Tag team elopement

[statcoffee]

I work on a bit of Hellish unit. 10 bed holding area, patient acuity levels vary greatly, and also do a massive amount of admissions/discharges/transfers. This past week I ended up with two patients (out of 5) on watch. A 2 to 1 by psych for unpredictable behavior, and the other a psych 1 to 1 with PNA and a raging Heroin addiction who was also actively withdrawing. The 2 to 1 had been on the unit for several days and had been well behaved, directable and while he made the other staff and patients nervous we had a good relationship. The 1 to 1 on the other was a new admit, very nervous, diaphoretic, yawning, etc - withdrawing. The morning was unremarkable, however the 1 to 1 had become increasingly agitated and wanted his cell phone to call his family. I got his property from property office and gave it to the CNA doing the watch telling him he was allowed to have his phone but do not give him his clothing. The rooms do not have lockers, and there are no secure areas on the unit to lock up a patients property unless we put it under the desk but honestly I don't like doing that in case something were to go missing.

Right about dinner time, the 2 to 1 goes off the handle, screaming about how he demands to be discharged and takes off into the hallway (this unit has no prosec system or doors which lock) we try talking him down and reasoning with him for about 45 minutes, his doctor shows up during this time, he threatens his doctor and myself with serious bodily harm, I get in between the two of them to try and talking him down. When it finally seems to reach a lull, out of nowhere I see the 1 to 1 patient sprint from his room into the hallway and jets off to the elevator. It was almost like he could see his opening to flee due to the chaos being caused on the unit by the other patient. The CNA followed him but due to the fact that he was 6ft tall 200+lbs and desperate - she did not get on the elevator with him. Smart move on her part, because if she did catch him, she could have put herself in serious physical harm. I could not take off after him, due to my current patient's excited state and my concern for his safety as well as the other patient's on the unit (this guy was 6'5" and in excess of 250lbs). So I immediately called Hospital police, the primary team, my supervisor and filled out an incident report. The patient who eloped , had done so with his medlock intact (at least I assume so, seeing as I did not take it out personally). So 911 was also called. Unfortunately the patient was not found, and I was just made aware that there was going to be a root cause analysis performed and the staff questioned individually to determine what and why this happened, and if this is sentinel event worthy. If you have read this far, I thank you. Here are my questions:

- The CNA at no point alarmed me or the other nurse that the patient was dressing. I feel if I had at least been made aware of this, I could have removed the patient's medlock and called hospital police. To what degree would you say I am at fault?

- Are nurses allowed to hold a patient's property from them if the patient is AOx3 and alert? I thought giving him his phone would help calm him down and provide comfort so he could speak to his family. I did not think the CNA would have allowed him to get his clothes.

- Has anyone else had a situation like this occur and how did you handle it?

Thank you for any input. I understand that this really isn't in anyone's control as addiction in such a horrible disease and the unit itself has nearly no way to keep a patient from eloping if they chose to do so. Honestly, I am distraught over this and very worried that I could be terminated as a result.

[Hoosier_RN, MSN]

It may vary by your state; to my best knowledge, though, you cannot hold a patient or their belongings against their will if they are not there under court order. To do so is against the law (diversion and kidnapping). The CNA may not have realized the patient was dressing either. You should have given her only the phone if that was all that you wished the patient to have access to, and allowed the situation to play out from there. I had a patient on med surg years ago with a pain pump. He wanted to go smoke. I told him I had to disconnect pump. He said no, and waited until my attention was elsewhere. He then snuck out, pump off of the pole and under his shirt. He didn't realize, or care, that that this was theft of a narcotic. The police caught him walking down the street. He was arrested, pump returned, and he got to be in pain in his cell.

[Nurse SMS, MSN, RN]

Maybe it is different everywhere, but when we had a patient under 1:1 for potential harm of self and/or others, we WERE allowed to hold all belongings and we definitely never let them have their cell or anything else.

[statcoffee]

He was on observation for lack of insight, nothing about self harm or violence. I would have surely not given the CNA any of his belongings if that were the case. He was AOx3, alert and even stated multiple times he would stay for length of treatment. Seems he just wanted to feed his habit more than he wanted to be cared for I suppose. Going forward, I decided I will halt any admit on observation with possibility of elopement and try to redirect the patient to a floor with secure patient lockers and a functioning prosec system.

[Altra, BSN, RN]

Several things stand out to me about this scenario.

1. Have you all had some type of non-violent crisis intervention training, such as CPI? Reading of staff running after patients, getting in between patient and other staff ... I'm not seeing evidence of appropriate training.

2. If there is some procedure to remove patient belongings ... there is some procedure with criteria for returning them.

3. Speaking of procedures -- what was the admitting dx that required an ambulatory patient at high risk of flight to have a peripheral IV?

I'm glad to hear that there will be a (hopefully thorough) root cause analysis of this event -- there is much to improve.

[statcoffee]

1. We have not been given any orientation specifically. Generally, it's call the hospital police, or get the doctor to order restraints. HP usually does nothing, and the staff must be put in harms way to point restraint someone.

2. Belongings were ticketed in admitting but when the patients come to our unit we usually receive their belongings so they may transfer with their property. Due to the design of the unit there are no lockers or areas where personal items can be safely secured unless we put them under our desk by our feet. I am highly uncomfortable with this as belongings are constantly being left on the unit long after patients are transferred or discharged. I gave the patient the phone because I foolishly thought it would help calm him down. I realize now he was testing the waters. When I gave the CNA the patient's property and told them not to give him his clothes, I also realize this was a horrible mistake.

3. He had PNA and COPD exacerbation. Sat's were in the 80's, RR into the 40's, Tachy. He was getting IV abx. I was going to d/c the IV after his meds were done but I didn't get the chance as my other patient started up.

The unit is unfortunately just not physically set up for patients like this. The lack of prosec devices or lockable passage ways and easy access to multiple exits is just a formula for disaster.

Thank you for responding.

[amoLucia]

What is prosec??? A security system?

I know prosec as the 'little purple pill'.

[amoLucia]

What is prosec??? A security system?

I know prosec as the 'little purple pill'.

Little late but I just realized something & I stand corrected. Prilosec is the 'little purple pill'.

[paroxetina]

What is prosec??? A security system?

I know prosec as the 'little purple pill'.

I believe prosec refers to the little black (usually) boxes that you hold your ID up to in order to unlock the door. Correct me if I'm wrong.

As you've already realized, the little purple pill is Prilosec.

[hppygr8ful, ASN, RN, EMT-I]

My only question is if you Heroine Detox patient was on an appropriate medication protocol to address his symptoms? The COWS protocol when properly applied keeps the Opiate detox patient pretty comfortable and compliant. It sounds like your patient was in a room just "sweating it out" which is not appropriate. No wonder he skipped.

HPPY