Psychiatric Patients in ER

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I am interested in studying post traumatic stress disorder in psychiatric patients resulting from being placed in seclusion and/or restraints in the emergency room or psychiatric unit. Many patients arrive who are not criminals or violent, just suffering from strong emotions or intense mental anguish, and their misery is made much, much worse as a result of being subjected to restraints and seclusion. To the nurses who work in these places, have you observed patients suffering worsened emotional problems after being treated with involuntary measures in the ER or psych unit?

Thanks.

Dolphin,

I am trying to see your point ... but as an ER nurse, I have never slapped 4 point restraints on a civilized, non violent patient seeking help for depression ... I think I missed something here.

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Yes, you did. Please re-read my post. I described situations where a psych patient expressing suicidal ideation tries to leave the ER without being evaluated. Even if they peacefully get up to leave they will be threatened with restraints.

I have never worked in ER, I have never restrained a patient or a psych patient in ER. However I do know that conditions in ERs all over this country are deteriorating on all fronts. How do I know? It is a situation that is discussed on 60 mins., 24 hours and every written publication in the country. It is also comman knowledge throughout the healthcare business. This is due to lack of funding at all levels. Money for treatment of human beings with mental health issues is in particularly short supply. Everyday in everyway ERs are falling short of the goal of giving proper treatment to people who are in a crisis state whether it is physical or mental or emotional. While I type this people are dying of heart attacks and bleeding to death in waiting rooms. It is not the fault for the most part of the meager ER staffs. It is the fault of a society that has money for bombs, guns and toga parties coming out of it's wazoo while it crys poor about the funding needed to fill the most basic of human needs.

Specializes in ER.

If someone says they are going to kill themselves are you in favor of letting them leave without being seen? At our hospital they need to have at minimum a plan in place to prevent suicidal behavior (friend to stay with them) and agree not to harm themselves before we let them go. If they are just depressed they make their own choices, and we are a resource/consultant.

So if they are suicidal and say they are going to go home and kill themselves I don't think we have any choice but to stop them. Whether we can convince them to stay voluntarily or we have to hold them physically is up to the patient. I can't think of ANYONE who gets a kick out of using restraints, but if it saves their life it has to be done.

Specializes in Obstetrics, M/S, Psych.
Originally posted by Dolphin777

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Yes, you did. Please re-read my post. I described situations where a psych patient expressing suicidal ideation tries to leave the ER without being evaluated. Even if they peacefully get up to leave they will be threatened with restraints.

I see where you are missing something here, Dolphin. If a patient presents expressing thoughts of self harm, the staff is legally obligated to make every effort to ensure that patient's safety. The threat may not be genuine, but the staff cannot know that until the patient is evaluated. The ED is responsible for their safety and liable if they harm themselves. Leaving peacefully is not the issue here. If anyone goes to an ED expressing suicidal ideation, they can expect not to leave alone until deemed safe. Period. I agree those with borderline personality are not going to get the optimal treatment from an ED for their disorder, but hopefully will be directed to an agency that is better suited to assist them.

Originally posted by Dolphin777

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.

UHmm.... excuse me... I am a nurse on a Gero-Psych unit. It is our entire hospital's policy (Not just our unit) to not restrain unless the patient is a danger to him/herself or others and ALL other measures have been exhausted. Nor do we chemically restrain. I am highly offended at your remark that psych units strip patients of their dignity. One of our highest priorities is to ensure our patients' dignity - both literally & figuratively. Perhaps in your research, you'll get some more concrete facts from somewhere other than where those came from.

Now... I have been hit, slapped, kicked, spit on, cussed out, peed on, had feces wiped on my clothes, food spit out at me, etc. But not once have I ever restrained an Alzheimer's patient or stripped them of their dignity. I don't think Alzheimers is criteria for restraints. :rolleyes:

Please check your facts... closely.

Originally posted by sbic56

I see where you are missing something here, Dolphin. If a patient presents expressing thoughts of self harm, the staff is legally obligated to make every effort to ensure that patient's safety. The threat may not be genuine, but the staff cannot know that until the patient is evaluated. The ED is responsible for their safety and liable if they harm themselves. Leaving peacefully is not the issue here. If anyone goes to an ED expressing suicidal ideation, they can expect not to leave alone until deemed safe. Period.

this is the way things are in my little corner of the world. regardless of a medical or mental health diagnosis, if a patient comes into my ED either saying or having said "i'm going to kill myself," that person will be evaluated by one of those "pitiful master's degrees" and action will be taken from there. those actions will only include physical restraint IF that person strikes out at a healthcare member or at him/herself. legally, legally, LEGALLY.....we have to be assured that patient is not going to walk outside and do harm to themselves or someone else.

Dolphin777,

I still do not understand the purpose behind your post. Is this for academic or personal needs? I can state that over the past 15 years I have yet to see a patient in the programs I manage develop PTSD due to the type of emergency care that they received during an acute psychotic or neurological episode. My populations consist of newborn to 110 year olds. Tracking iaotrogenic injuries and illness has been in place since 1993 via ICD code. In 100,000 + lives with over a million ED visits in 50 states and 3 territories, PTSD from emergency care for acute mental or neurological illness has never been diagnosed. None of my staff know of any of our employees or their families who have a history of emergency department care for acute episodes of mental status change or suicidal ideation and developed an adverse outcome. All clients returned to the community and did very well unless they had a rapidly terminal disease (less then 6 months of life expectancy).

We work for a non-health care employer and monitor those employees and their family members closely who have had mental status changes and suicidal ideation. (The ones not as closely monitored are those who have elected to live on the streets.) Some of these clients did require isolation to minimize the symptoms they were having, and an emergency department is not a low stimulation location. Of course isolation does not mean they had no contact with anyone. We have also had employees with chronic mental health conditions come to us and request our assistance during a flare of illness in getting them care because "I think I need to be restrained or I need to be in a quiet place." In some employment locations under the Americans with Disability Act we have created low stimulation rooms to allow those disabled employees to give themselves a break from the onslaught of multiple stimulation in the workplace. In fact it is a form of self-isolation to help them manage their symptoms.

Considering the lack of community mental health care and despite my frustrations in accessing care for our employees, I think the emergency departments have done an outstanding job and continue to evolve and develop new methods to deal with such an insurmountable situation here in the US. In the past two years there have been a few cases I thought would surely need to be restrain at the emergency department but in fact the staff were more then up to the challenge and avoid the use of restraints.

Dolphin777

Your bio is rather scanty: Are you a nurse?

I will have to agree with most posters.

The ER is not a place to go to get some talk therapy. Nor does the triage team have the time to play the "If you dont talk to me I'm going to kill myself" game.

I have NEVER seen someone such as you describe treated in such a manner as you describe.

Most individual with AxisII dx are not appropriate for in-pt psych tx either. These pts do well with a skilled outpt therapist and in peer supported group settings.Folks that are honest willing and able recover quite well and can lead happy productive lives where their emotion needs get met without damage to anything or anyone else.

Specializes in Geriatrics/Oncology/Psych/College Health.

I also have NEVER seen anyone be restrained who wasn't being uncontrollably violent at the time. Period. It's illegal to restrain without good cause and a doctor's order, and, at the risk of being flip, it's too darned much paperwork to do just for kicks. Alternatives to restraints are less traumatic and easier on everyone.

I have seen people be confined in locked units against their will (i.e. a 72 hour hold) if they threaten or do harm to self or others or if they are unable to care for themselves (gravely disabled) or otherwise unable participate in their own decision-making (understand and sign a voluntary application.) Those are the criteria for involuntary holds. And yes, it is perfectly appropriate to hold someone against their will if those circumstances exist and there are no other alternatives. It's our legal obligation.

dolphin777, have you ever worked in an ed?!?!?

personality do or not - if someone says they are going to kill themself when they leave - what should we do - hold the door open for them??? you are right - they are given a CHOICE - let someone come talk to them - perhaps still go home - but give us a chance to help-- it is lose/lose w/ you - we are damned for keeping them there and damned for helping them

and mind you that the majority of axis II diagnosed patients HAVE been given adequate care - because they SEEK IT OUT - it is within most of the personality do's to do this because they want the attention rather than truly wanting to hurt themselves - so IF they lose house/husband/job - primarily it is due to no follow up -by the patient

no real nurse would ever strip a pt of dignity "for the fun of it" - but at times it does happen -

so if you have a better solution - please share it with us - i am sure that the millions of psych doc's/instructors ect haven't done their best to solve this......

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Several posters have asked me whether I think it would be all right to let someone expressing suicidal ideation leave the ER, even if they went on to commit suicide. My answer to their questions is YES. You would not detain someone against their will if they announced they were planning to gain 100 pounds and smoke 3 packs a day of cigarettes, would you? Well, if someone states they want to kill themselves, 9 times out of 10 it is a desperate cry for help, a figure of speech, and they need the psych & ER staff to address the REAL, underlying problems instead of using restraints and other degrading measures.

As for the 72 hour hold, those 72 hours only apply to Monday through Friday excluding holidays. If a mental patient arrives the Friday evening before a major holiday weekend, that 72 hours could very easily turn into a one week prison sentence in the psych unit. A whole lot of bad stuff could happen in that one week, or "just" those 72 hours: 1)college student could flunk an exam or get hopelessly behind in their courses and have to drop out of school, 2)working stiff could lose their job, 3)single parent could lose custody of their children, 4)caregiver of a sick spouse or elderly parent could end up with their loved one placed in a nursing home, 5)person could end up homeless as a result of being unable to pay their rent or mortgage.

One of the saddest cases I heard involved a single, childless woman who had three cats. She was locked up in a psych hospital, missed her rent payment, and the landlord went into her apartment, found her cats and took them to the pound where they were euthanized. When this poor woman got home after her psychiatric incarceration, her pets were gone. She soon learned they were dead. Who in their right mind could possibly think this woman was "helped" by the psychiatric staff who imprisoned her, prevented her from paying her rent, and caused her beloved animal companions to be put to death courtesy of the landlord and local pound?????

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