Autistic Patient Aspirates After Being Left Unsupervised By Nurse

This case involves an autistic female patient who was suffering from excessive volitional water intake. She was admitted to the ICU with seizure episodes and uncontrollable vomiting. The patient was placed on a water restriction with an order for restraints and round-the-clock observation to enforce the water restriction. The patient was recovering well for the first 2 days. On the evening of the second day, during the nurse shift change, the patient’s restraints were removed. She was permitted to go to the bathroom and was left without observation. 13 minutes later, the patient was found drinking copious amounts of water in the bathroom. Soon thereafter, she had another seizure and was given a sedative. After being sedated, the patient was left alone in the room and began to aspirate on her vomit.

Question(s) For Expert Witness

1. What is the protocol for avoiding any kind of consumption in a patient with known psychiatric disorders?

2. What is the standard procedure to avoid aspiration when a patient is incapacitated?

Expert Witness Response E-116253

I do not know of any hospitals (aside from psychiatric hospitals) that have specific protocols for preventing patients from consuming water. What I think that this question really means to address is what are the institution's protocols for properly restraining a patient. Although this typically falls under the purview of nursing, I can offer the following observations about restraining patients at my current institution. First, nurses are to use the least restrictive means possible to restrain a patient. This can be simple redirection for patients who are alert, oriented, and capable of following commands, but can progress to having all four side rails up on the bed, lap belts, Posey vests, soft wrist restraints, soft four-point restraints, and locked leather restraints for those patients who are aggressively combative and at risk of hurting themselves or others. Nurses must document restraint status every 2 hours and determine whether they are still necessary. Physicians must place orders for restraints at the level of soft wrist restraints and higher, and the order must be renewed every 24 hours. If the nurse deems that the patient had made an improvement and no longer requires a certain level of restraint, he or she may remove the restraints, which nullifies the physician order. If the behavior worsens and restraints are necessary again, the physician must reorder the restraints. Other key factors for patients who require close monitoring from a behavioral perspective include proximity to the nurses station and whether bed alarms were used.

Aspiration precautions are also likely to be institution-specific, and again, are typically monitored by the nurses despite being ordered by physicians. Conventional components of an aspiration precaution bundle include raising the head of bed to greater than 30 degrees and the provision of oral care. Usually, they are accompanied by a consultation to the speech and language pathology service to determine the most appropriate diet for the patient. Medication routes should also be clarified, as should instructions for taking if done orally (crushed, with pudding, with supervision, etc.). Obviously, risk of aspiration is closely tied with mental state, which can fluctuate easily in patients with delirium, psychiatric disease, and changes in clinical condition, necessitating frequent assessment.