Depressed self-referral to ED

Published

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.
Exactly. ED is an entirely different world. "I'm a psych X," :) and the scenario described by the OP would never happen on an inpatient psych unit. However, in my experience with ED, it's not at all uncommon a scenario for an ED. Is it my first choice of how I would like to see the situation handled? Of course not. Am I surprised in any way that it played out the way it did? Other than the restraints, which seem overkill to me, not at all.

OP hasn't confirmed or denied it, but I've never seen an ED psych patient left naked, either. So, depending on how/if OP responds to that question it could be significantly worse.

But even if she was in scrubs or a gown... restraints are a big deal, yeah?

Up Vote Up Vote ×
Specializes in Oncology; medical specialty website.
Exactly. ED is an entirely different world. "I'm a psych X," :) and the scenario described by the OP would never happen on an inpatient psych unit. However, in my experience with ED, it's not at all uncommon a scenario for an ED. Is it my first choice of how I would like to see the situation handled? Of course not. Am I surprised in any way that it played out the way it did? Other than the restraints, which seem overkill to me, not at all.

You strip your psych patients naked in the ED? We had several floridly psychotic patients present to the ED. While they were put in the locked room, we didn't make them stay back there, shivering with nothing to cover up.

There is no reason, none at all, to do that. If you're that worried about someone being a danger to him/herself, then there should be a staff member back there monitoring the patient frequently. Sometimes we had to monitor patients q 5min. It was frustrating, because it tied up one staff member for one patient, but we did what we had to do.

If there are places that are stripping their psych patients and locking them in a room, or even using 4 points, it sounds like that is more for the convenience of staff than out of an abundance of caution for the patient.

It doesn't matter whether the patient was in the ED or on a psych unit. You still treat the patient the same way. Basic psych care us not dependent on location in the hospital.

Up Vote Up Vote ×
You strip your psych patients naked in the ED? We had several floridly psychotic patients present to the ED. While they were put in the locked room, we didn't make them stay back there, shivering with nothing to cover up.

There is no reason, none at all, to do that. If you're that worried about someone being a danger to him/herself, then there should be a staff member back there monitoring the patient frequently. Sometimes we had to monitor patients q 5min. It was frustrating, because it tied up one staff member for one patient, but we did what we had to do.

If there are places that are stripping their psych patients and locking them in a room, or even using 4 points, it sounds like that is more for the convenience of staff than out of an abundance of caution for the patient.

It doesn't matter whether the patient was in the ED or on a psych unit. You still treat the patient the same way. Basic psych care us not dependent on location in the hospital.

The OP said that they made her undress and secured her clothing, but hasn't said that they made her sit naked in a room for the entire ED stay. I'm assuming that she was made to change into a gown. Perhaps that is a mistaken assumption, but I can't imagine anyone making someone sit naked alone in a locked room. I agree that would be completely unacceptable, if that is what actually happened.

And, again, I'm not saying any of this is preferred practice -- just that I'm not surprised to hear an ED handled this scenario this way (which was the OP's original question). In my limited ED experience, ED people aren't psych people, and frequently handle psych situations badly.

Up Vote Up Vote ×
Specializes in PDN; Burn; Phone triage.

Most of my psych admissions were through the ED. I have only been restrained once and I had it coming. What I found to be much more humiliating was hospital policy of cuffing you for transport both within the hospital and outside of it -- even as a voluntary, cooperative, non-altered patient. Nothing discrete about getting hauled to the psych ward by two hospital cops in handcuffs.

It's a scary place to feel vulnerable and afraid and to have the people who are telling you to trust them do things to you that make you feel even more vulnerable and afraid. One of the child psych units I essentially lived on as an adolescent also did a full CAVITY search on top of the typical nude skin check every time you were admitted.

Edit - I have also been stitched up in the ER without lidocaine (dozens of stitches and over a hundred one time) on a few occasions which in hindsight pisses me off more than anything.

Up Vote Up Vote ×

Invitale said:

I strongly disagree that the OP should avoid using her own discretion. I disagree with the implication that being familiar with hospital policy is a substitute for the OP's judgment. I think the OP very much needs to use her judgment about whether or not the patient was treated appropriately.

I'm going to be lazy here and quote LadyFree28, because she summed it up well:

However, knowing policy and procedure will help determine what options the OP has with clinical judgement.

Even if the OP has issues, KNOWING how to use resources, the OP can call the ethics hotline, help create and/or change policy and procedure so an event such as this won't happen again...that's using nursing judgement in lieu of policy and procedure, which as a nurse you still have to have some knowledge of facility policy to determine whether there needs to be a change, prompting advocacy due to nursing judgement. :yes:

Also, laws vary from state to state. It's important to have an understanding of the laws of the state in which one is practicing, for the same reasons above.

Up Vote Up Vote ×

So, OP, was the patient naked or not?

Up Vote Up Vote ×
They get shacked in four point restraints naked? Never happened when I worked in psych, and certainly never happened when I worked in the ED.

Nope. Not naked. 4 pointed all the time though. That said, I will repeat, there seemed to be no indication for any type of restraints in the OP.

BSN GCU 2014.

Sent from my iPhone using allnurses

Up Vote Up Vote ×

It doesn't matter whether the patient was in the ED or on a psych unit. You still treat the patient the same way. Basic psych care us not dependent on location in the hospital.

Actually the locked psych units I've worked on, pt's had a lot more leeway to act out before being put in restraints. The ED is just way too public of a place to allow that. My experience, and that of several others suggest it is not an apple to apples comparison.

BSN GCU 2014.

Sent from my iPhone using allnurses

Up Vote Up Vote ×
Specializes in Oncology; medical specialty website.
Actually the locked psych units I've worked on, pt's had a lot more leeway to act out before being put in restraints. The ED is just way too public of a place to allow that. My experience, and that of several others suggest it is not an apple to apples comparison.

BSN GCU 2014.

Sent from my iPhone using allnurses

I said "basic psychiatric care." Preserving a psych pt's dignity shouldn't be different, whether it's in the ED or on a psych unit. That is not saying it's apples to apples.

Up Vote Up Vote ×
Well, I can only hope it didn't. I tried to be as polite and friendly as I could. I commented on her (perfect) pedi when I was taking her shoes off. Not much opprotunity to say much else. But she said thanks and smiled a little. She was polite too, and was (obviously) appreciative - rather than rude or acting like it had been unnecessary - when she was finally given her clothes back to her to put on. Barefoot, and carrying her shoes in her hands as she walked through/out of the ED, I thought accentuated the defeated look one might thought her to have had - as I did anyway... But it had been extremely chaotic that night.

Did she leave with a detailed plan for followup and most importantly someone to check on her and make sure she does?

The reaching out and asking for help is often the biggest hurdle to getting proper treatment. It's overwhelming, physically and emotionally exhausting, and initially humilitating. Hopefully the shackles don't deter her due to fears about what follow up might be like.

You sound like you did your best, it's your facilities policy that I'm shaking my head at.

Up Vote Up Vote ×
I said "basic psychiatric care." Preserving a psych pt's dignity shouldn't be different, whether it's in the ED or on a psych unit. That is not saying it's apples to apples.

Sigh.

Okay, so here's the thing.

Someone who comes to my ED telling me that they're considering self harm is going to at the very least be asked to dress down into a gown. That means removing socks and underwear, and any article of clothing where they could conceal razor blades, pills, or any item that could be used for self harm.

Bottle of pills hidden in your underwear? Tough beans.

Yes, I will change the room from a basic medical room to a "safe" room by removing the oxygen heads, tubing, tanks, or any other object that could be used to harm oneself.

These things aren't bad. I am NOT going to be the nurse that puts the patient with verbalized suicidal ideation into a room where there are ample supplies and opportunities to do actual harm to themselves.

This can all be done while preserving patient dignity. All you have to do is explain why you are doing what you are doing, and treat the patient with respect.

I have had active SI, with a plan, and the means. I know how to be lethal. I would not blame my caregivers in the least for doing what they needed to do in order to keep me safe. In fact, I would expect nothing less.

When a person comes to you for help, they expect help.

Up Vote Up Vote ×

Just want to add, it's not hard to be lethal at all. I take every claim of SI seriously because I do not want to be that nurse that receives that phone call that that patient who jumped off a building after having been seen and released from our ED. Even worse is the homicide/suicide.

I could so easily kill myself if I wanted to, and those of you advocating for minimal intervention in the interest of "patient dignity" would be complicit.

I would far rather be accused of taking SI too seriously, than not having taken it seriously enough.

Being an ER nurse caring for a person with active SI is a huge responsibility- one which I do not take lightly. I don't really care to hear from anyone who has not been in that position.

Up Vote Up Vote ×
+ Join the Discussion