Purpose: To establish staff guidelines for the management of patients in need of a psychiatric assessment that will help ensure the safety of patients and staff in the Emergency Department.
1. Triage of patients with psychiatric complaints will be done expeditiously.
Patients with suicidal or homicidal thoughts; those involved in violent altercations before coming to the ED, those who verbalize threats, or those who are psychotic will be classed as TRIAGE CAT I and placed immediately and have a sitter assigned. At no time during the handoff between triage staff or ambulance staff to primary staff will the patient be left alone. At least two staff members, preferably one a security guard and one ED staff member, will disrobe patient. (All Peds patients who meet these criteria will be assigned to the Main Room.)
Patient with psychiatric complaints and who are not suicidal or homicidal may be classified as TRIAGE CAT II but need frequent re-evaluation every 60 minutes and should remain in sight line of staff. (Pediatric patients who meet these criteria will be evaluated for safety in Pediatric ED and, if necessary, transferred to the Main Room through the coordinator.) Preferred placement of these patients is in room 10 or 11 in the Main Room.
2. All patients presenting for a psychiatric assessment will be totally undressed upon room placement, and clothes and personal belongings will be secured in department lockers.
Any psych patient or those with alcohol or substance abuse, those brought involuntarily by family or police, or those expressing suicidal ideation or homicidal thoughts will have security present to assist with disrobing and placing patient in a gown.
All patients’ belongings will be searched by security for weapons. All medications will be secured and removed. If patient is admitted and meds are unable to be sent home, forward to pharmacy at the time of admission.
3. Preferred location for those needing a patient safety evaluation is Room 10 and 11 in the Main Room. If those rooms are unavailable, the coordinator will assign another appropriate room with immediate "sitter" observation. Procedures for disrobing and evaluation will occur quickly. This assessment and evaluation is not dependent on room assignment.
All belongings will be bagged, labeled, and removed to department lockers where patient/family is not allowed easy access. Never give clothes to family prior to completing evaluation. Security staff will secure any weapons found. Patient’s belongings will be transferred with them upon admission or returned upon discharge. CONSIDER SECLUSION for those patients who were involved in significant violent events prior to coming to the ED or who exhibit threatening behavior or language.
4. An assessment for safety and cooperation needs to occur within the first 15-30 minutes the patient is in the room. It is preferred that psych liaison staff participate in this assessment with the RN or MD. If they are not immediately available for this assessment, they will evaluate the patient and communicate with the primary RN within 45-60 minutes.
- Is the patient directable?
- Does the patient appear agitated or irritable?
- Is the patient’s physical stance threatening?
- Is behavioral decontrol evident?
- Is the patient making threatening remarks?
- Was the patient acting erratically before coming to the Emergency Department?
- Is the patient an elopement risk?
5. Medical evaluation of the patient needs to occur within the first 30-45 minutes the patient is in the department.
- Complete vital signs.
- Complete medical and psych history.
- Lab evaluation according to the following protocol: Upon arrival of patients needing a mental health evaluation in the Emergency Department, the following panel of tests will be done:
- complete blood count;
- comprehensive metabolic panel;
- urine drug screen;
- point-of-care pregnancy tests on all childbearing age woman.
The Emergency Department physician or mental health liaison staff may request the following tests upon further evaluation:
- electrocardiogram if patient is currently using cocaine or history of heart disease;
- blood alcohol level if patient is under the influence of alcohol;
- computed tomography scan of the head in patients with altered mental status, in all age groups, or new onset psychotic/agitated behavior in older adults;
- acetaminophen/salicylate levels if suspicion of overdose;
- medication levels such as Depakote, Tegretol, lithium, etc.;
- urinalysis in elderly or if patient is symptomatic.
- neuro exam;
- pain assessment;
- physical exam;
- determination of capacity, which may be done only by a physician.
6. A psychological assessment will be conducted ASAP by the psych liaison staff to determine continued safety and disposition. Need for a sitter or restraints may change based on this assessment. Goal is to have assessment under way within 45-60 minutes of patient’s arrival in ED.
Assessment will include but not be limited to:
- appearance;
- level of consciousness;
- emotional state;
- speech;
- memory (recent/remote);
- orientation;
- reality testing;
- judgment and insight.
7. Based on the evaluation, and consultation with the Emergency Department physician, patient may require sitter, seclusion, and/or medication or physical restraints to maintain patient and staff safety. Seclusion and restraints will be carried out in keeping with the hospital administrative policy on restraints.
8. Any patient deemed to be at risk for violence, elopement, or suicide requires continuous observation while in the Emergency Department.
- Only staff trained in observation will be assigned this role.
- Observation assistants (OAs) sent from nursing service.
- ED transporters with OA class;
- ED techs with Crisis Prevention Institute training (CPI);
- NO FAMILY MEMBERS may be used as sitters.
9. Continuous observation responsibilities are as follows (continuous observation may be done in person or via video/auditory monitoring):
- ultimately responsible for patient and observer;
- RN responsible for introducing observer to patient; informing observer of patients plan of care and rationale for 1:1;
- assess the need for intervention and checks in with observer each hour;
- checks that the observer has adequate meals and breaks;
- documents according to administrative policy.
10. Key role and responsibilities for observers/sitters:
- Their ONLY responsibility is observation of the patient and documentation of assessments, in person or via monitors. (They cannot read a book or newspaper, speak on the telephone, etc. The patients in the ED still are being diagnosed and are not deemed stabilized.)
- Sitters need to identify and maintain open communication with respective primary RN.
- They immediately notify ED staff for assistance, by voice or use of alarm.
- They are not expected to intervene physically in a crisis situation unless CPI-trained.
- They can observe both monitor screens simultaneously.
- They can directly observe up to two patients requiring safety precautions.
- They cannot leave the patient or monitored area without replacement.
- They know the patient’s plan of care.
- They know how to obtain help.
- They inform RN of behavior changes.
- They notify RN before moving patient from the room.
- They identify alternate contact, i.e., coordinator.
- Observers are responsible for documentation every 15 minutes, according to policy.
11. Staff safety needs to be maintained.
NO staff entering seclusion rooms should have objects that could be used to hurt them, i.e., scissors, hemostats, etc. Staff need to secure stethoscopes, pens. etc., and take as little as possible into the room. When the patient has exhibited violence toward the staff, security or police also should be present when staff members enter the room.
Reportable Cases
Northwest Community Hospital has zero tolerance for abuse, or threats of abuse, against any employee. All abuse or threats of abuse need to be documented in patient’s record and via occurrence reports.
If patients injure employees, they have the right to notify the police and press charges. Employees need to complete form for work-related injury.
If a patient injures another patient, Security and Risk Management will follow up as necessary with authorities.
Source: Northwest Community Hospital, Arlington Heights, IL.
Purpose: To establish staff guidelines for the management of patients in need of a psychiatric assessment that will help ensure the safety of patients and staff in the Emergency Department.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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