Got some attitude from the NOC shift last night...

[fiatslug]

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So on call last night, while I'm in the ER and have been for about 6 hrs, I get a call from the unit about a grossly disorganized, delusional, psychotic, abruptly confrontational female pt in flagrant mania who is refusing meds, running around the unit and being disruptive. They'd already had to call security on her for pocketing the med she would take (Li+). I'd seen her earlier in the day, and wasn't surprised--really textbook mania, zero insight. The nursing staff wanted a "now" order, so I wrote for olanzapine (zydis) 5 mg po and told the nurse to tell the patient she could either take it orally or IM. Get a call a few minutes later, she's refused po and escalating, so I wrote for 10 mg olanzapine IM now. It's change of shift at this point, and they're waiting for pharmacy to deliver the IM shot. When the new shift comes on, the charge nurse informs me that she won't give the IM, since we haven't tried seclusion and other means less along the "denial of rights" line (this is a newish pt, and has not yet been Riesed--CA law for court order to give psych meds against pt's will). She also said since the pt was not threatening herself or others at that point, she wouldn't give the IM med--"I don't want to get sued."

Now, I've been in this situation multiple times before on the unit, and have NEVER gotten this kind of refusal from nursing staff (in fact, they usually want to snow someone long before I'm ready to). I was actually kind of shocked, and told her I'd never had someone refuse to give an IM med in this situation before. She held her ground and continued to refuse. I didn't want to get into a pissing battle with her; I called my attending and left a message about it. I KNEW things would escalate with the patient--surprise, "time outs" don't work with floridly psychotic manic pts!--and sure enough, 2 hrs later, at 2 am, I get a call from the nurse who refused to give her the shot earlier saying the patient became hostile and combative, and they gave her the IM shot and put her in the seclusion room. To which I responded, "and now I have to come in because you wouldn't give her the shot I ordered 2 hrs ago?" Fortunately she was at least cool enough not to lock the seclusion room door, so I didn't have to come in and write a note.

What pisses me off most about the whole situation is that I think it's irresponsible to let a disruptive, agressive manic patient progress to an agitated hostile psychosis--not just irresponsible to the milieu of the unit (and patient/staff safety), but it's poor care for the patient: the worse the mania gets, the harder it is to break. In my mind, she was suffering, and needed treatment, and we delayed it because a nurse was more concerned with covering her own butt. But maybe I'm wrong and she's right--we didn't have a Riese, she hadn't escalated in her agitation to DTS/DTO status, though that was inevitable. Colleagues, what do you think?

 

[Psyclops]

I think you got screwed by a well intentioned protocol. I've seen this situation transpire many times. My experience is congruent with your's, nursing staff usually wants to put the patient down before the MD does. I also think that rules ad regs can get in the way of patient, staff, & other patient safety, this case is a prime example. You, as the expert with good intentions, knew what would happen given enough time for the patioent to escalate. Nevertheless, I think the Riese as you call it in CA, is set up to avoid gross abuses by medical staff against difficult "mentally disturbed" patients. This is likely left over from days when the abuses were more common.

I will say when I started working in inpatient MH about 5 years ago (PA the state), we were allowed to essentially provoke the patient into assaultiveness, and then restrain (manually, mechanically, or chemically). Oposition was grounds to put hands on. Much of this has changed, and for the most part I htink it is for the best. It can be frustrating when you know what the unltimate result will be, and dangerous stuff has to happen before you can help the patient. It's a trade off I guess.

 

[Anasazi23]

So on call last night, while I'm in the ER and have been for about 6 hrs, I get a call from the unit about a grossly disorganized, delusional, psychotic, abruptly confrontational female pt in flagrant mania who is refusing meds, running around the unit and being disruptive. They'd already had to call security on her for pocketing the med she would take (Li+). I'd seen her earlier in the day, and wasn't surprised--really textbook mania, zero insight. The nursing staff wanted a "now" order, so I wrote for olanzapine (zydis) 5 mg po and told the nurse to tell the patient she could either take it orally or IM. Get a call a few minutes later, she's refused po and escalating, so I wrote for 10 mg olanzapine IM now. It's change of shift at this point, and they're waiting for pharmacy to deliver the IM shot. When the new shift comes on, the charge nurse informs me that she won't give the IM, since we haven't tried seclusion and other means less along the "denial of rights" line (this is a newish pt, and has not yet been Riesed--CA law for court order to give psych meds against pt's will). She also said since the pt was not threatening herself or others at that point, she wouldn't give the IM med--"I don't want to get sued."

Now, I've been in this situation multiple times before on the unit, and have NEVER gotten this kind of refusal from nursing staff (in fact, they usually want to snow someone long before I'm ready to). I was actually kind of shocked, and told her I'd never had someone refuse to give an IM med in this situation before. She held her ground and continued to refuse. I didn't want to get into a pissing battle with her; I called my attending and left a message about it. I KNEW things would escalate with the patient--surprise, "time outs" don't work with floridly psychotic manic pts!--and sure enough, 2 hrs later, at 2 am, I get a call from the nurse who refused to give her the shot earlier saying the patient became hostile and combative, and they gave her the IM shot and put her in the seclusion room. To which I responded, "and now I have to come in because you wouldn't give her the shot I ordered 2 hrs ago?" Fortunately she was at least cool enough not to lock the seculsion room door, so I didn't have to come in and write a note.

What pisses me off most about the whole situation is that I think it's irresponsible to let a disruptive, agressive manic patient progress to an agitated hostile psychosis--not just irresponsible to the milieu of the unit (and patient/staff safety), but it's poor care for the patient: the worse the mania gets, the harder it is to break. In my mind, she was suffering, and needed treatment, and we delayed it because a nurse was more concerned with covering her own butt. But maybe I'm wrong and she's right--we didn't have a Riese, she hadn't escalated in her agitation to DTS/DTO status, though that was inevitable. Colleagues, what do you think?

Two words:

Nursing - Supervisor

Next time, watch how quick they get the IM out.

 

[Solideliquid]

As a side, I see you used Olanzapine, in the same situation would ziprasidone or risperidone (Maybe M-Tab although we don't have that as formulary) been a faster acting/break the psychosis/calm the patient faster agent?

Just wondering because my attending was going over why we shouldn't use olanzapine in overweight individuals yesterday morning.

And I totally agree with you assessment and actions. We should start our very own nurse stories thread. I filled out a discharge sheet for the first time and I must have asked the nurse three times if she wanted me to put anything else on it. THen she calls me back 30 minutes later to come back and write four words on it.

 

[fiatslug]

Two words:

Nursing - Supervisor

Next time, watch how quick they get the IM out.

Tempting, indeed... but as someone who has a year's worth of calls between now and mid September, I hesitate to piss off someone who could make the hours of midnight to 8 am very miserable for me! I am going to pursue this with the attending, however.

 

[fiatslug]

Just wondering because my attending was going over why we shouldn't use olanzapine in overweight individuals yesterday morning.

You won't find less of a fan of olanzapine for long term use than me! (In fact, if I were at a Big Research Place, here's my dream study: 5 years, five arms: Zyprexa alone, Zyprexa + Metformin, Zyprexa + Lipitor, Zyprexa + Metformin + Lipitor, and Zyprexa + diet/exercise support. Outcome measures: lipid profile, weight gain, onset of DM. It would have to have a gigantic N, to counter dropout... it's a pipe dream!).

But in an acute situation, I'm not worried about long-term metabolic effects. I'm generally partial to the old "5250" in emergencies: 5mg haldol, 2mg ativan, 50mg benadryl (in CA, 5250 is also the name of our 14-day hold 😉 ). But we've also had good luck with the Zyprexa IM, and the primary team already had this pt on Zyprexa. IM Geodon--our ER loves it (Geodon has been very effective at marketing itself to ERs for emergency tx of agitation), but we don't use it much on the inpatient unit.

 

[Poety]

I think the nurse is right for CHOA (covering her own ass), as a former psych nurse myself, I woulda done the same without the proper protocols already instituted. Unfortunately, the reality is that when it comes to psych, nurses are often time pinned in a lawsuit right along with the physicians - its psych nursing 101, CYA with these patients.

I wouldn't fault her for her decision, but it would suck to have to go back in to sign the SRO at a later time. Psych is a lot more complicated than regular medicine too.

I don't think starting a nurse bashing thread is the best idea - ever, you would seriously have to walk a day in their shoes to have an inkling about what they go through.

 

[50960]

Welcome to Ca!! How is it that nursing staff can refuse an order?? I am in favor of the new olanzapine tranq darts......... 😉

 

[MBK2003]

I am in favor of the new olanzapine tranq darts......... 😉

Personally, I'm supporting the development of Olanzapine mist - you just spray it into the room (or the whole psych ER) and pts' mania and psychosis resolve within minutes.

MBK2003

 

[Milo]

Fortunately she was at least cool enough not to lock the seclusion room door

This isn't seclusion in Ca?

In my state if the patient has the perception that they cannot leave a geographic area it is seclusion. It doesn't matter if it's a lock or just a burly psych tech with a menacing look posted at the door.

I also find it interesting that seclusion is considered less restrictive than medication. The medication you were proposing is certainly not a chemical restraint, like a 5250 (or the occasional 52100 I've seen).

Maybe I've got it bass ackwards but it seems to me that the loss of a constitutional right (liberty in the case of seclusion) is more restrictive than a one time, non-depot involuntary therapeutic intervention.

 

[Hurricane]

This isn't seclusion in Ca?

In my state if the patient has the perception that they cannot leave a geographic area it is seclusion. It doesn't matter if it's a lock or just a burly psych tech with a menacing look posted at the door.

I also find it interesting that seclusion is considered less restrictive than medication. The medication you were proposing is certainly not a chemical restraint, like a 5250 (or the occasional 52100 I've seen).

Maybe I've got it bass ackwards but it seems to me that the loss of a constitutional right (liberty in the case of seclusion) is more restrictive than a one time, non-depot involuntary therapeutic intervention.

Same thing here. We're not allowed to put anyone in seculsion unless they've "failed" medication, meaning we have to document that they've been given meds before or at the same time they were put in seclusion. But this is in the ER - maybe it's different on the floor?

 

[50960]

I have ordered restraint procedures many times, but putting someone in a locked room here is "no-no". No meds against their will unless they are conserved and the legal conservator agrees to a standing prn order. Soft-ties, four-points etc are allowed on an emergency basis with a written order (MD, PhD). VO's must be signed in 1 hr.

 

[Anasazi23]

The standard of care now is to use what the patient actually wants in terms of their psychiatric advanced directive.

It's not that uncommon for patients to ask for seclusion over medication, and even prefer restraint over seclusion. Usually the latter patient has an ego-dystonic history of violence.

As always, you can do pretty much whatever you need to and what is right for the patient, with proper documentation.