5150 patient absconded from the ER........

[TazziRN]

CHP initiated a 5150 on a psych pt and called the ambulance for transport. Medic says pt needs medical clearance and brings him to us instead of taking him to a psych facility. We are a 6-bed ER, with two RNs and a tech on at a time. My coworker and the tech were behind a door taking care of a sick baby, so I had the rest of the ER. CHP decided that he didn't need to stay to babysit the pt so he said "Call me if you need me." Like a fool I let him go. I checked on the pt frequently, even got him a dinner tray. Fifteen minutes later his bed was empty and he was gone, along with the knife from the tray. I started storming about how I shouldn't have let the cop leave, and the doc tried to pin it on me! Yes, I bear some of the responsibility, but how was I supposed to babysit him and take care of the other 4 pts???

Yes, I called dispatch, and I also called my manager. She is supporting me but I have been kicking myself with "I should have's" and "What if's?"

ARRGHHH! :banghead:

[jojotoo, RN]

That's another reason I'm kicking myself....I knew better than to give him regular utensils and I just wasn't thinking. I know that we can't make a 5150 stay, but if he had been observed he probably would not have left and if he had tried one of us could have called dispatch while another tried to talk to him. There are lots of things that, looking back I could have or should have done.

Actually you can make a 5150 stay. We have a locked psych floor in our hospital and 99% of the patients admitted there are medically cleared through the ER. Sometimes they are in the ER for several days before a bed opens up on the psych unit. This does not make for a very comfortable stay for the psych patients. But they are not free to leave. We use a combination of CNAs or ER techs as sitters. After a certain point, if we are holding too many in the ER, we get an extra RN to help watch them. We use Haldol, Ativan, Benadryl, Geodon and Restoril to try to keep everyone calm. But it is a rare 24 hr period that somebody is not in leather restraints until a "cocktail" kicks in. We also have an occasional escape. But is usually witnessed - the patient was just faster getting to the door than us. A foot chase by ER staff and/ or security ensues. We catch them, drag them back, restrain them and medicate them. If they truly get away, we notify local PD and they start searching for them.

[htrn]

The 5150 is a LEGAL hold, not a medical hold. It doesn't matter if he was a danger to himself or someone else, a judge decided he needed to go to psych and the cops were responsible for enforcing that. He was only in the ER for medical clearance, that was your role.

So what, you gave him metal utencils - oops - I don't know about your hospital, but we don't serve steaks and definetly no trays with steak knives, just butter knives!!!

Relax, let me buy you a drink

[santhony44, MSN, RN, NP]

Read my last post again.

In my entire career I have never had a 5150 who was a danger to others, only to themselves. I'm not stupid enough to have put myself in dangerous proximity with him, but he was not a danger to others. He has a looooong psych history and had absconded from a halfway house in another county yesterday morning. If he was a danger to others I would have insisted that the cop stay, but I doubt he would have thought it was safe to leave in that case.

I wasn't saying that you're stupid. I was saying that I've seen people so determined to leave that they were willing to run over whoever was between them and the door. You can get hurt just being pushed out of the way.

[TrudyRN]

It is fascinating that your facility has no written policy about this. This surely is not the first time this has come up.

Is a 5150 a Court ordered patient? I thought you said this person was just brought in by cops. No arrest. Just cops saw him, thought he was in need of Psych eval/Med eval, and brought him in.

As for someone being dangerous only to himself - no way to be absolutely certain. The calmest, sweetest animal will kill if pushed hard enough.

[TrudyRN]

Actually you can make a 5150 stay. We have a locked psych floor in our hospital and 99% of the patients admitted there are medically cleared through the ER. Sometimes they are in the ER for several days before a bed opens up on the psych unit. This does not make for a very comfortable stay for the psych patients. But they are not free to leave. We use a combination of CNAs or ER techs as sitters. After a certain point, if we are holding too many in the ER, we get an extra RN to help watch them. We use Haldol, Ativan, Benadryl, Geodon and Restoril to try to keep everyone calm. But it is a rare 24 hr period that somebody is not in leather restraints until a "cocktail" kicks in. We also have an occasional escape. But is usually witnessed - the patient was just faster getting to the door than us. A foot chase by ER staff and/ or security ensues. We catch them, drag them back, restrain them and medicate them. If they truly get away, we notify local PD and they start searching for them.

Are you at Olive View? LAC-USC?

[TazziRN, RN]

No, we can't make a 5150 stay. We are not a psych facility so whenever we have a 5150 we have to transfer to another facility (nearest one is an hour away) for a psych clearance. They either admit the pt on a hold to inpt or release from the ER.

Yes, it's a legal hold but it's not enforced by a court. Most of ours are initiated by the ER doc and is either cancelled or reinforced by psych on their eval. Every once in a while, like last night, it's initiated by law enforcement.

Most of our hold are not violent but depressed; they don't do anything and do not protest when someone is watching them.

Yes, it was just a table knife, with just the tip serrated, but someone who is depressed can do plenty of damage to themselves with that.

This particular pt could have easily been transported straight to psych for a mental health eval since CHP started the 5150, but the medic on duty is well known for bringing all pts to our ER because she insists the pt be medically cleared first.

I'll take that drink but can you make it a root beer? I'd just as soon not mess up my sobriety. :cheers:

[West_Coast_Ken, BSN, RN]

He...had absconded from a halfway house in another county yesterday morning.

RN = Medical care

CHP = Enforcement

Seems clear to me who's responsible for this pt running off and it's not you. Also, did the officer know about the pt running off the day before? If so that's another stike against him/her.

[TazziRN, RN]

RN = Medical care

CHP = Enforcement

Seems clear to me who's responsible for this pt running off and it's not you. Also, did the officer know about the pt running off the day before? If so that's another stike against him/her.

Oh yeah! He even called the facility and they told him he was not welcome back. His reasoning for leaving was that the pt was cooperative (to a point...we had to explain everything very clearly and rationalize it before he would let us touch him) so we should be able to handle it.

5150's are supposed to be placed in the room closest to the desk but we were full. Plus I was overextended because my fellow nurse was tied up with a 1:1. Yes, I know that I did all I could personally but I'm kicking myself because I should have either insisted the cop stay, or I should have insisted the house supe find me a sitter. I did neither because I let myself be talked out of it.

[Noryn]

My opinion is that this is entirely the doctor's fault. The doctor should have properly assessed pt's mental condition and ordered one on one care if this was needed. The doctor should have also ordered the proper restraints if pt was a harm to himself or others. I actually dont feel this way but since all the blame seems to go to nursing, it just makes sense for me to play the game too and pass the blame.

The whole situation is ridiculous. Law enforcement (yes I love them, and have family members who are police) have some responsibility for the emergency crisis we are facing now. Somewhere along the line, one of them thought, wait a minute, why should we spend our time and money monitoring a drunk pt, the ER is open and they have to take patients! Or lets take this pt to get a drug screen at the ER. Ultimately law enforcement and other community resources are misusing the ER along with the general public.

You arent the policeman's supervisor. You cannot and should not have to tell him what to do. You were pretty much alone after he left. So what would you have done if the patient had become violent and ran toward the door? Would you have took him down and arrested him? How can you provide one on one care to this man when there are other patient's who need you?

I probably wouldnt have given the man silverware, but hindsight is 20/20 you know. I did work the ER and I dont feel that anyone should be eating in it, as it for the most part is nasty as can be. I also feel that if you have to go to the ER you really should be too sick to eat (for the most part, yes I know there are exceptions such as pt's who are hypoglycemic).

Anyway, in no way can I see how you are responsible for this mess. You along with most of your patients are the victim of a failing emergency care system where you literally have pt's dropping dead in waiting rooms, have sick people waiting often for hours for a bed, etc.

[TazziRN, RN]

I did work the ER and I dont feel that anyone should be eating in it, as it for the most part is nasty as can be. I also feel that if you have to go to the ER you really should be too sick to eat (for the most part, yes I know there are exceptions such as pt's who are hypoglycemic)

Oh, I have to comment to this. Here's an example. I had a woman who had been bitten by a cat. She came in the late afternoon and had to be there for several hours because a medication that she needed we didn't have and had to send to another facility for it. She was there over the dinner hour and was hungry. We shouldn't feed her? And this 5150 had not eaten since the night before, so he was going on 24 hours. He was medically fine. We shouldn't feed him?

[ERNP]

I wouldn't beat myself up about this. I don't live in CA but as far as I am concerned whoever initiated the involuntary psych paper trail has the responsibility for seeing that the patient remains in the intended environment.

When I initiate such a paper trail, I also initiate an order for security to monitor the patient one on one. If it is something security can't handle the police are called to assist with the situation.

In your case, if the paperwork was initiated by the CHP, then they had the responsibility for seeing the proper environment was maintained. Even if that meant they had to sit there for 3 days.

For goodness sake, the police sat for 12 hours the other day with a dead body that was a coroner's case. They can certainly sit with the living in need of assistance.

[Noryn]

Oh, I have to comment to this. Here's an example. I had a woman who had been bitten by a cat. She came in the late afternoon and had to be there for several hours because a medication that she needed we didn't have and had to send to another facility for it. She was there over the dinner hour and was hungry. We shouldn't feed her? And this 5150 had not eaten since the night before, so he was going on 24 hours. He was medically fine. We shouldn't feed him?

I said there were exceptions . Unless you have a top notch housekeeping crew that disinfected everything after each pt, I still would never eat in the ER. There are just so many bugs (mainly causing gastroenteritis)you can pick up. The examples you bring up though are my whole point and to be honest that is another post and argument which has been fought too many times. Unless someone has developed cellulitis from a cat bite, it really isnt an emergency. A routine medical evaluation for a psych pt isnt an emergency.

I will use this case as an example, the pt that eloped needed psych treatment. He needed counseling, possible medication change, close monitoring in a protected environment, etc. But what happened? He didnt get the treatment that he needed because he was in the ER. A RN cannot babysit another pt in the ER, unless you want someone to die--it is that simple.

My whole point it to not beat yourself up over this. You are doing everything you can, the system is a failure, that isnt my opinion that is from recent studies. The pt should not have been brought there unless there was a medical need, if the patient was brought there with the police, the police sure shouldnt have dumped him and left.