Psych pts protocol

[joyful_wanderer]

So I realize this is a nation wide problem and I wasn't sure which specialty to ask this question under but my ER sees a LOT of psych pts. Mostly are honestly drunkacidal but the police bring them in on holds and then we have to keep them until they are sober enough to be cleared by our behavior health team. The other group of people we get are meth patients that our brought in for odd behavior and SI statements as well and we have to hold them in our ER.

So here is the issue for my department. We have no set protocols or standards as to what to do with these pts. We place them all in chairs in a room and let security watch them. However, there is constant debate as to if we should get them changed, or let them keep their phones, or if we just need to take their backpack/bags away from them while they are there. It is all provider dependent. I cant even tell you how many times in the last month we have caught patients shooting up with meth/heroin in the psych room or BR.

Any way, I spoke to my manager and am creating standard protocols that will apply to every patient being brought in for psych/SI/HI behavior. I was wondering what are some practices that others have at their facility or protocols that you follow when getting in a new psych related pt? 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.

Any advice is appreciated.

[~Mi Vida Loca~RN, ASN, RN]

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.

I would imagine so. I don't know on what planet having a bunch of acute psych patients in a confined closed area with chairs is ever a good idea. I am actually surprised the various agency's having jumped all over this.

[canoehead, BSN, RN]

One of the patients' rights is ability to communicate with the outside world, and on top of that, if you take their possessions without consent, that's theft. I agree that the precautions are a good idea, but wonder how you get around those legalities.

[Workitinurfava, BSN, RN]

I am surprised you don't follow similar protocols like those in the psychiatric facilities. You see them at their worst. They don't need their cellphone, they can use the phone in the hospital.

[audreysmagic, RN]

One of the patients' rights is ability to communicate with the outside world, and on top of that, if you take their possessions without consent, that's theft. I agree that the precautions are a good idea, but wonder how you get around those legalities.

My facility is inpatient psych rather than ER, but hope this is helpful to explain...

We offer them access (within reason) to the hospital phone at my facility, which covers their right to communicate with outsiders. If this has to be restricted for any reason due to abusing it, the doctor has to write an order and we have to fill out a state-required restriction of rights form that is given to them and also kept in the chart. Most of the times, patients will give up their belongings (though not without griping) if you explain safety protocol and emphasize they they will get them back when they're discharged. If they don't - restriction of rights form and MD order. It needs to be on our contraband list to be covered under this, of course, but most of the things people insist on keeping with them that take it to this level are. And an additional copy of the rights form is required to be maintained by the facility and the state does look at them when they come through, so we can't get away with just restricting rights willy-nilly...but when it comes to safety issues in psych, sometimes rights do have to be stepped on. We just have to make sure it's well-documented, ordered, and that the proper forms are filled out. Though, as always, your own state law and facility protocol may vary and overrule anything I might have to say.

[MunoRN, RN]

The legal process for this is well defined by each state, although I have experienced working in facilities where these laws aren't well understood, which in one case led to a nurse losing their license and facing criminal charges, so this should be taken very seriously by nurses and remember that how things are commonly done in a facility in no way protects you.

The most important thing to remember is that holding someone against their will and taking their belongings and their ability to communicate is a criminal act, it only becomes legal when a well-defined process occurs which is usually much more strict when it comes to a psych hold vs a medical hold. Generally, a hold or restrictions has to be placed by a person who is legally designated to do so, often a mental health LIP, you can't place a hold or restrictions on your own prior to that evaluation occurring. In many states a physician can initiate a temporary hold so that they can be evaluated, but this is often limited to only 4 hours and only allows for the patient to be kept on site.

[canoehead, BSN, RN]

Thanks guys, I've worked in the US and Canada and never come across paperwork that limits personal possessions, although I've very often seen things taken for safety reasons.

[tyvin, BSN, RN]

When I worked inpatient psych the ER had a set protocal. When a psych patient was brought into the ER or went in, the social worker would give them a choice whether to go to inpatient psych ward voluntary or involuntary. This is after a history and doing a check to see if they were one of our regular psych patients known to us or someone new. The ER does not keep them; they send them to us.

We do get the drug addicts as well who choose to come to inpatient psych to detox or not; but if not, are admitted on a 72 hour involunatry hold (small island). When I say addict; I include the alcoholics because alcohol is a drug.

[topdoc]

Hi all, we were recently cited by CMS for forcing behavioral ED patients into scrubs. We were placed in immediate jeopardy. Once we stopped forcing patients into scrubs, the immediate jeopardy was removed. We were recently told we will be receiving a full CMS survey any time now. They will be looking at use of seclusion/restraint, forcing scrubs, etc. Bottom line is that you cannot use force to get a patient into scrubs as the use of force is the trigger for a violent situation, that can lead to harm to staff or patients. More to come.....

[PeakRN]

Hi all, we were recently cited by CMS for forcing behavioral ED patients into scrubs. We were placed in immediate jeopardy. Once we stopped forcing patients into scrubs, the immediate jeopardy was removed. We were recently told we will be receiving a full CMS survey any time now. They will be looking at use of seclusion/restraint, forcing scrubs, etc. Bottom line is that you cannot use force to get a patient into scrubs as the use of force is the trigger for a violent situation, that can lead to harm to staff or patients. More to come.....

We have all psych patients change into a gown that is psych specific for safety and identification, if they are on a hold they do not have a choice. CMS in well aware of our practice and doesn't have any concerns with it.

[JKL33]

Hi all, we were recently cited by CMS for forcing behavioral ED patients into scrubs. We were placed in immediate jeopardy. Once we stopped forcing patients into scrubs, the immediate jeopardy was removed. We were recently told we will be receiving a full CMS survey any time now. They will be looking at use of seclusion/restraint, forcing scrubs, etc. Bottom line is that you cannot use force to get a patient into scrubs as the use of force is the trigger for a violent situation, that can lead to harm to staff or patients. More to come.....

Hello topdoc -

I do think you should ask a few more questions about the citation.

It would surprise me to hear that CMS expects you to leave dangerous materials and/or weapons in the patient's possession - which would be an occasional effect of not having a routine gowning policy - - unless you're saying CMS's idea is that frisking/searching every patient and then allowing them to remain in their own clothing is preferred. Rather, I suspect there were other/additional issues besides the idea of gowning and that your rates of requiring force and restraint were out of line in ways not solely related to gowns. That I can believe; either that or CMS received a specific complaint and found concerning circumstances upon investigation. Too many HCWs have behaved aggressively like some sort of rogue posse when dealing with these very volatile and sensitive situations, even displaying a personal-appearing aggression sometimes. Not at all acceptable. Helping a patient follow a safe protocol in the course of getting help they need is not meant to be today's sporting event or adrenaline release or camaraderie activity.

If you were placed in immediate jeopardy then CMS has other concerns besides psych patients wearing gowns or even the occasional and appropriate use of team effort for conflict resolution/unsafe behavior management. One way or another your place is an outlier.