How do you treat involuntary holds?

[New2ED]

i have been working in the er for a year now and i am completely baffled by my hospitals lack of willingness to stand behing a policy regarding involuntary holds or ga 1013 status for people that are a harm to self or others. when a ga 1013 is signed by the md, we then notify security and they are suppose to come to the er and sit in near vicinity of that room. as a nurse caring for sick patients i don't have the time, patience or energy to constantly check in on these people, many of whom are there only for "3 hots and a cot". the problem comes in when we have a elopement and everyone wants to point fingers about why it has happened but ultimately nobody realizes this could be a sentinel event if we have an elopement followed by a mass casualty or even a suicide!!! and of course the person that is ultimately responsible for the pt is the rn. so i need to hear some feedback or policies that you may have in your hospitals and how they are enforced because i feel like this is a very unsafe position for all the nurses in the ed and we are getting thrown under the bus!

[racing-mom4, BSN, RN]

We typically keep them 1 on1 in the ER with the help of paramedics till we get them a bed either in on the psch unit or the ICU if they are not medically stable. Both of wich are locked units, if they have a 72 hour hold on them and they try and "escape" we call a code strong that brings all avail help including the paramedics, or last resort we call the police. If they do manage to "escape" we dont put our selves in harms way trying to stop them, we just call the police to find them.

If they are truley a threat to themselves or others we break out the leather restraints until chemically calm.

[mountainnurse]

Our ER calls security when a patient is placed on an 8 hour hold and within minutes a security officer is at the bedside. The problem is what happens next. A recent policy change states that the security officer is not allowed to touch the patient so if the patient attempts to leave we have to stand back (unless they have given us a valid reason to restrain them), allow them to walk out and then call the police to pick the patient up. Many of our psychiatric/detox patients have no medical insurance and come in grossly intoxicated so while they wait to get medically cleared to get a psychiatric evaluation the police leave. The next step is placement in a psychiatric facility. If they have insurance we have to wait until their alcohol level is less than 150 for an eval and then for a bed in a nearby facility. Our county psychiatric facility is overwhelmed and patients with no insurance end up staying in our ER for days (the most I have seen is four days).

This is not an appropriate situation for the patient who needs a different level and type of care which we are not equipped to offer being in a busy ER with medical patients with immediate need. They are often forgotten and/or ignored (not on purpose) and are a strain on our ER resources when they return every other day to repeat the process over and over again.

As to your question, your hospital should provide security or a sitter as you physically cannot be there 1:1 with the psych patients if you have other patient assignments, so it is an unsafe situation for both your patients and yourself.

[gonzo1, ASN, RN]

We take all their clothes and belongings and lock them in a secure cabinet

security checks the pt with a metal detector

pt is placed in room with a camera

security watches said room

beeper on room door goes off if pt opens door

leather or chemical restraints sparingly used as needed

we only have 2 of these rooms, need about 6 and more every day

[jenfromjersey]

We are not a screening center so we do not have seclusion rooms like other ERs I have worked that were. When a patient comes in and is deemed risk to self or others, they are placed on a 1:1 observation. One of the ER techs is pulled from their assignment and placed in the room and given a direct observation sheet that needs to be signed off on in time intervals. All of the patient's clothes, shoes and belongings are removed and security is called to store them temporarily. All drawers are locked and wires removed (tele wires, BP monitor, pulse ox, etc.) A psych screener comes from the local screening center and assesses the patient on-site. Once it is deemed that they are going to be held on screening docs or voluntarily signing in..then arrangements are made for transport once a receiving facility accepts them for transfer. We do not have inpatient psych so they must be sent out. The nurse is not expected to sit in the room and watch the patient. The tech is assigned.

[aaronrnmedic]

Our ED requires us to notify security right away and to place them into blue paper gowns. This makes it easier to identify them when they attempt to run out of the ED. We see a lot of psych pts and usually have on average 4 of them either being seen or waiting to be seen at any given time. To be honest, somedays I bet up to half of our pts could use a good eval! After security goes through their belongings and determines that they do not have anything that can hurt themselves or others, their clothes and belongings are placed in bags and kept out of the pt's reach. Ideally, they are placed in a room that does not contain any cords and is monitored also with a camera. But our ED is so busy that many times these pt's are placed in "normal ED rooms", which are closer to exits (and running ambulances!). Don't ask! An affidavit needs to be filled out and they need to be medically cleared before being sent to the floor or transferred. We rarely have people that can come and sit with these pt's and we have to pay much more attention to them. Kind of hard when you have other critical pt's. We have sec. techs that can help but they are usually extremely busy. We have Paramedics but they operate much more like RN's in our ED and are needed for the more critically ill or injured pts. In a pertect world (at least in the ED) most of the psych pts would be sent directly over to the psych floor where they would be evaluated by a doctor to be medically cleared. They would then be admitted, transfered, or not. That is just my opinion though.

[BillEDRN]

There are essentially two types of involuntary holds. Those associated with psychiatric issues or those with temporary decisional incapacity, usually related to alcohol or other intoxicants.

Either way, you are responsible for their safety. A physician or other independent licensed provider (NP or PA) is usually tasked with making a determination about their ability to leave AMA. If they cannot make an informed decision, or are considered a threat to themselves or others, then the hospital is responsible for keeping them safe. Restraints (both chemical and physical) can be used, but within the guidelines established by regulatory agencies (Joint Comm., CMS, State Dept. of Health).

How much force and for how long you can keep them, even the criteria for determining danger to self or decisional capacity, is full of grey areas, so don't expect to see a lot of specific information about exactly what you can and cannot do. Check your state statues, but don't be surprised if the situation isn't specifically addressed.

From a liability standpoint, it's best to have a physician make the determination and then make sure charting accurately reflects the patient's condition, behavior, and attitude, as well as all attempts to keep him if things look like they're heading towards restraint-ville.

[mmutk, BSN, RN, EMT-I]

We had seclusion at the last ER I worked at and therefore they went into a room (locked) with nothing in the rooms or wall and we had audio visual monitoring. It worked mostly very well. They beat on the door sometimes, but then security would chill them out.

At the current place I work they only have regular rooms, and if they become violent or a flight risk security will be with them 1:1. But of our security 3/6 are overweight and not really a threat. So then as a member of the male nsg staff I have had my hand in a fight or two. But as a general rule I'm not getting my as* kicked over some elopment.

I do miss those seclusion rooms

[thegreenmile]

I, on the other hand am the Psychiatric Specialist who works in one of the only regional inpt units in our area, receiving referals for available beds, which are often a rare commodity due to high census and or acuity and short staffing. In my experience, if the local ED that is the referal source, has county MH Crisis Center professionals on staff, the transition to a psych facility goes much smoother. They have all of the resources, knowledge and experience to expedite the process and manage the patient in the mean time. Most often, the patient presenting to you has been in the system a while due to the chronicity of their illness and the Crisis Staff are familiar with them and the patient is familiar with the Crisis Rep. With this pt. population sometimes its as simple as a familiar face and a skill set that makes all the difference in the world! I entirely understand your frustrations!