Psych patients and personal belongings

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
I

Interpolfanclub

Full Member
15+ Year Member
Joined
Apr 11, 2006
Messages
189
Reaction score
109
All,

My facility has a policy that all patients in the ER on a psych hold must be in paper scrubs and relinquish all personal items. This sounds fine but in reality it leads to situations where ED staff are physically trying to take things away from psych patients and make them get into scrubs. The patients resist, often with violence.

I will sometimes allow patients to remain in street clothes and keep personal items in an attempt to defuse difficult or violent situations. This has been met with resistance by nursing staff who feel that we shouldn't make exceptions and that it gives people a chance to retain things they can use to harm us or them, which is certainly true. We do still have security search and wand these patients.

It would be great if everyone willingly got in scrubs and gave us their bags but they do not and I'm not sure how aggressive I need to be in making them comply. Do we call the police? Sedate them and restrain them? I feel like trying to make all psych patients get in scrubs and hand over their belongings at all costs is going to lead to injuries of patients and staff. What are your EDs doing in this situation? Advice appreciated.
Members don't see this ad.
 
I worked at place that did this. Generally I thought it was overkill as did most staff. I didn’t care unless the patient had SI or HI or was clearly psychotic. We’d just explain there was no option on not wearing the gown until they were cleared from a mental health perspective. When a patient resisted putting on a gown I found having 2 staff (RNs or techs) of the same gender coax the patient into it almost always worked as long as they were out of eyeshot of other gawkers. Sounds obvious but the more staff you have watching the discussion go down the more uncomfortable the patient gets and the larger an audience you give them to do something dramatic and stupid. It also frees you up to do doctor things. And if the patient gets combative over it there’s a good chance something else would have set them off anyway and you would have had to sedate/restrain regardless.


Sent from my iPhone using SDN mobile
 
Members don't see this ad :)
When I was an intern and early 2nd year I would sometimes try to negotiate/de-escalate a little bit. I've since stopped and just let the nurses do their thing. There's just too much institutional momentum, and I would not want to be the person responsible for someone getting shanked, anyway. As the volume of patients I see in a shift increases, its just not worth it to try and negotiate and place the other staff in a potentially dangerous situation. One exception is sometimes they put these old folks with hyperactive delirium in the drugs/alcohol area and try to make them nekkid, I'll tell them to stop and that its a "medical patient" in those cases, or if one of our FF alcoholics comes in clinically sober with an actual medical complaint like a sprained ankle.

If someone won't change/give up their stuff, and the nurses ask me to come over, its a quick conversation -
"the rules are you have to change and give up your stuff - if you do this i'll ask behavioral to come see you right away, and you can have cookies and ginger ale and get up to use the phone and bathroom. otherwise security is going to hold you down while we inject you with medicine to make you sleepy, you'l be tied to the gurney, and you wont be seen by behavioral for 8 hours. its up to you, ill be back in 5 minutes"
 
I agree with the OP that most of the time this is overkill and certainly not worth antagonizing the patient about. I think if the patient is severely psychotic/violent or truly and actively suicidal then they need to be disrobed for their and our safety. In this case a show of force followed by restraint is appropriate. If they are cooperative, maybe an oral sedative followed by a short trial of benign neglect (with security in the room watching them) may be appropriate.

If the patient is malingering (i.e. Suicidiality with a side of sandwichopenia) or just a chronic psyche case who showed up for unclear reasons, then I don't think it's worth escalating about.
 
One thing to consider is that often patients on psych holds have a statutory right to be in their own clothes.

California's statute:

5325.
Each person involuntarily detained for evaluation or treatment under provisions of this part, and each person admitted as a voluntary patient for psychiatric evaluation or treatment to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered, shall have the following rights...
(a) To wear his or her own clothes; to keep and use his or her own personal possessions including his or her toilet articles; and to keep and be allowed to spend a reasonable sum of his or her own money for canteen expenses and small purchases.

Codes Display Text.

Florida's statute:

(6) CARE AND CUSTODY OF PERSONAL EFFECTS OF PATIENTS.—A patient’s right to the possession of his or her clothing and personal effects shall be respected. The facility may take temporary custody of such effects when required for medical and safety reasons.
Statutes & Constitution :View Statutes : Online Sunshine

Personally, I think "department policy" and not an individualized reason would not stand up to the "as required for medical and safety reasons" exception.
 
Siggy said:
One thing to consider is that often patients on psych holds have a statutory right to be in their own clothes.

California's statute:

5325.
Each person involuntarily detained for evaluation or treatment under provisions of this part, and each person admitted as a voluntary patient for psychiatric evaluation or treatment to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered, shall have the following rights...
(a) To wear his or her own clothes; to keep and use his or her own personal possessions including his or her toilet articles; and to keep and be allowed to spend a reasonable sum of his or her own money for canteen expenses and small purchases.

Codes Display Text.

Florida's statute:

(6) CARE AND CUSTODY OF PERSONAL EFFECTS OF PATIENTS.—A patient’s right to the possession of his or her clothing and personal effects shall be respected. The facility may take temporary custody of such effects when required for medical and safety reasons.
Statutes & Constitution :View Statutes : Online Sunshine

Personally, I think "department policy" and not an individualized reason would not stand up to the "as required for medical and safety reasons" exception.
Click to expand...
I would say a pt brought in without knowledge of what’s in their possession and without knowledge of their future intent qualifies as required for medical and safety reasons. Have fun being stabbed because you’re misinterpreting a statute.
 
Arcan57 said:
I would say a pt brought in without knowledge of what’s in their possession and without knowledge of their future intent qualifies as required for medical and safety reasons. Have fun being stabbed because you’re misinterpreting a statute.
Click to expand...

Show me where I said you can't search them?
 
Siggy said:
Show me where I said you can't search them?
Click to expand...
Your post strongly implied that separating a patient from their belongings was illegal. If you can tell me how to perform an appropriate search of belongings without at least temporarily separation, I’m all ears. Otherwise, stop posting things that don’t apply to the ED and are frankly dangerous if taken at face value.
 
Arcan57 said:
Your post strongly implied that separating a patient from their belongings was illegal. If you can tell me how to perform an appropriate search of belongings without at least temporarily separation, I’m all ears. Otherwise, stop posting things that don’t apply to the ED and are frankly dangerous if taken at face value.
Click to expand...

1. There's a difference between "Gowns only, no exception for any patient on a hold" and "search the person."
2. I'm missing the legal carve out for the ED.
3. The "Patient is on a psych hold and has no legal rights to anything, including the right to refuse aspects of care, including the right to be in their own clothing" is pervasive throughout the health care system... and again legally wrong. If the patient is being combative, then sure, you can sedate them. However just because they are on a hold doesn't mean that they can be forced to take an antibiotic, as an example.
 
Siggy said:
1. There's a difference between "Gowns only, no exception for any patient on a hold" and "search the person."
2. I'm missing the legal carve out for the ED.
3. The "Patient is on a psych hold and has no legal rights to anything, including the right to refuse aspects of care, including the right to be in their own clothing" is pervasive throughout the health care system... and again legally wrong. If the patient is being combative, then sure, you can sedate them. However just because they are on a hold doesn't mean that they can be forced to take an antibiotic, as an example.
Click to expand...

We can force them do get blood draws, and other testing to rule out a "medical emergency" and for medical clearance. I'm not in favor of searching people, because we don't have law enforcement officers available to do this, and there is a potential for liability related to this. I am in favor of the "green gown" for everyone, and belongings locked away in a secure site.

Fortunately, I don't deal with any of this. It's all done by nursing staff, and none if it at my order, so if there's ever a violation of statute, it won't fall on me.
 
Members don't see this ad :)
Tenk said:
As someone who has had a very large knife pulled out on them in the ED while I was in the room with the patient, you may hate this policy until you realize in person why it exists.
Click to expand...

100% agreement, this is the way it has to be. I trained and work in a county hospital, It's happened to me, I've seen it happen to others, I take a pretty hard line with these psych players.
 
GeneralVeers said:
We can force them do get blood draws, and other testing to rule out a "medical emergency" and for medical clearance. I'm not in favor of searching people, because we don't have law enforcement officers available to do this, and there is a potential for liability related to this. I am in favor of the "green gown" for everyone, and belongings locked away in a secure site.

Fortunately, I don't deal with any of this. It's all done by nursing staff, and none if it at my order, so if there's ever a violation of statute, it won't fall on me.
Click to expand...

"Doctor Veers... you gave an order for sedation because a patient was invoking his rights, is that not correct?"
 
Small double coverage community ED. Wasn't my patient, but had a psych patient refuse to give up her clothes or bag while being screened. After screening in nursing found a pipe bomb in her bag, ready to be lit with the lighter in same bag she refused to let anyone take away from her or look into.
 
Siggy said:
"Doctor Veers... you gave an order for sedation because a patient was invoking his rights, is that not correct?"
Click to expand...

No, I ordered sedation because the patient's violent behavior was threatening injury to the staff and even the patient herself. Patient and staff safety are crucial in my opinion.

HH
 
Siggy said:
"Doctor Veers... you gave an order for sedation because a patient was invoking his rights, is that not correct?"
Click to expand...

Does invoking your rights involve laying hands or threatening staff? If so, I will happily sedate that patient. My answer will be "I sedated a violent patient who assaulted my staff and was an imminent threat to his/her own health and safety as well as that of others. Please see where I documented this here."

Severe reactions to common psych prns are uncommon, and good luck getting a jury to find in your favor after you attack someone (it's more likely to end in criminal charges against you once you turn it into a legal battle).

If it's saying calmly "i want my things back" then I am not getting involved. I usually hand back phones (biggest source of conflict in the non-psychotic) if you're not being an a*shole.

While it might be possible to pursue a physician in court for this, it's unlikely to offer much of a payout. Most institutions also have a policy regarding this, and the hospital has much deeper pockets.
 
dadaddadaBATMAN said:
Does invoking your rights involve laying hands or threatening staff? If so, I will happily sedate that patient. My answer will be "I sedated a violent patient who assaulted my staff and was an imminent threat to his/her own health and safety as well as that of others. Please see where I documented this here."
Click to expand...
Nope. I'm talking about the patient who is simply refusing to change into the hospital required gown.
While it might be possible to pursue a physician in court for this, it's unlikely to offer much of a payout. Most institutions also have a policy regarding this, and the hospital has much deeper pockets.
Click to expand...

Policy can't override statute though.
 
Siggy said:
Nope. I'm talking about the patient who is simply refusing to change into the hospital required gown. Policy can't override statute though.
Click to expand...

You're quoting a statute out of context. Further down the statute there is an entire paragraph that allows exceptions "for good cause."

Anyway the first sentence says the statute applies to "health facility as defined by section 1250." And in Sec 1250, the very first sentence defines "health facility" as a place that "admits for a 24 hr stay or longer." Thus it does not even apply to the ED.
 
Siggy said:
Nope. I'm talking about the patient who is simply refusing to change into the hospital required gown.


Policy can't override statute though.
Click to expand...
Misinterpreting statutes is dangerous. Your faulty interpretation puts the people who would listen to it in danger. Maybe you’re playing devil’s advocate and just trying to make people consider that arbitrarily confiscating in perpetuity a patient’s belongings simply because of they have a mental illness is wrong. That’s not the situation we’re describing. Society has decreed that we are required to assist the mentally ill when they are dealing with a medical or psychiatric emergency. Because this is not a perfect world and we don’t have infinite resources, in very select circumstances, they may need to give up certain freedoms until they have been stabilized and can safely exercise those freedoms. But you already know that...
 
Last edited:
I don't think I've seen anyone mention staff splitting and manipulation.
It very well may just be the population I work with, but once our patients know they can get an inch etc etc. I appreciate staff (be they docs, nurses, techs, whatever) who set expectations and hold patients to them because then everyone doesn't have to deal with "Oh but THAT doctor said this...THAT nurse let me do that..."

The other thing is that you don't know how that patient's presentation is going to evolve. They may calm down for the moment because you've let them keep their things and clothes, but a couple minutes from now, something else might trigger them and then good luck getting them under control then, because they already know you'll give in to what they want.
 
Dr.McNinja said:
It's hospital policy. That's fine. That's for security/PD to take care of. Not you. You don't remove the belongings from the patient.
Click to expand...

This.

In addition, I never really understood the stories of my former co-residents about being punched/kicked by these patients. Keep your distance, and under no circumstances should you be involved in physically restraining them - this is security's job, not your's.
 
I think we should do this for all patients, not just psych. That or mandatory metal detectors.
 
GonnaBeADoc2222 said:
This.

In addition, I never really understood the stories of my former co-residents about being punched/kicked by these patients. Keep your distance, and under no circumstances should you be involved in physically restraining them - this is security's job, not your's.
Click to expand...

What if you don't have security? Many EDs don't.
 
miacomet said:
What if you don't have security? Many EDs don't.
Click to expand...
Then you tell management it isn't your job. You see, if a patient gets injured from you restraining them? That isn't malpractice. It's assault. Your malpractice doesn't cover it.
You can tell management they are welcome to come up with a way to enforce their policies. Or you simply leave.
Anecdotally, I've never worked at any ER that didn't have some semblance of security. They don't all have police presence, and often "security" looks like they would lose any fight they got into while having a cardiac event at the same time, but they still have it.
 
Dr.McNinja said:
Then you tell management it isn't your job. You see, if a patient gets injured from you restraining them? That isn't malpractice. It's assault. Your malpractice doesn't cover it.
You can tell management they are welcome to come up with a way to enforce their policies. Or you simply leave.
Anecdotally, I've never worked at any ER that didn't have some semblance of security. They don't all have police presence, and often "security" looks like they would lose any fight they got into while having a cardiac event at the same time, but they still have it.
Click to expand...

Agreed. I've met so many docs who just love to be macho and intervene and take down patients. Not me. All psychs I keep my distance, at least 6 feet, and don't touch them unless there's a specific complaint I need to address. If they do anything aggressive, or try to leave, I step out of the way and call security/police. It's not our job to restrain or assault people, and certainly not worth my life or livelihood to do so.
 
Oh, we told them that. Now we have security at one site. We don't have security at the other. I do have a record of admin stating we can't afford security, which could prove...fruitful.
 
Last edited:
GonnaBeADoc2222 said:
This.

In addition, I never really understood the stories of my former co-residents about being punched/kicked by these patients. Keep your distance, and under no circumstances should you be involved in physically restraining them - this is security's job, not your's.
Click to expand...

I 100% agree. I’m an athletic guy and bigger/stronger than the vast majority of our security but my job is to be the patients’ doctor not a bouncer. I have no desire to wrestle violent patients. The only time I’m willing to pull double duty as security is when I or one of my staff is in danger and security hasn’t/can’t arrive yet. I would much rather diffuse the situation and move on to see the next patient though.


Sent from my iPhone using SDN mobile
 
Dr.McNinja said:
Then you tell management it isn't your job. You see, if a patient gets injured from you restraining them? That isn't malpractice. It's assault. Your malpractice doesn't cover it.
Click to expand...

I have considered that it is very dangerous for a physician to restrain a patient from a legal-liability point of view. An attorney could argue "you are not specifically trained and practiced in safe restraint technique" and should the patient be injured by your actions you are not covered by a policy or scope of duties.

This does raise the question what do you do if you need to restrain a patient (active SI trying to leave AMA) but you are at a facility with no security present and patient is actively b-lining for the door (too late to verbally de-escalate).
 
RoyBasch said:
I have considered that it is very dangerous for a physician to restrain a patient from a legal-liability point of view. An attorney could argue "you are not specifically trained and practiced in safe restraint technique" and should the patient be injured by your actions you are not covered by a policy or scope of duties.

This does raise the question what do you do if you need to restrain a patient (active SI trying to leave AMA) but you are at a facility with no security present and patient is actively b-lining for the door (too late to verbally de-escalate).
Click to expand...

You call the police.
 
RoyBasch said:
I have considered that it is very dangerous for a physician to restrain a patient from a legal-liability point of view. An attorney could argue "you are not specifically trained and practiced in safe restraint technique" and should the patient be injured by your actions you are not covered by a policy or scope of duties.

This does raise the question what do you do if you need to restrain a patient (active SI trying to leave AMA) but you are at a facility with no security present and patient is actively b-lining for the door (too late to verbally de-escalate).
Click to expand...

I don't believe putting myself in harm's way by getting into fisticuffs with a psych patient falls under my scope of practice.
 
Siggy said:
Policy can't override statute though.
Click to expand...

I'm willing to be certain that lawyers have looked into this type of thing: changing clothes vs statutory law saying you are allowed to be in your own clothes. Either lawyers routinely win these cases, or they are not picking these cases up because they can't win them. For whatever reason.
 
I agree with all ya'll who don't get involved with physical stuff.

I don't care if the patient has the most emergent of all emergencies....1) a knife sticking out of their neck, 2) a STEMI, 3) acute testicular torsion, 4) HR 160, BP 70/30, and 5) a dead right leg from a dissecting abdominal aorta...all at the same time!!!

If they threaten me, brandish any sort of weapon, or spitting on me, or in anyway going to harm me in anyway I'm off to the next patient. I ain't seeing them. I might order the 5-2-1 cocktail and once calm I'll fix them. What good are you to your family, your wife, your kids if you end up being a patient undergoing an exploratory laparotomy for a stab wound to the abdomen, then have to deal with ongoing recurrent adhesive disease, abdominal wall hernias, and you can't practice medicine anymore.
 
RoyBasch said:
This does raise the question what do you do if you need to restrain a patient (active SI trying to leave AMA) but you are at a facility with no security present and patient is actively b-lining for the door (too late to verbally de-escalate).
Click to expand...

I let this patient walk out as I call 911, then the magistrate (if I don't already have a court order for a hold), then I chart the above.

I do not physically stop patients from leaving.
 
thegenius said:
I agree with all ya'll who don't get involved with physical stuff.

I don't care if the patient has the most emergent of all emergencies....1) a knife sticking out of their neck, 2) a STEMI, 3) acute testicular torsion, 4) HR 160, BP 70/30, and 5) a dead right leg from a dissecting abdominal aorta...all at the same time!!!

If they threaten me, brandish any sort of weapon, or spitting on me, or in anyway going to harm me in anyway I'm off to the next patient. I ain't seeing them. I might order the 5-2-1 cocktail and once calm I'll fix them. What good are you to your family, your wife, your kids if you end up being a patient undergoing an exploratory laparotomy for a stab wound to the abdomen, then have to deal with ongoing recurrent adhesive disease, abdominal wall hernias, and you can't practice medicine anymore.
Click to expand...

What's the "1" in "5-2-1"?
 
WilcoWorld said:
That's funny, because it's probably safer than haldol, ativan and benadryl.
Click to expand...

Yup.

They freak out at the dose (5 mg/kg) because it ends up being a "big number." Also it's a logistical effort to put patient on cardiac monitor. Funny how the same effort can be managed when they wanna bring 8 patients back from the waiting room at once.
 
Thanks to everyone who replied. I think it's not worth the mental effort, disagreement with nursing or potential for a bad outcome by making exceptions to the "scrubs and no belongings" rule.

I find the psych patients to be some of the most mentally exhausting patients we see. Also some of the most dangerous from a personal safety standpoint. Good points make in the thread, tx.
 
We don't have a paper scrub policy per say but just utilize a lot of common sense. If they are SI or HI, we remove belongings and they obviously have a 1-1 sitter. If they are violent or hyper aggressive, you just have to get used to chemical/physical restraints early in the game. A lot of these people can be talked away from the ledge. On the other hand, I'm not hesitant to hyper aggressively control these patients when the sh** hits the fan. They can suck up enormous resources in your dept and endanger the rest of the pt's that you are treating. I had one pt try to strangle my nurse with oxygen tubing and when I went in there he was trying to hang himself with bedsheets. Half my ER staff were standing around the room on a busy night with sick sick patients. He got intubated, sedated and I extubated him later on in my shift at which point he was much more compliant and then got dispositioned by psych. Those situations are rare, but they happen on occasions.
 
Interpolfanclub said:
All,

My facility has a policy that all patients in the ER on a psych hold must be in paper scrubs and relinquish all personal items. This sounds fine but in reality it leads to situations where ED staff are physically trying to take things away from psych patients and make them get into scrubs. The patients resist, often with violence.

I will sometimes allow patients to remain in street clothes and keep personal items in an attempt to defuse difficult or violent situations. This has been met with resistance by nursing staff who feel that we shouldn't make exceptions and that it gives people a chance to retain things they can use to harm us or them, which is certainly true. We do still have security search and wand these patients.

It would be great if everyone willingly got in scrubs and gave us their bags but they do not and I'm not sure how aggressive I need to be in making them comply. Do we call the police? Sedate them and restrain them? I feel like trying to make all psych patients get in scrubs and hand over their belongings at all costs is going to lead to injuries of patients and staff. What are your EDs doing in this situation? Advice appreciated.
Click to expand...
If you're sick enough to be in the ED, because you might possibly kill yourself and others, you're sick enough to change into paper scrubs so we can rest easy you won't kill yourself and/or others with what might be in your pocket. If you're not that sick, you're well enough to be discharged in whatever clothes you want to wear, so you can call your PCP for a referral to an outpatient mental health provider. But you can't have it both ways.
 
You must log in or register to reply here.

Similar threads

Angry Birds
I like treat and street patients
2 3
Replies
131
Views
8K
Mount Asclepius
Mount Asclepius
KGflyboy
Anybody else's Hospitalists not admitting patients anymore?
2 3
Replies
106
Views
6K
Splenda88
S
N
Psychiatry patients and solutions
Replies
20
Views
2K
thegenius
thegenius
Angry Birds
How can we protect our patients against ICE?
2 3
Replies
119
Views
5K
Old_Mil
Old_Mil
H
Patients per Hour
2
Replies
50
Views
5K
LChristmas
LChristmas
Top