EXECUTIVE SUMMARY
Psychiatric patients awaiting transfer in the ED pose multiple legal risks involving security, deterioration of the patient’s condition, and unsafe handoffs.
To reduce risks:
- provide ongoing care with psychiatric and social work services;
- direct oncoming EPs to review the patient’s progress and condition;
- consider ordering medications in consultation with psychiatry.
All transfers of ED psychiatric patients must occur in compliance with EMTALA, with a receiving physician and properly completed transfer forms, stresses Laura Pimentel, MD, vice president/chief medical officer at Maryland Emergency Medicine Network. Other requirements:
- Like all transfers, psychiatric patients must be stabilized;
- The benefits of transfer must outweigh the risks;
- Psychiatric patients should be cleared medically to the degree necessary to establish that the presenting symptoms are not from an organic cause.
Pimentel says the period while the patient is still in the ED, awaiting transfer, is particularly high risk. This is true both for patients and EPs.
“An initial decision is the proper security status for boarded patients,” Pimentel says. If actively suicidal, patients require one-on-one observation. If agitated or combative, patients may require sedation, restraints, or seclusion.
“All associated hospital policies must be followed,” Pimentel stresses. She offers these risk-reducing practices:
- Provide the patient with ongoing care from psychiatric and social work services while in the ED, if possible.
- Consider ordering antidepressant or antipsychotic medication in consultation with a psychiatrist, so that treatment can begin in the ED.
“It is prudent to consider continuing the patient’s usual medications, if known,” Pimentel offers.
- Address the patient’s co-existing medical problems.
“In my experience, the deterioration of co-existing medical problems is common in this population if not explicitly addressed,” Pimentel says.
Conditions to specifically consider are withdrawal syndromes from alcohol and narcotics.
“Initiating protocols for the nursing staff to regularly assess and treat these conditions should be done,” Pimentel notes. Similarly, if mental health patients have chronic diseases such as hypertension, diabetes, or seizure disorders, orders for their regular medications should be completed. “Regular vital signs and glucose checks should be ordered,” Pimentel adds.
- Create a psychiatric observation order set.
“Some of our practices have done this, with good success,” Pimentel reports. The order sets include all diagnoses, certification status, vital signs, neurological checks, diet, medications, psychiatry and social work consults, and security status.
- Follow safe handoff practices within the ED.
Psychiatric patients often spend hours to days in the ED waiting to be transferred, spanning several EP shifts.
“Each EP caring for the patient should place an assumption of care note on the chart, updating the patient’s condition and progress during that shift,” Pimentel advises.
Oncoming and outgoing EPs should review all diagnoses, vital signs, lab results, and recommendations from the consulting psychiatrist or mental health provider, Pimentel adds.
Michael Jay Bresler, MD, clinical professor of emergency medicine at Stanford University School of Medicine, recommends EPs include this documentation in the transfer note and the ED chart, if a psychiatric patient is being transferred: “At this point in time, there is no evidence of a non-behavioral medical emergency that would preclude transfer, but the patient should have a medical as well as psychiatric evaluation after arrival at the receiving hospital.”
“That’s important, because some psychiatric hospitals view the ED workup as an admission history and physical, which it is not,” Bresler explains.
For instance, a patient’s overdose might not become apparent until after ED discharge. In one such case, a patient presented to an ED and was transferred to a psychiatric facility, and later suffered a seizure, which resulted in brain damage.
“It turned out that the patient overdosed on lithium,” Bresler says. “The EP was sued for not finding the overdose.”
SOURCES
- Michael Jay Bresler, MD, Clinical Professor, Emergency Medicine, Stanford University School of Medicine. Email: [email protected].
- Laura Pimentel, MD, Vice President/Chief Medical Officer, Maryland Emergency Medicine Network. Email: [email protected].
Legal risks include security, deterioration of the patient’s condition, and unsafe handoffs.
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