Someone is becoming disruptive in the ED waiting room, and ED personnel decides to call law enforcement. Scott Zeller, MD, has seen many such cases.

“What sometimes happens is [staff will] see an individual and assume they are loitering and say, ‘We need to get police and security involved,’” explains Zeller, vice president of acute psychiatric medicine at Vituity in Emeryville, CA.

When asked if a medical screening exam was performed, as is required by the Emergency Medical Treatment and Labor Act (EMTALA), the response usually is no. ED personnel often say they left it up to police to decide what to do. “The police can only assist with criminal issues. Meeting EMTALA requirements is not the police’s obligation,” Zeller notes.

In one such case, a patient with schizophrenia was in an ED waiting room after registering. The patient became agitated and threatening while waiting to be seen. “Security was called and felt the patient was dangerous, so they contacted police,” Zeller reports.

Police officers put the patient on an involuntary psychiatric hold. Per their protocol, they arranged for an ambulance to take the patient to another hospital with a psychiatric unit. The ambulance crew arrived with a gurney, placed the patient on it, and transferred him directly out of the waiting room to the other facility.

At no time did any physician or licensed independent practitioner see the patient while in the ED waiting room. “The patient was effectively transferred to another hospital without any medical screening exam, efforts to stabilize, or even contact with the facility receiving the transfer,” Zeller says. The receiving facility contacted the original hospital, whose medical director insisted “it was a police matter, so we didn’t get involved.”

“However, the situation was a de facto transfer without the sending facility meeting any EMTALA requirements,” Zeller says.

Under EMTALA, the hospital is required perform a medical screening exam and stabilization to the best of its capability for anybody seeking assistance within 500 yards of the hospital. It may, in fact, be appropriate to ask police or security to escort someone off hospital grounds. “But there should be an opportunity to do at least a basic medical screening exam as part of that process,” Zeller adds.

This is true even if police are putting somebody in handcuffs. “The EP attending physician should have a few moments where they can determine if this is somebody who does have an emergency medical condition,” Zeller offers. With a bad outcome shortly after the episode, the hospital and responsible medical staff would be liable for both malpractice and EMTALA violations.

If the EP can clear the person and believes there is no medical emergency, Zeller advises documenting it as follows: “I have conducted a medical screening exam of this individual and find that no emergency medical condition exists.”

“The EP can say, ‘We’ve already screened this person, and they don’t meet criteria,'” Zeller explains. “Then, it can be up to the police or security what happens next.”

Zeller says the safest approach is to presume that anyone in the ED waiting area is presenting for evaluation and medical care, unless they indicate otherwise. “Even if an individual is not clearly stating they want help or to see a doctor, just assume that is the case. That way, you’ll always be on the safe side,” Zeller suggests.

Staff, especially security personnel, should be trained to approach anyone on their campus who appears to be medically or psychiatrically compromised to determine if they need help and want to see a doctor. Some people may be incoherent or unable to state their intentions. This could be because they have a psychiatric illness. It also could be an underlying medical condition that’s causing an altered mental status.

“A patient with very low blood sugar can have symptoms that look like acute psychosis,” Zeller says. Individuals with head trauma or an intracranial bleed, which might not be immediately obvious due to hair or a hat, can appear psychiatrically impaired.

“It’s just like if somebody came to the ER and passed out,” Zeller says. “We wouldn’t decide that because they aren’t able to ask for our help that they didn’t want our help.”