Preplanning can ease psychiatric transfers
Fewer resources reduce transfer options
The recent fining of Behavioral Hospital of Lutcher (LA) for allegedly failing to appropriately accept transfers of two patients suffering psychiatric emergencies may have offered a bit of consolation to ED managers who are increasingly frustrated by their inability to successfully transfer such patients, but it was also a sober reminder of the severity of the problem.
The hospital paid a $30,000 fine for its violation of the Emergency Medical Treatment and Labor Act (EMTALA), which is significantly below the $50,000 fine per case allowed by law, according to Robert A. Bitterman, MD, JD, FACEP, president of Bitterman Healthlaw Consulting Group in Charlotte, NC, and vice president for Emergency Physicians Insurance Co. (EPIC) in Auburn, CA.
Number of psych hospitals decreasing
More important than the amount of the fine, however, is the underlying problem it reveals, he says.
"This is a huge problem, primarily because there has been a shrinking supply of psychiatric hospitals," Bitterman notes. "Fewer state facilities now exist, and private hospitals do everything possible to avoid taking patients without insurance or financial resources."
But aren’t those private facilities required by EMTALA to accept psychiatric patients? The answer, it seems, is yes and no. "They may say they do not take violent patients or those with dual diagnoses,’ or the patient is out of their catchment or referral area, or they may claim the ED has already stabilized the patient," he notes.
However, many of these assertions are "bogus" claims, Bitterman says. "If a patient is suicidal, it may be true that the ED can stabilize them, but we can’t treat their underlying emergency medical condition: their suicidality," he adds. "Nevertheless, many facilities will tell the ED that since the patient has been stabilized, they will not accept the patient in transfer unless the patient has insurance."
The net result, unfortunately, is that "these patients are stuck in the ED for many hours, even days, using up resources and personnel time, which adversely impacts the ability of the ED to deliver ongoing services," Bitterman says.
This problem affects every emergency physician in the country, because every ED has psychiatric patients, says Joan Kolodzik, MD, an emergency physician with Upper Valley Medical Center in Troy, OH. "And because of federal regulations, we are obligated to see all of them," she says.
On our own?
EMTALA does not give ED managers a clear legal advantage, Bitterman says. While many psychiatric hospitals claim that they do not have to accept patients under EMTALA if the patient has been legally stabilized by the transferring hospital, several EMTALA experts, including Bitterman, contend these hospitals are incorrectly interpreting the statute.
Bitterman and others say that an accepting hospital’s duty to accept patients under EMTALA is not a derivative of or dependent on the transferring hospital’s duties, but instead is an independent duty under EMTALA’s "nondiscrimination" section.
Thus, if a hospital can’t treat the patient’s underlying emergency medical condition, such as suicidality, then another hospital asked to accept the patient in transfer must do so regardless of the stability of the patient, as long as that hospital has the capability and the capacity to treat the patient’s emergency condition, Bitterman says.
However, despite years of inquiries from organizations such as the American Hospital Association and the American College of Emergency Physicians, the Centers for Medicare & Medicaid Services (CMS) has declined to resolve the issue, he says. Additionally, it may not resolve the issue until the term of its advisory group ends about two years from now, Bitterman notes.
The CMS EMTALA Technical Advisory Group (TAG) has a term of 30 months, starting from March 2005, he explains. It is probable that CMS will wait until receiving the TAG recommendations before taking any remedial action on the issues, Bitterman points out.
What, if anything, can ED managers do in the meantime to increase the likelihood of successful psychiatric transfers? "You need to plan in advance how to handle them," he advises.
"Do you have locked units or dual diagnoses units available? Do you have psychiatrists who can see patients in the hospital?" he asks.
In addition, you know what kinds of patients will come in the door, so talk, in advance, to nearby psychiatric facilities, Bitterman suggests.
"Find out what kind of facilities and resources these potential accepting hospitals have, and under what conditions they can accept transfers," he says.
Another option may be "way-station" facilities, which are small psychiatric holding centers with nursing and medical staff, Bitterman says. Finally, he advises, "Discuss the issue with the accepting facilities in advance, with legal counsel if necessary, and come to a mutual understanding on how you intend to interpret EMTALA with respect to transfers."
Kolodzik agrees. "The best way to address this from an ED manager’s point of view is to do it upfront," she says. "Tell your docs, If you have a patient who meets these criteria, find out in advance where the most appropriate place is for transfer.’"
Kolodzik also recommends joining with psychiatric facilities in your community to discuss potential barriers to transfer.
"Sometimes, there could be an issue about who handles the transport of a suicidal or homicidal patient: an ambulance, or the police or sheriff," she adds. "Or the receiving facility may want us to pre-medicate potentially violent patients before transfer to make sure they are calmer."
Sources
For more information on psychiatric transfers, contact:
- Robert A. Bitterman, MD, JD, FACEP, President, Bitterman Healthlaw Consulting Group, 4500 Swing Lane, Charlotte, NC 28226-3422. Phone: (704) 544-7917. E-mail: [email protected].
- Joan Kolodzik, MD, Upper Valley Medical Center, Troy, OH. E-mail: [email protected].
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