ED Resources for Psych Patients

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

I've been doing some research for my BSN toward developing a "toolkit" for my ED to help us provide safe, consistent care to psych patients in the ED. This toolkit would consist of advanced assessment scales, community resources, that kind of thing. We have a big ol' binder full of names and numbers, but it's getting a bit tattered through overuse, and it needs an overhaul. I'd love to add some material to it for those patients who clearly don't meet inpatient criteria, but are going to fall through the cracks if they're not given some resources (and thus return in crisis to the ED over and over). I've found a bunch of great material, and I'm hopeful that this toolkit will help us out.

I'm just wondering what kinds of different resources your EDs have for psych patients. Do you have a special area/cluster dedicated to psych patients? (One study looked at a "guesting area" as an alternative for psych holds, which was kind of interesting.) Do you have an emergency psych RN on staff? Are sitters readily available for one-to-one patients? Do you have written procedures in place for suicidal patients, like putting them into paper scrubs and inventorying belongings? Anything (process, procedure, etc.) you've found to be unique to your ED, or you think is worth a mention? Have you noticed a big uptick in the number of psych patients over the last couple of years? I sure have. At least, it feels like it!

Thanks for all responses.

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Specializes in Nephrology, Cardiology, ER, ICU.

The level one ER in our area has masters-prepared therapists available 24/7. They provide a screening exam that is legal in IL and then make referrals to the MDs in the ER as to resources: the pt needs admission: they arrange it and also arrange transportation since often the pt is placed hundreds of miles away, if the pt is not a threat, they hook them up with community resources.

Before this program started, it was chaos to say the least as all the MDs viewed psych pts differently.

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Specializes in ER, Trauma.

In the ER psych pts will do anything to meet your expectations if they're voluntary. One place I worked went against my suggestion of showing the patient dignity.They started with security gaurds searching and wanding every patient, then doing line of sight in special rooms. This turned into a game with patients finding ways to smuggle weapons of self destruction into the ER under the tongue, in their hair, and elsewhere, then cutting themselves in the ER. This escalated and that ER now has a locked psych area with security gaurds, more advanced screening, all pts in paper gowns. HORRIBLE and not needed.

The ER I worked in most recently we took the dignity approach. Acknowledge the patients distress, promise to help, explain the need to remove personal belongings if the nurse felt it necasary to help the patient protect themselves. No security, wanding, line of site except with the occasional uncoopertive pt. This approach was easier on the pt and staff with the pt understanding that they determined how they were treated in the ER with their own actions, not mindless blanket rules and polices. FAR BETTER OUTCOMES.

In both ER's we would arrange for followup with local resouces if possible, or if admission was needed, transfer sometimes hundreds of miles away.

Hope all this helps. I'm a big fan of the dignity approach as it avoids setting the expectation of escalation as an adversarial approach. It just made me sick when I warned the first facility what would happen and was ignored.

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Specializes in psych nursing/certified Parish Nurse.

:redbeathei am a veteran forty-year psych nurse (graduate education in clinical psychology)--now retired, basically out of distress of current trends in treatment. ER contact is so gravely important in "introducing" people to both what is expected in the way of behavior (by this, I mean, there is "programming" that happens through the expectations of the staff, as well as the staff's feelings about the "psych" patient--how each is received and the words spoken to them--and also what they overhear from comments in the halls, etc.), as well as how much dignity and respect they are given as HUMAN BEINGS. Behavior actually is meaningful--even though it may seem random or irrational. A simple question about a person's motivation will sometimes access such revealing information--you may find the person's behavior completely changing (because someone cared enough to ask), plus it will also provide insight into that person's "modus operandi" that will tell you very much about who that person is. Another grave mistake by both docs and nurses is assuming someone is not telling the truth... or "being grandiose"... or talking "in code". Many, many times I have seen grave mistakes made--when the person was being straight-forward. There have also been far too many reports of people coming in asking for help (chemical restraint, etc) and then not receiving it: to go on to commit acts of terrorism. Oh, how my heart hurts for these!:redbeathe

as long as current biological psychiatry insists on "categorizing" what is uncategorizable: the unique and highly-special human person with a divinely-created and self-healing (mostly) brain... and insisting there are "incurable" psychiatric disorders (in the face of all the new work in neuroplasicity)... giving them "medicine" that they insist have to be taken for the rest of the life (all these affect every system in the body)... we will continue to have the kind of attitude-problems amidst the healthcare workers (who are mostly so over-worked they simply do not have time to either keep up with the field, or take time to "listen".) By the way, FYI, "involuntary" patients work the same way! It may be helpful for you to know that restraining a non-combative patient/ECT/forced involuntary treatment with neuroleptics is called "torture" by the United Nations (there is now prosecution going on in Maryland on this basis). If a patient is "combative" perhaps it has something to do with the way they are being "treated" (or not, whatever the case).

there are so many loving and concerned responses on this website--I am grateful.:yeah:

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Specializes in psych nursing/certified Parish Nurse.

hello, nurse administrator... please note my post below...

using the word "threat" sounds provocative... please be very careful about using these kinds of words... I thank you for hearing my concern.

a graduate-educated behavioral health professional forty years in the field

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Specializes in psych nursing/certified Parish Nurse.

I am responding to a personal message asking for response--and due to the constraints of this website, do not know how/there seems to be no avenue for responding... to nebrgirl: I'd be honored to consult on your project--feel free to "google" me (I use a "public name") letha christina chamberlain, my public email address is noted.

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Thanks!

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Specializes in ER.

My own personal preference is not to strip down anyone who is cooperative and able to answer and make sense. I ask them if they have anything that they could hurt me or themselves with, and then request that they give the items to me. I haven't been turned down yet, although some people are reluctant. I also remove their shoes, I've been kicked in the chest in the past. When I explain my reasoning my patients have been quite cooperative.

Our hospital has a psychiatric nurse practitioner available monday to friday for crisis appointments, and the triage nurse can call her without an MD order. She's been such a huge help because our frequent flyers know her, and she knows their issues. If someone comes in during the off hours and gets a less than sympathetic MD we can always say they are welcome to come back during the hours she is available for more assistance.

Having 24hour security available is also a great thing. They sit with restless patients and are a great backup crew. If we need more than that we can call a code white and get 5-6 people within 30 seconds from all over the hospital. Our docs tend to sedate rather than use physical restraints, it seems to give people a mandated time out, and they wake up a little more cooperative.

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Specializes in Trauma/ED.

Any patients who present with psychiatric c/o or for detox go to our "safe rooms" and have their belongings secured. We have been burned too many times. We have a girl watch the girls and a boy watch the boys get undressed. There is cameras and the capability to lock each room. We have "captains" beds that are bolted to the floors and has loops for restraints. Our secure area basically looks liked a locked-unit on a behavioral inpatient floor.

I've personally had bad experiences with OD's, guns, and knifes...please be safe!

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Specializes in emergency room.

I am a nursing student in need of a presentation topic for the ED where I am doing my preceptorship. I plan to go into psych nursing and your post intrigued me. Could you please point me in the right direction to learn more about handling the psych patient in the ED? Help...I need the info fairly soon. Thanks.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
I am a nursing student in need of a presentation topic for the ED where I am doing my preceptorship. I plan to go into psych nursing and your post intrigued me. Could you please point me in the right direction to learn more about handling the psych patient in the ED? Help...I need the info fairly soon. Thanks.

Try this link: http://www.ena.org/IQSIP/ENAStrategicPriorities/Psych/Pages/Default.aspx

The ENA has made dealing with psych patients in the ED a "practice priority," so there are some resources on the ENA website. Good luck!

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Specializes in Emergency.

We're the county psych screening center, so we see a lot of psych pts. The screeners are masters prepared psychological interventionalists. They will do mobile outreaches based on calls from local counseling organizatios, pts, docs, families, pd, ems, whoever calls in. Maybe 1/2 of our pts are known to be coming in before they arrive.

We have a secured area with 5 private locking rooms that have beds which allow for 4 points to be attached and then a lot of recliners in the hallway. The "ratio" is 8:1, but that can go to 10:1 depending on the pt/rn mix. At least 1 security guard is always present, there is a dedicated tech and rn for this area. We have a small office for the rn (& tech if no 1:1's). The screeners have a larger office. There is also a psychiatrist on site 8-5 m-f, off-hours, tele-psych video conferencing is used for psychiatrist interviews.

We request all pts to remove all of their clothing which is then secured in a locker. Pts are given 2 gowns, non-skid slippers and a blanket. If pts don't want to remove their clothing, they have to turn out their pockets. All possessions stored witnessed rn & security.

Every pt coming into the er gets a "depression" screen to id potential si/hi, these questions are not just limited to "psych" pts. The questions can get more in-depth depending on the initial responses and can create an order for a 1:1 if enough flags go up. We confirm meds through pharmacies, families & docs treating the pts when possible. Our goal is to have meds ordered within 4 hours after medical clearance. Med clearance is cbc, cmp, u/a, uds, hcg (if appropriate), salyc/acet levels (if si). Obviously, any medical concerns would result in added orders. We also check depakote/lithium levles if those meds are being taken. We have a psych order set which the rn inputs to get thngs rolling that includes all of the above.

There's more but that's the basics. Sorry for rambling. We take psych issues seriously.

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