>>How do you restrain the patient who wants to go - what physical means
do you use, and how many staff does it involve.

Depends how badly they want to leave.  Sometimes the fact that someone
stands in the way is enough.  If, after a member of staff has explained
why they are not allowed to leave they try to and use physical force to
do so, we restrain them with an equal (well, a little bit more) and
opposite force a la Newton.  This would initially be done by our own
staff but we are fairly proactive about getting security in, in advance
(often their burly presence alone is helpful).  There are usually two
security people but if we need more I have seen four of them or a mix of
security/police/staff.  It is often helpful, and the patient is often
willing, to have a dose of an oral benzo like Diazepam 10mg which can
help take the edge off some of the agitation and perhaps clear a little
of the thought processes.

How long will you then keep the patient "held down" and what is your
end-point?

Once a patient is 'down' then we would try reasoning with them again.
Again, I try to give them the benefit of the doubt, and most don't want
to go through the physical restraint again.  Having shown them we are
willing to, and have the ability to restrain them they often don't try
again.  Even the psychotic have some ability to think through an issue
and realise when they are beaten.  In circumstances where someone is so
psychotic that they continually try to escape and run the risk of
becoming more distressed or physically injured by our attempts to
restrain them I would then consider some form of sedation...personally
I'm a Lorazepam/Haloperidol man myself.  Often this will be taken
willingly, again they do have some insight to their distress/illness at
times but if necessary it is given against their will.

Does anyone use handcuffs?

Not at work, no.

Simon


> -----Original Message-----
> From:	McCormick Simon Dr, Consultant, A&E
> [SMTP:[log in to unmask]]
> Sent:	17 August 2006 12:48
> To:	[log in to unmask]
> Subject:	Re: Psychiatric patients leaving the emergency
department
> 
> Locally we use our security to stop the clearly psychotic, or the
police
> if necessary.   I think this is perfectly reasonable under common law
as
> the psychotic patient by definition has no insight to their problem
and
> will therefore be incompetent.   Those who leave before assessment and
> there are concerns about we ask the police to find and return, if
> possible.   Not sure what else you are supposed to have done.
>  
> Those who are strictly neurotic but in danger of self harm are much
more
> difficult and a topic in themselves.   I don't subscribe to the
blanket
> 'wanting to self harm means you are incompetent' school of thought but

> I think they often have altered thought processes which do mean
holding them
> against their will under common law is defendable.   Again, it also
comes
> down to a judgement call of how likely you feel they are to harm
> themselves (or others).   That sort of call is difficult to make as a
> psychiatrist as we see in tragic cases in the media, but as a an ED
> consultant we make these decisions on a fairly irregular basis.   As
for
> your average F2 SHO, what chance have they got!
>  
> Simon
>  
> P.S.   Interestingly, I suspect like many of you our Mental Health
Crisis
> team is usually very good with most of these patients and they are of
> course...nurses with extended training!   they do, of course, have to
ask
> for back up on occasion but manage mostly on their own.
>   _____
> 
> From: JULIAN HUMPHREY [mailto:[log in to unmask]]
> Sent: 17 August 2006 11:19
> To: [log in to unmask]
> Subject: Psychiatric patients leaving the emergency department
> 
> 
> Can I give the list a new topic to consider.
>  
> At an inquest earlier this week our emergency department was 
> criticised by HM Coroner for not having a policy to deal with patients

> deemed to be at risk from mental health problems, who decide to leave 
> the department. He ordered us to formulate a policy and write to him 
> to tell him and the family concerned what we have done.
>  
> The case revolved around a woman who presented to the department with 
> symptoms of acute psychosis, who did not express any suicidal
ideation.
> She was seen and assessed by an SHO and was referred immediately to 
> the on call psychiatric team. Before they arrived she left the 
> department. The police were informed and asked to bring her back. 
> Eventually she went home to her parents house only to disappear again 
> and jump off a local motorway bridge later that night.
>  
> I have written to the MPS to clarify the legal position.
>  
> In the meantime, do any of you have local polices to deal with this 
> situation? As I understand it we are unable to use section 4 or 5 
> under the MHA as patients in the emergency department  have not been 
> admitted (inpatients). The department is not a public place under 
> section 136. So where do we stand? Restraint under common law?
>  
> Any thoughts or experiences welcome off list if prefered.
>  
>  
> Julian Humphrey
> Emergency Department
> Barnsley
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