Psych pts protocol

Editorial Team / Moderator · May 29, 2017

Yikes. You are doing a great thing creating that protocol. Otherwise eventually something bad is going to happen, like an SI/HI patient using a weapon on himself/herself, staff, or other patients. They should have belongings removed, placed in hospital clothing (paper scrubs/gown, etc.), and be 1:1 observation at all times for their safety. We all know the ED isn't typically therapeutic for psych patients in crisis, but we need to make it not as dangerous. In the military (and my previous civilian time), we took their complaints very seriously.

~Mi Vida Loca~RN, ASN, RN · May 29, 2017

I have seen it vary so much in the many ER's I have worked, but majority of the places we take everything. Patients get paper scrubs or a gown. (I was more of a fan of the paper scrubs, it made more sense to me then a gown with a tie in the back) We take all belongings, now some times after initial evaluation one hospital would allow doctors discretion on getting the phone back. But it would end up causing issues having the phone. We always got blood and urine right away and some facilities we did an EKG. One hospital had a standard to check TSH levels with the blood work and I found that helpful because there were multiple times it ended up being elevated and accounting for the behavior.

OlivetheRN, ADN, BSN, RN · May 29, 2017

We do the same as PPs. All belongings are taken in triage and bagged, and they are changed into hospital provided clothing all the way down to their underwear. They get mesh underwear, paper scrubs, and non-skid socks. We draw blood and get urine to clear them medically and do a UDS. SI/HI patients automatically get a 1:1 order and it's up to the RN and MD discretion whether or not that's d/c'd once they're in a room and get a 15 minute safety rounds order instead. In our ED all the behavioral med patients are in one area (till they start overflowing into regular medical rooms) so we typically will d/c a 1:1 and do 15 minute checks like everyone else gets, which is really more frequent because there's a tech who sits back by those rooms and has eyes on pretty much everyone and there's also an officer there as well. We will use 1:1s for our SI patients who are actively trying to harm themselves in the room or SI patients who aren't back in that area in a stripped down behavioral room until we can get them moved.

Then we have other policies like no silverware (even plastic spoons), no straws, no pens or pencils unless they're writing something down under supervision, no plastic med cups, no cup lids, no hot drinks, no hard fruits like apples, and no caffeinated drinks. No outside food. When visitors visit they have to leave bags and purses with the officer. We have certain visiting hours and certain hours they can use the phone which are posted.

For some patients its overkill, yes, but when we explain the why behind it, "Yes, Ms. Smith, I understand you are not planning on hurting yourself, but for the safety of you, the staff, and other patients, we can't have personal patient belongings in your room with you" they understand, at least those who are A&Ox4 and aren't out in left field somewhere.

Exceptions and modifications have been made before. A young adult came in c/o depression and triage didn't think that anything would come of it so they didn't dress her out or draw blood, but did take her belongings from her and leave them with me at the desk and sat her in a hall bed since she wasn't dressed out. She ended up leaving an hour later. Another time a patient came in manic...after being discharged from the inpatient that morning. She was going to be going right back to an inpatient bed. The day shift nurse had tried evvverything to get her into some paper scrubs short of bribing her with cash but she wasn't having it. Since they get direct admits in street clothes all the time and those were the clothes she left in, I wasn't about to push the issue and get her riled up and sent her to the unit in what she came in.

Sorry, I started to ramble, but I work in the psych area generally at least one shift a week, and had recently worked at a facility with horrible, meaning no, policies for their SI/HI patients, so I'm glad you're stepping up!

JKL33 · May 29, 2017

As per previous posters. Belongings removed.

If you receive pushback, remember the rules can't (shouldn't) change based on which nurse or provider is assigned...you have the staff who don't want to be as "judgmental"/"mean" (???) as the rest of us and quite frankly they put the whole department at risk. This is one of those things where everyone needs to consistently do the same thing, with exceptions being very rare.

Phones take the drama to the level of "circus" IMO, and should be included with the removal of all the other belongings. Sometimes we have to temporarily get them back out in order for people to access contact info stored in the phone.

Forgot to add: Good for you for your willingness to work on this!

Lev, MSN, RN, NP · May 30, 2017

Paper scrubs. Wanded in triage and again when they change into scrubs in the rooms and their belongings are secured. They are only allowed to keep underwear and sometimes glasses. We take all the chords and stuff out of the room. Family who come visit have to be wanded before entering the room. If they are suicidal with a plan/acting out/elopement/big fall risk they get a sitter. All psych patients get basic labs, UA, urine tox, urine pregancy (if child bearing age) and then the ODs get a tylenol level and salicylate level too. The drunks/benzo ODs get CIWA. We breathalyze the drunks to make sure they are sober. Call security PRN. All suicidal patients or those who are psychotic/violent must be cleared by psych before leaving.

Why do the drunks in your ED need to be cleared by the behavioral health team? Why not the ER attending?

How do you keep them all together? Don't they feed off each other? Must make behaviors hard to control.

Meriwhen, ASN, BSN, MSN, RN · May 31, 2017

Why do the drunks in your ED need to be cleared by the behavioral health team? Why not the ER attending?

By the OP's use of the word "drunkicidal" they mean that these patients verbalized thoughts of dying/killing self/killing someone else while drunk or stoned. Whether you're intoxicated or sober, once you start voicing SI/HI,you've earned yourself a psych consult.

Psych won't clear a person until they're sober, because we don't know if it's the Gallo burgundy or a bona-fide depression/psychosis that is making someone feel suicidal and/or homicidal.

DTWriter · May 31, 2017

"I have always come from ERs where everything is removed and given a hospital gown and no access to a phone until seen by BH. "

^Definitely the above.

Plus, it would be a big help to BH staff if you give the patient's belongings (especially medications) to any family member present, if possible.

No shoes with shoelaces or Velcro (give them to the family/friend if possible).

No shirts or hoodies with drawstrings (give to the family/friend if possible, or warn the patient that the drawstrings will be cut or the clothing will be locked up).

No hair ties or pin (give them to the family/friend if possible).

Please consider do an EKG on the patient before sending the patient to BH - at least on the elderly ones and medically-complex ones.

If the person has COPD, asthma, or some sort of respiratory disorder, please make sure their breathing is stable before sending them to BH. I do not know about other BHs but at the one where I work, staff cannot give an inhaler to a patient until the patient has been seen by a medical physician who works with BH patients.

Ask your BH staff for their input.

bgxyrnf, MSN, RN · Jun 1, 2017

An amalgamation of various facilities with which I've been affiliated:

Keep a security guard on scene maintaining continuous line-of-sight with a ratio of no more than 1:2.

Change everybody into unique attire

Remove everything except personal-assist items (e.g. glasses, hearing aids, etc)

Posey belts for patients in the hallways waiting for rooms

CBC/C7/EtOH/APAP/Salicylate/UTox on everyone, UPT for females between 8 and 80 (roughly)

IVs on everybody to permit rapid B52's as needed

Limited visitation

Free visitation

No cell phones or personal devices

No restrictions on cell phones/personal devices

Escort and line-of-sight while in bathroom

Showers q48 and PRN

No showers available

Access to TVs and selected videos

No access to TVs and selected videos

RNGummy40 · Jun 1, 2017

At my hospital, patient's evaluated for Suicidal Attempt/Ideation, Mental Heath Evaluation, Altered Mental Status, or Homicidal Ideation are placed generally in one area. It is a locked mini unit in the ER with individualized rooms, camera's to view patients and a connecting nursing station to observer and document behaviors.

All belongings are removed, and patient's are placed required to wear specific color scrubs for elopement risk. If they are suicidal or homicidal and are waiting for a psychiatric evaluation then they would be wearing the specific scrubs so all employees could recognized that those patients cannot just walk out of the hospital till they have been evaluated and are deemed safe to discharge.

As posted in prior comments: CMP, CBC with DIff, Hgb, UTOX Screen, ETOH labs would be collected. The patient's should not have access to any drugs because if the provider and nursing staff are assessing for SI/HI and considering detaining the patient, how do you prove what was the initial presentation when the patient first arrived at he hospital, especially if they have to wait to be assessed.

MD's are expected to enter an order for "Restriction from Discharge: Psychiatric Eval needed," so nursing staff understands that the patient is waiting for a psychiatric evaluation. Medical clearance is also required to be documented if the patient does not need treatment for other diagnoses. It the patient is presenting with immediate risk and they are insisting on leaving, as long as they are medically cleared, we would call a county representative if the patient meets the criteria for danger to self, others, or grave disability. Your policy should include how you are keeping track of your detained mental health patients to prevent psychiatric holds from being dropped and maintaining treatment plans for psychiatric hold.

All belongings should be removed due to possible altered mental status and risk of danger to staff and other patients. The combination of a weapon/altered mental status/and or SI/HI places your hospital at increased risk for liability. Also, if patients are shooting up with drugs in the hospital and you have no preventative measure that will add to the liability risk.

All of our patient admitted current history of IVDU and are being treated with abx therapy through a central line are placed on a specific unit. We use a cap/label system to prevent patient's from having access to their central lines and risking overdosing.

Good luck and your hospital should give you a raise!!!

joyful_wanderer · Jun 1, 2017

Phones cause so many issues!!!

joyful_wanderer · Jun 1, 2017

RNGummy I love the way your unit is set up! Ours seriously was an old supply closet that we emptied out and placed chairs in it. There are no doors and its down the back hallway of the ER. Its a horrible set up. Pts try to run all the time and they feed off of each other like piranhas.