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]

You're free to ask a patient presenting with SI if they would change into a gown, but you can't legally require them to or initiate any forms of restraint that legally requires pre-approval of an LIP or LIMHP. There is no temporary exemption for non-violent mental health patients as there is for violent patients or in facilitating medical examination and treatment where a nurse can legally initiate restraints and then seek approval after the fact. Your legal option is to provide a safe environment (a safe room and/or 1:1 sitter) but prior to being evaluated the patient is free to leave at any time. I get that the goal is to do what the nurse thinks is best for the patient, and that's what many patient's rights are specifically for; to protect patients from overzealous staff who are so sure they know what is right for the patient that don't properly balance the patient's rights with the legal steps required to take away their rights.

The reason why we limit these decisions primarily to LIMHP's is that one of the worst things you can do is to lose the trust of the patient. Patient's should be encouraged to seek help when SI occurs, they should not be unnecessarily punished or unfairly treated, all that does is ensure that next time they won't come to us for help.

The best way to take SI seriously is to treat the patient with respect which includes respecting their rights.

[Anna Flaxis, BSN, RN]

^ Again, this varies from state to state, which is why it is important to be familiar with your state's statutes.

I always make sure to emphasize that anything I do is for the patient's safety, and whenever discharging a person, I make sure to impress that if their symptoms make them feel unsafe, we are happy to see them and that the ED is a safe place for them to come for help. Everything we do is for their safety, and not to make them feel disrespected or undignified.

[MunoRN, RN]

^ Again, this varies from state to state, which is why it is important to be familiar with your state's statutes.

I always make sure to emphasize that anything I do is for the patient's safety, and whenever discharging a person, I make sure to impress that if their symptoms make them feel unsafe, we are happy to see them and that the ED is a safe place for them to come for help. Everything we do is for their safety, and not to make them feel disrespected or undignified.

Up until the mid 90's there were some state-to-state differences in initiating involuntary measures for a patient presenting with SI, but since then it's the same basic rules for every state.

[Anna Flaxis, BSN, RN]

Well, that may be, but I've read the statutes from my state, and we are allowed to keep a person from leaving pending evaluation by a QMHP per physician's discretion.

[MunoRN, RN]

Well, that may be, but I've read the statutes from my state, and we are allowed to keep a person from leaving pending evaluation by a QMHP per physician's discretion.

A physician is an LIP and LIP's can place a hold on a patient, ED RNs cannot.

[Anna Flaxis, BSN, RN]

Yup, that's where the "per physician's discretion" part comes in.... what am I missing?

[MunoRN, RN]

Yup, that's where the "per physician's discretion" part comes in.... what am I missing?

Your statement earlier was that a patient can be prevented from leaving without having been seen, and then it's up the Physician to decide if they can leave, which is the opposite of how it works, the patient can always leave unless the physician (or an LIMHP) says they have to stay. They cannot be held by protocol even if it's a physician directed protocol, all patients being held for this purpose must be evaluated individually.

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.

[jana82]

No, pt was not held naked for the duration. After taking her clothes, she was brought a gown - just as she would have been anyway, from what I know now. Her underwear would've been taken too. It's just I didn't know if it was necessary at the time. By anyway, I mean even if she hadn't attempted to leave. It had only been 10 minutes maybe. She didn't try to runaway screaming or anything, but she didn't go back to her to room either, so there was legitimate concern there, I feel.

Like I said before, it was surreal because of how calm she was otherwise... I tried to help initiate her disrobing by taking her shoes off, myself and casually complimenting her on her bare feet as I did. I don't agree with the restraints either, but they didn't stay on that long. If she had been transfered to a facility instead of released, she would have left in restraints and only the gown she had on. I think the restraints were overkill, and I get not judging her by her appearance/calmness - just made it a little wierd in making her strip completely naked... ED is quite a bit different than psych from what I gather - which only seems logical to me.

[jana82]

She had been seen by physician, btw. I thought I said that somewhere.

[OCNRN63, RN]

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.

I didn't advocate for minimal intervention. But mental health laws, heck, even CMS state that psych patients be treated with the least restrictive means possible. And again, FTR, I have been in the position of caring for suicidal patients in the ED.

I'm done with this discussion.

[Anna Flaxis, BSN, RN]

Again, I'm struggling to see the disconnect here. If the physician has determined that the patient presents a danger to themselves and requests a mental status exam by a QMHP, they certainly *can* prevent the patient from leaving prior to said mental status exam.

[Anna Flaxis, BSN, RN]

I didn't advocate for minimal intervention. But mental health laws, heck, even CMS state that psych patients be treated with the least restrictive means possible. And again, FTR, I have been in the position of caring for suicidal patients in the ED.

I'm done with this discussion.

I went back over the discussion, and what it appears is that we're talking about different things. Not once I did I advocate that the restraint described in the OP were okay- in fact, I've intentionally avoided commenting on that specifically because something about this whole thing stinks to high heaven. I can't state, based upon an internet post in which the information is filtered through a person who appears to lack a basic understanding of their state's laws and facility policies, coupled with a communication style that makes it difficult for me to understand what exactly occurred and in what order and is lacking in any background information that might put events into context, whether what occurred was morally ethically, or legally correct.

What I have been speaking to is the need for a comprehensive triage using a standardized scale and an algorithm that guides the ER staff as to what level of precautions are indicated. Dressing down (changing into a gown or paper scrubs) and being placed in a safe room (NOT seclusion, but a room in which all items that could be used for self harm have been removed) are not violations of the patient's rights, and do not have to be a violation of their dignity when done in a way that is respectful and where every step and its rationale is explained. In my state, we can prevent the person from leaving, per the physician's discretion, prior to their evaluation by a QMHP. If the person presents an immediate danger to themselves and all less restrictive means have been exhausted, we can initiate restraint or seclusion prior to obtaining the physician's order.

Complaints of SI should be taken seriously. If the patient were to attempt to leave prior to being seen by the QMHP, the ER physician can implement a hold and the patient be prevented from leaving (this is what was described in the OP, but again, I'm not certain we're getting the facts). If the patient is cooperative, then restraints/seclusion are not indicated.

That is all I've been speaking to. Whether the patient in the OP was handled appropriately, I do not know and will not speak to, because I don't think we're getting the whole story.

But ultimately, I don't think that reasonable precautions to keep the person safe while under our care are necessarily violations of the patient's dignity when handled in a compassionate, respectful way.