Go find your patient

[irmaRN]

Greetings.... tell me what you think of this....the other day we had a few patients presenting to triage. I went to call the patient (who was 9), and no answer. the registration clerks said "He's outside running around". (the complaint was suicidal gesture). From where I was standing I saw no one outside, so I called the next patient. The ER doc working that day asked me "Where is this kid?" I told him that the clerks said he was outside but I saw no one. Well this ER doc tells me that it is our responsiblity to go find this kid. He says, "Once they're on our property, they are our responsibility". So, to all you seasoned ED nurses, who know that some days in triage can be a nightmare, you have to go round up your patients if they are not in your waiting room when they are called? That seems ridiculous!! what if they are on the other side of the hospital grounds which can be pretty far away? Thanks

[PhoenixTech, LPN]

cookienay phoenixtech,

you are both missing a very important situation here, the 9y/o patient had not only not recieved a mse (medical screening exam) but also had not even seen the triage nurse yet.

nope. i got that. as mboswell pointed out, the question here revolves around whether the nurse had a "duty to act".

a- the patient was on the hospital grounds, seeking help.

b- the nurse was aware that the patient was suicidal.

you sound as though you would be comfortable in front of a jury, or the bon, explaining why you had no duty to act. i wouldn't.

regardless of how that information got to the nurse, whether through the registration process, or an actual triage, i believe that the nurse had an obligation. i'm no expert, but i have done a bunch of reading about negligence. liablility has been proven with a lot less than this.

this is a "left without being seen" patient. the nurses responsibility here should be to call for the patient in the waiting room 3 times 5 minutes apart. if no answer *maybe* notifiy security to check the campus. otherwise move on to the next patient on the list waiting to be triaged.

alternately, you could notify security immediately, call the police and notify them, let the charge nurse know what's going on, and make a quick note documenting the above. while this might take a couple of minutes more than the course of action you recomend, it is probably worth the time. remember- years down the road, you may have to defend your actions.

i have always working in large busy ers and there are frequently patients who sign in and change their mind about wanting to be seen or opt to go to another hospital prior to receiving a triage, these are lwbs patients and if i searched the entire campus everytime this happened i would never get to see another patient.

i have been following this thread, and must have missed the part where somebody suggested that any time a patient leaves without being seen, the triage nurse should drop everything and search the entire campus. you are right that this would be a bad idea.

i personally think many people should leave without being seen. or even better, either stay home, or go to their doctors office, or a walk in clinic. most people who leave without being seen don't need emergency care. many of them don't need medical care at all, and would benefit more from lifestyle changes and better choices. it rarely bothers me when somebody leaves without being seen. in fact, it generally amuses me when somebody threatens to leave to go to another hospital.

[/quote]

as i wrote earlier, i don't think all patients should be treated the same. while the registration process only gives limited information, it does give you something to work with. let's say you have 5 patients waiting to be triaged: 3 dental pains, a chronic back pain, and a girl wanting a pregnancy test. a 6 year old with sudden onset acute abdominal pains is carried in. would you treat all these patients the same? would you triage these patients in order of arrival?

i suggest that the fact that thurse was aware that the patient was suicidal (and yes, i do realize it is unlikely that the patient was actually suicidal, and in immediate danger), created an obligation which the nurse failed to fulfill.

:yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat:

[Medic/Nurse, BSN, RN]

I think there are several of us - missing the point.

I think it is an a**hole comment from the doctor - but, there is some seed that is useful in his "concept".

The patient is a 9 (NINE) year-old? Was there a "responsible party" with this patient.

LWBS and LOA and any # of variations - could be seen in many ways.

I will bet that there are clear policies/procedures at any facility that details PSYCH patients and addresses security and safety of the patient, others and the duties involved for all. You are always responsible for following your own p & p 's.

EMTALA is what it is - responsible for the patient that presents on the "property".

I think there could be any number of "bad" things that could have happened in this case. I get the OP point of not stopping and searching for a "missing" patient. Your duties may differ with a competent adult vs. child patient. It is simply impossible to plan and prevent all issues that pysch (or any) patients will present with - we do have finite resources. The key will be - are you following your facilities P & P's, did you document comprehensively, notifications made as necessary and standards of care followed. Even if you do everything right - a bad outcome may not be prevented or a lawsuit many not be defended against you.

High risk events are real in healthcare. They may not happen frequently, but your duties remain the same.

Suicidal ideation and all psych patients are risky business for healthcare folks. Most ED's are poorly set up to handle these patients - they do not have secure facilities, enough dedicated staff many lack any posibility to even transfer psych patients because many states do not have any "beds" anywhere. Add that many "chronic" psych patients are uninsured, have uncontrolled medical problems, lack housing, suffer with abuse, substance abuse and some have legal issues - well, it makes it difficult for the triage nurse, treatment nurse or ED overall to fully do what these patients need. Add the fact that this is a child and the issues multiply exponentially.

It is a tough spot - even the best you can do may not be enough. Do what you can - safety is the PRIORITY for all. Call security, CPS or local law enforcement. No pysch patient can be unattended safely.

Your facility is in a perfect spot now to review and make this a learning event and hopefully prevent problems like this in the future, or at least let everyone know the who, what, when, where, why and how surrounding these patients (and all patients).

Follow the rules.

Write it down.

Involve those that need to share the responsibility for these patients.

Carry your own Liability Insurance.

Practice SAFE!

[bjaeram]

So who is going to be held responsible when the patient is found hanging in the lobby bathroom? We had it happen in our ER!

[cookienay]

mmtuk, I most definitely got the point. your point just happens to be different than mine. The OP had a duty to act. The OP did not act in a prudent manner and a jury or BON would most likely agree. Regardless of EMTALA, MSEs, triage, etc... the main issue is that failing to act in this instance showed poor judgement.

NREMT also made a very good point. Sometimes the best you can do is not enough. But you have to be able to say you actually did something. Doing something to prevent a poor outcome and failing is completely different from failing to act and then having a poor outcome.

And ditto everything hherrn said.