QUESTION
I work on a behavioral health unit at an EMTALA hospital. When our unit is full the admission staff has been told it is our responsibility to find placement for patients that come into the emergency room. Is it legal for us to find placement for patients in the emergency room when we cannot see them and have nothing to do with their care?
ANSWER:
EMTALA requires your hospital to provide a medical screening examination and stabilizing care for patients presenting to your hospital. That specifically includes patients presenting with symptoms of psychiatric disturbances, which are deemed true emergencies by the law.
If the patient is assessed as having a psychiatric disturbance in the Emergency Department then your facility must admit them or — if you are unable to care for the patient — transfer them to a facility capable of assessing or caring for the patient. EMTALA does not specify who in your facility must make the arrangements, but a physician (or QMP designated by the hospital bylaws) must order the transfer after completing the medical screening examination and must certify the necessity/risk/benefits of transfer. It is up to the hospital as to who is responsible for making the calls to find a transfer location.
If patients present directly to your unit rather than the ED or are moved to your unit without ED assessment, then EMTALA considers your unit to be part of the Emergency Department, and the medical screening exam and mental health screening exam must be provided in your unit prior to transfer.
Financial information cannot be obtained from the patient prior to the completion of the medical screening exam and mental health screening.
CMS is the governmental enforcement agency for EMTALA. Previous citations issued to mental health intake units indicate that the medical screening must precede the mental health exam to rule out traumatic, medical, or toxic (or intoxicated) causes for the possible mental health condition or to identify conditions that might be masked by a mental health condition.
For more information, see PP 329 -332 EMTALA Field Guide 3rd Edition.
If a patient presents to a psychiatric ER and following medical screening refuses further assessment what is best practice and law. I don’t want to violate patient rights or detain patients but I am being told every patient must have a complete a psychiatric assessment before alllowing to leave behind the locked doors. Can you please clarify this for me thank you!
If the MSE reveals history, events, or observable conditions that suggest that the patient is a danger to self or others, you have to follow the state involuntary procedures if the patient wants to leave.
How do EMTALA laws apply if a patient presents to an ER at a medical center with a psychiatric unit, the psychiatric unit staff are called to the ER to do a mental health assessment and they determine that the patient is “too high acuity” for their psychiatric unit though there is an open bed and there are no other available beds at outlying mental health inpatient units.
This often happens and the patient is left in the ER or taken to jail untreated for long periods of time awaiting a bed at a state facility.
What EMTALA laws might apply to this situation if any? Under what circumstances would the psychiatric unit attached to the ER in which the patient presented not be accused of breaking EMTALA laws?
I have been advised by CMS in several cases that psych units cannot impose “arbitrary” access rules beyond their license restrictions, such as acuity criteria, selection for the “milieu”, previous patients, etc. I would suggest that the 2017 record South Carolina fine stands for the position that you cannot board psych patients in the ED if you have psych beds available –and if there are no beds in the unit available, then psychiatrists must provide on-going care to patients boarded in the ED. Sending the patient to a jail because you don’t have a bed would be at very high risk for an EMTALA violation. The best standard for evaluating your EMTALA approach to care of psych patients is whether it would be an appropriate approach to a trauma patient — because they are both EMTALA emergencies.
If we have a minor patient that presented to our Psychiatric Emergency Department (more of an assessment area for potential patients with chairs and not beds, without the ability for him to sleep there) for SI with his mother. The mother presented with court documents stating that the patient is not allowed to have contact with any minor nor able to be without a family member present with him 24/7. The concern for my facility was that we would not be able to keep this order as he would be around a whole unit full of minors and family are not able to stay and be with him. I felt that an appropriate solution would be a transfer to the real Emergency Department of the hospital to allow them to provide the stabilization and observation for the SI. My plan was to send him by 911 to ensure his safety. Would this be appropriate?
It would be appropriate to move the patient to the Emergency Department to assess the medical and psychiatric needs of the patient. Transport by ambulance would be appropriate for EMTALA purposes and transfer to a facility capable of complying with the court order would appear to be an appropriate transfer. I have grave questions about why the court would release the minor if they were perceived to be that dangerous, but one can only deal with the case as it presents.