Psychiatric Patients in ER

**canoehead, BSN, RN** · Nov 2, 2003

What alternatives to seclusion would you suggest? No one enjoys doing it, that's for sure.

Rena RN 2003, RN · Nov 2, 2003

you're post would suggest that alternatives weren't tried before placing a patient in restraints. restraints are never used in our ED without cause and are always a last resort. you see, we follow maslow and determine that physical safety must be met in order for emotional well-being to be attainable. implying that restraint use is soley responsible for the amplification of emotional upheaval in a patient is ....well, crazy.

Dolphin777 · Nov 2, 2003

The only legitimate reasons for use of restraints or seclusion are if the patient has been formally charged with a crime or if they are actually violent (not just threatening, but a proven act of violence or crime). If a patient is viewed as being mentally ill or having Alzheimers Disease, they are typically stripped (literally and figuratively) of all dignity in ER's and psych units.

Surely the hospital staff cannot believe that use of restraints and seclusion "help" these people. Look at all of the homeless mentally ill people on the streets who have been subjected to the degradation of involuntary measures instead of receiving meaningful psychotherapy and job training and placement services. In addition to all these homeless people, there are approximately 3 million mental patients who are unemployed and existing on SSI/SSDI (this was not the situation in the 1960s and 1970s when long-term psychoanalytic psychotherapy was the preferred method of treatment).

teece3 · Nov 2, 2003

Sometimes alternatives aren't used. At the hospital where I work, after a particularly difficult and aggressive "psych" (and I use the term loosely here) patient was admitted to a M/S unit, the next psych patient (one with a long psych hx and a martial arts background) admitted there was kept in restraints and with 24 hour security guard monitoring until a bed was available on the psych floor. He never threatened anyone or behaved in an aggressive manner after he was in the hospital. I guess the rationale was: he could be aggressive, so he had to stay in restraints. Now the policy is: if a psych patient is in the hospital ER and the psych unit is full, the most stable patient is transferred off the psych unit to a M/S unit (with a psych staff providing 1:1 care the entire time they are on the M/S unit) and the patient in the ER is brought to the psych unit. No one has addressed the fact that the psych unit is now short staffed (because a staff has to go with the transferring patient) and a more acute patient is now on the unit! Most psych patients are not violent or aggressive and seclusion/restraint is only used as a safety measure when all other efforts have failed. Only in very few instances have I heard any of the secluded/restrained patients c/o further emotional trauma from the seclusion/restraint event.

teece3 · Nov 2, 2003

Originally posted by Dolphin777
Look at all of the homeless mentally ill people on the streets who have been subjected to the degradation of involuntary measures instead of receiving meaningful psychotherapy and job training and placement services. In addition to all these homeless people, there are approximately 3 million mental patients who are unemployed and existing on SSI/SSDI (this was not the situation in the 1960s and 1970s when long-term psychoanalytic psychotherapy was the preferred method of treatment).

The involuntary measures the mentally ill homeless have had to endure come more from the de-institutionalization mandated by the federal government that occurred in the 1960's and 1970's. These mentally ill persons were released from long-term psych hospitals without any reasonable follow-up because none existed. The individual communities had no where to house them, had no jobs for them and no programs were available to monitor their need for medications or to provide job training/supervision. In addition, these people faced the stigma of having been diagnosed with a mental illness and the communities didn't necessarily welcome them with open arms. People still have to cope with that stigma now...some 30-40 years later.

These people could not afford then or now psychoanalytic psychotherapy. For that matter, most people can't afford psychoanalytic psychotherapy as it's rarely covered by insurance and it's extremely time consuming. What these people need are programs set up to provide support, supervision, crisis intervention and access to the health care system. Sadly, this just isn't a priority in most states because it's expensive and it's not a popular cause.

Dolphin777 · Nov 2, 2003

A few years ago I went on an architecture tour of the new Hospital Where Patients Come First, and our guide pointed out two orange padded cells in the ER for the psychiatric patients. We sure have come a loooooong way in eliminating the stigma of mental illness, right?

athomas91 · Nov 2, 2003

i do not know about other states - however maryland is pretty strict re: restraints - you must document all other attempts to calm/pacify patient prior to restraints - if initiated (chemical or physical) one staff member must sit w/ patient to ensure patient safety

on the origional question of restraint use - the majority of patients that actually receive restraints (in my experience - which as far as psych goes is extensive) are more due to drug induced episodes rather than a true psych episode. staff safety must come first - and in a true psych episode (which has no drug influence) it is questionable if the patient when lucid even remembers the events (for ex. this is how people charged w/ crimes can get out of jail time "temp insanity")

so does it do more harm than good?? - no - one, if staff were harmed there would be noone to help care for the patient and possibly charges could be pressed - second, if the patient is compromising their own safety and medical care then they are a danger to self - which needs to be addressed. all in all - restraints should be used for short term until chemical agents can calm patient -

great med - geodon - works on all kinds of psych - but takes 20-30 min - many times we need physical restraints until the med works and 9/10 times the patient has no recollection of even being restrained.

sbic56, BSN, RN · Nov 2, 2003

Dolphin

I notice you are new to the boards. Welcome. Are you interested in treatment modalities of psych patients in the ED professionally? I only ask because you seem to be asking on more of a personal level and being on the outside looking in, you might not fully understand why patients are restrained on occasion. The first priority is to keep the patient and the staff safe. Without that, no treatment is possible. If restraints are used, they should be as a last option, all other less restrictive options being exhausted first.

The efficacy and use of "psycotherapy" in the '60-'70's" is very debatable. Seclusion and restraint were the preferred method of "treatment" then, as medications consisted of mainly Chloral Hydrate (a hypnotic), and Thorazine (one of the first anti-psychotics). I agree, SSRI's and the several other new psych meds are far from perfect, but immensely better than their predecessors, both in terms of reducing psychiatric symptoms and in that they produce less unwanted side effects.

No doubt, PTSD is induced by overuse of seclusion and restraint, but it's use today is minimal, especially when you consider 20, even 10 years ago, the patient having a psychotic episode was brought to a state psych hosptital and put into seclusion first, then evaluated when calmer, often much later.

Psych patients are some the most challenging for the ED staff to care for. The environment is often not as safe & secure as it should be, staff are limited and often the one to one staff needed for a patient in crisis is not available. State psych hospitals are only used for the sickest patients. Even with these obstacles, treatment of the mentally ill is a darn sight better and much less traumatic overall.

Tink RN · Nov 2, 2003

As someone previously stated, restraints are and should be a last alternative after other measures to de-escalate the patient have failed and the patient is deemed a threat to themself or others. Restraints are also used short term in the ER ... usually just long enough for the Haldol or Geodon to kick in. Most patients requiring physical restraint are not rational or "with it" at that point anyway and in most of the follow ups I have done, the patient denies any recollection of the ordeal.

Keep in mind, not all mentally ill patients are violent. As far as psychological effects of experiencing restraints, once again if the situation has progressed to that point, the patient usually has other issues far more greater to deal with than that.

Rena RN 2003, RN · Nov 3, 2003

If a patient is viewed as being mentally ill or having Alzheimers Disease, they are typically stripped (literally and figuratively) of all dignity in ER's and psych units.

where are your statistics for this? how many different ER's and psych units have you worked? is this something you see in your unit regularly?

i question this statement because as long as i've been in the ED, i have never seen a person put into restraints simply because of a disease process without that person taking the first swing towards a staff member or begin to scratch the hide right off his/her body with his/her own hands. never have i seen anyone "strip" a patient of dignity. whether that patient is lucid or not, every step of the process is explained as many times as it takes as to why those restraints are being used. the situation is handled with compassion and care. and as soon as the situation is under control and the patient has calmed to the point he/she is no longer a threat to him/herself or staff, those restraints are gone.

Dolphin777 · Nov 3, 2003

>

There is a HUGE difference between legitimate suffering from existential anguish, as seen in people with the Axis II personality disorders, versus people who are nuts because of a biological defect in their brains. The former group is the one I am concerned about; I realize if someone is out of their skull because of using angel dust or crack or from the truly biological mental illnesses, they may get violent and need restraints to protect innocent people.

There are numerous scenarios in which innocent people experiencing legitimate mental anguish are degraded by ER and psychiatric staff by being treated as mental patients instead of human beings with real problems. What about someone with borderline-narcissistic personality disorders who loses their job and livelihood and then their marriage or relationship breaks up? What about someone with borderline personality who is upset because of the death of a loved one combined with trouble at work or in a relationship? These people may naively turn to an ER thinking they would get someone to talk to, only to realize they are lumped in with the mentally ill and don't appreciate the degradation and humiliation that entails. If they decide to leave the ER after simply expressing suicidal ideation they can rest assured the security guards will be called and they will be given the "choice" of staying and being seen by some inexperienced resident or social worker with a pitiful masters degree OR ending up in restraints if they try to leave without being "evaluated". In teaching hospitals, insult is added to injury when the intimate details fo their lives are used as teaching material for students.

It is downright insulting for people with the Axis II personality disorders, many of whom are very well-educated and with successful careers, to be degraded by ER and psych staff and being put into the role of mental patient.