Safety with dangerous pts

NightNerd, MSN, RN · May 14, 2018

It's very rare, but our hospital has assigned security sitters in the past; otherwise the patient may be ordered a homicidal or a behavioral sitter, depending on the severity of the behavior.

JKL33 · May 14, 2018

1) Are you talking about patients who can't presently be medically cleared, or patients who are medically cleared and are awaiting a placement bed in another facility?

2) Out of curiosity, what have they said they expect you to do in these situations?

3) What kind of resources do you have? For instance - do you have hospital security? Good relationship w/ local LE? A social worker? A system for assigning sitters/attendants?

Hazelgirl_06 · May 14, 2018

1) Are you talking about patients who can't presently be medically cleared, or patients who are medically cleared and are awaiting a placement bed in another facility?
2) Out of curiosity, what have they said they expect you to do in these situations?
3) What kind of resources do you have? For instance - do you have hospital security? Good relationship w/ local LE? A social worker? A system for assigning sitters/attendants?

1. Pts who are medically and are awaiting a psych bed placement

2. They expect us to hit a button and wait until the cops show up which could be a while and in that time we could get injured

3. We have one security guard responsible for the whole hospital and is only there half the night. As for sitters it's only if we can find a unit to float someone to help. If not we have to deal with it.

JKL33 · May 14, 2018

There are a number of things that could potentially improve the situation:

ED initiates an appropriate medication regimen for agitation, 1:1 monitoring, having a case worker who can keep the process of finding a bed going even on off-hours, collaboration w/ local LE (something more than pushing a button), having a policy for a behavioral team response (overhead page with assigned responders just like a RRT/code team) which can be activated if there is a concern for escalation, staff training r/t communication and de-escalation, a policy for safety measures to be enacted when the patient is moved to your bed (safe environment, decreased environmental stimulation, etc.). Investigation of a system for tele-psych consult in order to obtain assistance with patient evaluation (it won't clear the patients you're talking about, but maybe others - who then won't be using ED/holding resources - and it might be helpful in consulting to initiate evaluation and treatment of your patients with appropriate medications).

Do these situations get unruly/dangerous on a regular basis? If actively violent patients are being admitted under these circumstances I would escalate my concern sooner rather than later. It is a situation that is unsafe for everyone; the patient, the staff, and the other patients. I get that they want to code for an obs bed and that they don't want to tie up an ED bed....but still. They have to be able to care for a patient they put in an obs bed.

Hazelgirl_06 · May 14, 2018

I'm referring to when they are admitted as a pt and not in ed. Our ed has more than adequate staffing and resources to handle these pts. Cpi and deescalation only goes so far with these patients. We have to rely on a button and pray they don't hurt someone while waiting ten mins for the cops to show. I'm hoping to get the police to collaborate with us and provide an officer with us since they drop these pts off.

KelRN215, BSN, RN · May 15, 2018

When I worked in the hospital, patients who were under arrest where the responsibility of the police. Patients who were incarcerated were the responsibility of the prison and they were usually shackled/handcuffed and guarded by 2 guards at all times. Other patients deemed dangerous were guarded by hospital security.

Now, this was a 400 bed pediatric hospital so it was relatively infrequent that patients had to be guarded by security because they were violent (more commonly, it was a child protection case and security had to guard the door to make sure the bio parents didn't come back to take the kid or it was a teenage psych patient who was a flight risk). I remember taking care of a teenager from juvie once (he faked seizures to get out of jail and come to the pediatric hospital where he had 3 hot meals a day, a TV and a video game system) and once taking care of a teenage child molester who had security planted at his door.

JKL33 · May 15, 2018

I'm referring to when they are admitted as a pt and not in ed. Our ed has more than adequate staffing and resources to handle these pts. Cpi and deescalation only goes so far with these patients. We have to rely on a button and pray they don't hurt someone while waiting ten mins for the cops to show. I'm hoping to get the police to collaborate with us and provide an officer with us since they drop these pts off.

Yes, I'm aware your situation is less equipped for this than the ED. I was trying to throw out a bunch of things that, altogether, if not already in place could make a difference (such as patients not coming to your unit until medical intervention for aggression has taken effect, making sure staff isn't inadvertently escalating the situation - have seen this innumerable times...for some reason people can't help themselves from arguing with patients, yelling at them to "calm down", etc) and this problem does have to be addressed on both ends if your ED needs beds so bad that they can't think of anything better than to send out-of-control patients to a unit that is not equipped to handle them. Every measure I mentioned goes to your problem, since this is a facility issue, not just a unit issue.

Sorry. This situation does sound very inappropriate and frustrating. If it's a regular occurrence and your admin isn't concerned about it, I'd be out of there, myself.

Good luck ~

K9lover, ASN, RN · May 15, 2018

People look at me with alarm when I tell them I work in corrections but it is actually quite a bit safer. We do not see anyone without an officer near enough to tackle the patient if need be.

Among the 100 other reasons I left bedside nursing several years ago was having little defense against violent patients (I do not count a security guard a few floors away as real defense.) I've had patients try and kick me, bite me, spit on me & one would have crushed my hand if the doctor next to me hadn't removed me from his grip. They are not all psych. We are devolving into a society wherein people think it is OK to act out on their base impulses if their med/food is 10 late or they are having a bad day.

Two Chicago nurses were held hostage, one of the nurses raped, after an unshackled inmate grabbed the officers gun, the officer hid in a closet. This inmate would have been quickly subdued in custody and should have been shackled to the bed in the hospital.

The latter is an extreme example but the lessor violence has been worsening in the 20+ years I have been an RN. Funny how much they impress zero tolerance for staff violence but not so for patients...it will not change until we start suing more and having those who are cognizant charged for their assaults. In jail/prison they actually ARE charged if they assault a nurse.

NoctuRNalED · May 15, 2018

What is your current process for these patients? Have they been searched by security for any potential weapons or contraband? Are they changed into hospital clothes? What stays in the room with them?

The first and easiest step is to make sure that any potentially dangerous patient (whether it's to themselves or staff) has as little potential ammunition to hurt anyone.

Who comes when the button is pushed? Our hospital panic buttons go to operator who notify hospital security and police so that no time is wasted by staff who may not have time to call police while dealing with a dangerous situation. Who responds from inside the hospital? ER staff, security, maintence? How quick do they get to you? If it isn't enough help or quick enough it would be worth it to ask management for an additional security guard to be staffed on the unit for only when a potentially dangerous patient is admitted. More than likely this won't be an option due to budget or staffing, but hopefully it starts a conversation about any extra staff that can be placed as a sitter for safety.

Are these patients coming from ER combative or waking up after being given medications in the ER? If they don't come to you safely, then that should be addressed with the ER providers.

Lots of questions, I know, but all facilities do something differently. It helps to know where your facility is at now to know what can be added to make it safer.

Eris Discordia BSN, RN · May 15, 2018

What my hospital has is something we call a "Code Atlas". It's an overhead page like any other code. People who are CPI trained (like ER nurses and techs, psych nurses, or anyone else interested in getting the cert), plus security, and the house supervisor all run and show up. If nothing else, it gets you a whole mess of people with some qualifications for escalated situations to show up. There is even a form to follow and fill out, like a regular code. We even do a very short debriefing afterwards for process improvement and prevention.

On average, four to six extra people show up for every Code Atlas. Whoever can get the best and quickest rapport with the patient leads the code. Theoretically, CPI teaches you the safest way for staff to de-escalate the situation and lay hands on the patient, if needed. If needed, usually the bed side nurse or house supervisor pages the MD for an IM or IV med to calm the patient down, if one isnt already ordered. Sometimes you can talk the patient into accepting the med without hands on. Sometimes, we have to lay many hands on the patient to administer the med. We have a protocol that if the patient is in "acute psychic distress" or an imminent physical threat to themselves or others, they can get the IM/IV, even if they do not consent. That's when lots of people around comes in handy.

Sometimes patients will just calm right down and back off when they see the entire calvary show up; being outnumbered will settle quite a few people very quickly. Others need a new face to vent their frustration or complaint to, like the supervisor, and just having their voice heard by a higher up, will calm them down. And a very few will just pop their top and get physical. Those get the antipsychotics or benzos injected.

The Code Atlas is great for those situations when you don't have much man power on your floor and you need back up fast. If you are interested in more details on how we do it, you can PM me and I can discuss our specific policies with you.

Good luck on your safety initiative!

Medic_Murse, BSN, RN, EMT-P · May 15, 2018

I would raise these issues up with your manager and straight up the chain. Trust me, I know what goes on with some of the unruliest of patients (psych or not). When I worked night shift, there would be calls overhead declaring a combative patient where we knew there was only two nurses. Myself, the nursing coordinator (who was a former deputy), and another employee (who we'll just say is B.A.D. "Big Ass Dude"), would run up there. We'd strip badges, glasses, pens, and whatever we had on us, throw them on the nurses station (as we would run into the room), and just tackle the patient. Now, before I get the boo's for being too aggressive. These were patients we were familiar with and knew were physically violent. For the verbally abusive patients, yeah, we responded just the same but once the situation was assessed, we eased back and calmly talked the patient down.