4 ways to give psychiatric patients privacy in your ED

Imagine a sullen teenager bring brought to your ED by her mother, who tells you she is suicidal. Behind her you see a man clutching his chest and a woman who reports blurry vision. Would you take the time to bring the patient to a private area before asking if she intends to harm herself? What if a hearing-impaired elderly man reports recent depression and you have to shout when asking if he takes antidepressants?

If other patients or staff can overhear a patient’s personal medical information, you are at risk for a violation of the Health Insurance Portability and Accountability Act (HIPAA), warns Ilze Sturis Hallman, APRN, BC, RN, CS, clinical nurse specialist for psychiatric emergency services at University of Michigan Health System in Ann Arbor. "Only the minimum necessary information needed for others to be able to do their jobs or fulfill their roles should be disclosed," she says.

Privacy and confidentiality often is overlooked in a busy ED, but this can have a negative effect on patient care, says Carol A. Ziolo, RN, LCPC, a mental health liaison specialist for the ED at Northwest Community Hospital at Arlington Heights, IL. "It is very difficult to develop a therapeutic rapport when a patient feels embarrassed by lack of privacy and perceives that everyone in the ED knows the reason for their visit," she says.

When caring for psychiatric patients, use these strategies to protect privacy:

1. Place patients in a private room if possible.

This privacy makes it more likely that the patient will give an accurate and complete history and not omit information about recent abuse or a suicide attempt, says Hallman. "If a private room is not available, placing the patient in a corner area of the ED for added privacy may be helpful," she says. "This has to be balanced with the need for added supervision for psychiatric patients, based on their presenting problem."

At Northwest’s ED, two psychiatric rooms offer patients privacy for evaluations and behavior management, and the rooms have cameras so that patients can be observed by a sitter in another area, says Ziolo.

However, there are times when a private space just isn’t available, acknowledges Ziolo. "There are many times that our two psych rooms are full, and we have to do evaluations with patients on carts next to the wall," she says. "During those times, we try to sit close to the patient and talk in a soothing tone of voice."

The goal is to obtain enough information to make a disposition as quickly as possible to remove the patient from the hectic ED environment, says Ziolo. "I explain to the patient that I understand that privacy is lacking, but that I will make every effort to maintain confidentiality," she says.

2. Limit interaction with staff.

"We try to limit the number of staff who interact with patients," says Ziolo. "Patients get very agitated when asked similar questions by numerous staff, so we ask only staff who have a need to know’ to interact with patients."

Although a lab technician may draw labs, the patient’s nurse will often obtain blood and urine samples. "We also suggest the volunteers do not interact with the patients as they may not be educated on the appropriate information to tell the patient," says Ziolo.

For example, people without knowledge of mental health laws may tell a patient that they may leave anytime they want, regardless of the situation. "Many ED staff are not aware that patients can be held against their will when they are going to be admitted involuntarily," she adds. "Patients may get incorrect information and escalate to aggressive behaviors when they are told inaccurate information by the mental health team."

3. Obtain consent from patients.

Ask patients to sign release of information consent forms before calling insurance companies, and have patients give consent before visitors are allowed in the room, says Ziolo.

If the patient can’t communicate, information can be obtained from a caregiver or family member if your clinical judgment determines that this is in the patient’s best interest, says Hallman. For example, family members may be able to provide information about the patient’s mental health history or current prescribed medications.

"If the patient is not incapacitated, obtain a written release of information from the patient for documentation purposes," she advises.

4. If monitoring is needed, inform patients.

At Cleveland Clinic Foundation, psychiatric patients who are at risk for harm or for leaving the ED are placed in a seclusion room for monitoring and are always informed when auditory and visual monitoring is done, reports Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for the ED.

The auditory monitoring is done by nursing personnel with headphones so no one else can hear. "It is possible for anyone within the nursing station walking by to see anyone being monitored, but no visitors or other patients outside the nursing station can see what is going on," she says.

The nurse responsible for the patient checks the patient in person every 15 minutes, and someone constantly sits at the monitoring station while the patient is in seclusion.

If a psychiatric patient is in the room with no need for seclusion or monitoring, the monitors are turned off. "Our policy specifically states that visual and auditory monitoring may not be used without the patient’s knowledge and without someone constantly watching the monitor and listening with the headphones," says Fielden.

Sources

For more information on privacy and psychiatric patients, contact:

  • Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, Emergency Department, Cleveland Clinic Foundation, 9500 Euclid Ave., E19, Cleveland, OH 44195. Telephone: (216) 444-0153. Fax: (216) 444-9734. E-mail: fielden@ccf.org.
  • Ilze Sturis Hallman, APRN, BC, RN, CS, Clinical Nurse Specialist, Psychiatric Emergency Services, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Telephone: (734) 936-5900. Fax: (734) 763-7204. E-mail: isturis@umich.edu.
  • Carol A. Ziolo, RN, MA, LCPC, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4145. Fax: (847) 618-3996. E-mail: CZiolo@NCH.org.