BSN, RN]

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.

Nope and nope we cant.

We can use partial restraint as previously stated and can not seclude unless they are under the act.

[Tenebrae, BSN, RN]

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.

As shocking as it seems there are other countries in the world that arent America and Australia:sarcastic:

[AZQuik]

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?

I agree the restraint was out of line unless the pt was somehow dangerous. The clothes thing is not uncommon. In my facility their belongings/clothes are taken and they are dressed in paper scrubs of a certain color. This signifies to the staff they cannot leave ama. Staff can and will restrain them if they try (usually a physical hold to get them back to the room )

Once they are evaluated and allowed to leave they change back into their things.

This can be done with respect and dignity, and explained so the pt understands.

BSN GCU 2014.

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[SleeepyRN]

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.

Now, I like that idea. The nurse's authority and ability to restrain a patient, then notify the doctor and either get an order for it or something else.

[Here.I.Stand, BSN, RN]

Now, I like that idea. The nurse's authority and ability to restrain a patient, then notify the doctor and either get an order for it or something else.

We do that in the ICU all the time.

[AZQuik]

We do that in the ICU all the time.

We do it in the Ed as well. Doc has an hour to evaluate after restraints are applied.

BSN GCU 2014.

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[NotAllWhoWandeRN, ASN, RN]

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

Plus if that were the reason for keeping her, the hospital restrained and secluded her for being potentially tipsy.

[NotAllWhoWandeRN, ASN, RN]

This can be done with respect and dignity, and explained so the pt understands.

When you tie a person's feet together for admitting she thinks about ending her life, you remove any possibility of "respect" and "dignity" in her care.

[Anna Flaxis, BSN, RN]

When you tie a person's feet together for admitting she thinks about ending her life, you remove any possibility of "respect" and "dignity" in her care.

I think it's a bit unfair to take AZQuik's comment so far out of context.

[AZQuik]

When you tie a person's feet together for admitting she thinks about ending her life, you remove any possibility of "respect" and "dignity" in her care.

Don't think I said anything about that. I don't disagree with you. Restraints are for immediate threats when other less restrictive means have failed. I was referring to changing clothes and placing them in a monitored room. Reread my post again.

BSN GCU 2014.

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[MunoRN, RN]

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.

I'm not sure where you're getting that I said someone who is drunk can't be deemed incompetent for medical decision making, they certainly can but it's not based solely on being drunk, it's based on the universal standard for determining competence to make their own medical decisions; do they understand what is medically wrong with them, do they understand what treatments are being proposed, and do they understand the risks of refusing any of those treatments. If they can answer those "magic questions" correctly they can make their own medical decisions. There is no alcohol level where their ability to answer those questions is overridden.