Reduce risks of screening mentally ill ED patients
Protecting staff, patients requires patterns, practice
Belligerent behavior, communication problems, inconsistent responses to questions, and lack of competency to refuse treatment: Any of these factors can get in the way of obtaining a good history and physical for a patient with psychiatric complaints, according to Barbara E. Person, an attorney with Omaha, NE-based Baird Holm.
To protect yourself from the unique liability risks posed by these patients, do the following:
Establish standard patterns and practice when confronted with difficult situations involving mental health patients. For example, if the patient responds inconsistently to questions about "where it hurts," repeat the questions in a consistent order a couple of times. "Document the inconsistency, but also affirmative responses with grimacing or other nonverbal responses that support clinical decision-making," says Person.
If you consistently perform an established series of range of motion tests on patients with particular complaints, document this. The documentation can be quite brief, but would signal a peer reviewer that the ED physician would have noticed any expressions of pain, says Person.
"Rules of evidence allow witnesses, in this case ED physicians, to testify to their pattern and practices," she says. "This is important if the ED physician does not have specific recall of the examination of a particular patient."
If the patient asserts his or her right to refuse a standard test or treatment or asks for one that is not medically necessary, document the request or refusal. Mental health patients are likely to refuse recommended tests and therapies that competent patients would not. "These decisions are particularly dangerous from the perspective of peer review. The peer reviewer will have concerns whenever the care fails to meet the standard of care," says Person.
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Avoid shortcuts with mental health patients "ED physicians and nurses are so used to seeing mentally ill patients and ordering the routine psych clearance labs, that often other conditions go undetected and untreated," says Robert B. Takla, MD, FACEP, chief of the Emergency Center at St John Hospital and Medical Center in Detroit. "In general, a stigma towards psychiatric patients exists by most healthcare professionals. This often leads to missed diagnoses and a lower standard of care." Often these patients have had multiple ED visits, says Takla, "and the perception is they need to be in a psychiatric facility'let's hurry and medically clear the patient.'" Patients with a history of mental illness or who have active disease may have their symptoms dismissed as part of their mental disease, says Sandra Schneider, MD, professor of emergency medicine at University of Rochester (NY) Medical Center. "A significant symptom of medical disease may be hidden or lost in a long litany of complaints associated with their underlying mental illness," says Schneider. "For example, a patient once complained of seeing things funny. It was later discovered that she had a sixth nerve palsy from her brain tumor." In addition, patients on significant psychotropic medication or those with severe disease may not perceive pain in the same way as well patients, says Schneider-something that is classically seen in patients with abdominal pain and schizophrenia. Takla says the most important thing is to "throw away your prejudices. Assume something beyond a psychiatric illness is going on and seek to uncover it. Medically ill patients have other co-morbidities such as diabetes, hypertension, coronary heart disease and the like. Their complaints need to be taken very seriously. Do not take short cuts and assume the complaint is related to a psychiatric condition." Patients who present with a request for medically clearance require a complete history and physical (H&P), not a focused exam, says Takla. If a patient refuses to answer a question, answers inconsistently, or gives answers that are false, Takla says to separate your H&P into these three parts and document all three as completely as you can: History. Here, you document what you obtain from the patient, the family, caregivers, emergency medical services, and bystanders. "You can only document what you are told. Acknowledge that the information is limited or unavailable," says Takla. Physical exam. Document what you find on exam, including the mental status and psychiatric exam. Based on the above information, determine what diagnostic tests are clinically indicated, such as blood tests, urine tests, and potentially other tests such as electrocardiogram or a head computerized tomography scan. ED course. "This is your synthesis of the above H&P and test results," says Takla. "What do you think is going on and why? The logic to arrive to your diagnosis(s) should be clear." Takla says that belligerent patients are more challenging than those who will not communicate. "Not only are you not afforded any history, you have a loud, disruptive, aggressive patient who wants to leave or hurt you and/or your staff," he says. "They must be calmed down." He suggests placing patients in a quiet room, enlisting the help of family members unless this escalates the problem, or utilizing chemical or physical restraints. This may make the patient more agitated, however, and must be weighed against the risk of inflicting harm to oneself and the staff. "A physical exam is still very useful even if the patient will not provide a history," says Takla. "Once the patient is calmed or sedated, the ED physician can garner valuable information simply by examining the patient." |
There is a thin line between mentally ill patients that are competent to make decisions about their care and those that need protection. "A seriously mentally ill patient has the right to refuse to take medications if they are competent," notes Sandra Schneider, MD, professor of emergency medicine at University of Rochester (NY) Medical Center. "Making the decision about competence often requires a prolonged interview, and many emergency physicians are not skilled in doing this."
Schneider says that when she is confronted with a difficult patient who is endangering himself or staff, she errs on the side of doing the best she can for the patient.
"This will not prevent a suit, but it will give you a better defense," she says.
For example, if you are dealing with an intoxicated patient with a possible head injury who refuses to lie still for a computerized tomography (CT) scan, sedating the patient against their will accomplishes the CT scan but may be viewed as battery.
"The defense for doing it is 'I only did what I would do if this were my brother. I wanted to be sure to save his life.' If you don't do it, you're left with 'But he refused. I knew he was drunk, but he refused,'" says Schneider. "Years ago, I had an intoxicated patient that threatened to sue me because we did a diagnostic peritoneal lavage even though he had refused it. When I gave that line to the attorney, the case ended."
Contact legal counsel or law enforcement when appropriate. Emergency Medical Treatment and Labor Act (EMTALA) regulations do not address mental capacity or competency. Person notes that there are some cases in which the right of self-determination is questionable, because the patient is not competent to make binding decisions.
"If this issue arises, it may be necessary to contact legal counsel to work through the issue," Person says. "This is particularly time-sensitive when the mental health patient wishes to leave the facility against medical advice."
Consider contacting law enforcement if the patient poses a threat to themselves or others, advises Person. "Hospital security may be able to intervene for the short term, if state law allows health care providers to hold patients for their own security and safety."
If a patient is belligerent and violent, it is not generally necessary for ED staff to place themselves at risk in order to safeguard the mental health patient, adds Person. "The standard is to respond with reasonable care. Generally, it is not unreasonable to seek to protect oneself from physical harm," she says.
Be specific when documenting irrational behaviors. These may include urinating on staff, trying to bite staff, or a patient deciding he wants to walk home when it is freezing outside and he has no shirt. "Juries and even attorneys will likely be swayed, if you document why you can't get information or need to force treatment because you believe the person to be incompetent at the moment to give consent," says Schneider.
Though the ED chart is generally brief, documenting the answers given by a patient and the reality known to the staff can be helpful. "For example, a patient seeking narcotics may suggest that they have not had any medication refills for months, when pharmacy records or ED records show a very different story," says Schneider. "One area of concern to me is the patient who presents with a suicide gesture then adamantly insists they are not suicidal. Luckily, these are fewand I always get a psychiatric evaluation on the patient."
Document that a patient is no longer a threat to himself or others. According to the Centers for Medicare & Medicaid Services Interpretive Guidelines for EMTALA, a patient who has made a suicidal gesture or threat is presumed to be in an emergency medical condition. In that case, any plan for discharge has to explain clearly the basis for the ED physician's or psychiatrist's conclusion that discharge is safe for the patient.
"Many EMTALA citations have come up in the past year where a psych consult occurs prior to discharge, but the peer reviewer is unconvinced that the emergency medical condition has been stabilized," says Person. "Documentation must show that the patient is no longer a threat to himself or others."
Add mental health evaluation prompts to electronic health records (EHRs). "Many of our hospital clients have had problems with evaluation of mental health patients, as their EDs have converted to electronic health records," says Person. The standard EHR prompts do not encourage documentation of observations relating to mental health status, so documentation of this information may fall through the cracks.
"Some EDs have enhanced their EHR to include prompts for a thorough mental health evaluation," says Person. "This can increase the comfort level of ED physicians in their work with mental health patients, and reduce the risk that mental health issues will be given short shrift in the ED."
Sources
Barbara E. Person, JD, Baird Holm, Omaha, NE. E-mail: [email protected].
Sandra Schneider, MD, Professor, Emergency Medicine, University of Rochester Medical Center, Rochester, NY. E-mail: [email protected].
Belligerent behavior, communication problems, inconsistent responses to questions, and lack of competency to refuse treatment: Any of these factors can get in the way of obtaining a good history and physical for a patient with psychiatric complaints, according to Barbara E. Person, an attorney with Omaha, NE-based Baird Holm.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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