Screening, Stabilization, and Transfer of Psychiatric Patients
By Robert A. Bitterman, MD, JD, FACEP, Director of Risk Management & Managed Care, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
The medical issues of treating psychiatric disorders are tough enough, but the legal issues concerning emergency management of the psychiatric patient are particularly difficult.
Screening issues include the ever nebulous concept of "medical clearance," extent of the evaluation and testing required, and the involvement of on-call psychiatrists or county psychiatric evaluation teams. Stabilization issues include patient or staff security, physical or chemical restraints, and the confusing question of when a psychiatric patient is stable for transfer. Finally, problems regarding transfer of psychiatric patients include economic considerations, transport mechanisms, and involvement of state or county sponsored mental health programs.
The malpractice risk in dealing with psychiatric patients is substantial. It may surprise many emergency physicians that "failure to prevent suicide" results in the highest average indemnity awards in emergency medicine-almost $400,000 per claim.1 Missed pediatric meningitis cases average fewer claims than missed suicide cases. Overall, about 2% of successful claims against emergency physicians pertain to psychiatric issues.1,2
Then there is EMTALA, the federal law governing emergency services, which micro-regulates all three aspects of emergency department (ED) psychiatric care.3 The Health Care Financing Administration (HCFA) has levied a substantial number of citations against hospitals for allegedly violating EMTALA in the evaluation, treatment, and transfer of psychiatric cases. HCFA's regulations and its freshly minted new interpretive EMTALA guidelines specifically address ED psychiatric services.4,5
This article aims to help the practicing emergency physician understand these issues and avoid the multifarious legal pitfalls in the management of psychiatric emergencies.
Case 1. The police arrive with a 23-year-old male after a domestic dispute. He had resisted arrest, and, in the standoff with police, threatened to commit suicide by "blowing his brains out" or ingesting medications. A swat team eventually extricated him from his house and delivered him, handcuffed, to the ED.
The triage records state the patient is agitated, confused, inappropriate, belligerent, and uncooperative. The chief complaint is "I took pills, bottles and handsful." His vital signs are 97.7°F, 138 P, 138/92 BP, and 22 R. The patient tells the police and emergency physician he wants to die and that he took some acetaminophen with codeine and two bottles of amitriptyline (which a doctor had prescribed for his "emotional problems"). The police confirm the patient told them he ingested amitriptyline and other medications, but they think he was just playing opossum in the squad car to avoid going to jail.
The history documents the patient to be totally uncooperative and his story as "suspect at the most." The physician does no mental status exam, claims the vital signs are "stable," diagnoses "antisocial behavior," and declares the patient fit for confinement in jail. The physician orders no tests except a urine drug screen. The patient, however, refuses to produce urine, so the doctor allows him to leave and instructs the jail to obtain a urine specimen for drug testing.
The jail refuses to confine him because he is only charged with misdemeanors, so the police take him to the county crisis center. Unfortunately, the crisis workers can't assess him because he's now "unresponsive." The patient wakes up a few days later in another hospital after prolonged coma due to severe amitriptyline intoxication.
The Health Care Financing Administration (HCFA) determined that the hospital violated EMTALA by failing to provide the patient a proper mental health screening examination within the capability of the hospital's ED. Specifically, HCFA stated "the mental health screen was insufficient to determine if an emergency medical condition existed. It could not be determined that affect, mood, speech, thought content, thought process, judgment, insight, or psychomotor activity were evaluated."6 The peer review office (PRO) physician noted the obvious failure to evaluate, observe, and monitor the patient for potential drug toxicity and failure to obtain an acetaminophen level.
The hospital claimed that the patient refused medical care, citing his uncooperative behavior and his refusal to sign the hospital's consent for examination and treatment form. The physician also claimed the patient didn't want treatment and that the heart rate of 138 was consistent with his aggressive behavior, not due to drug toxicity.
Who wins? Hint: the hospital paid $47,000 in civil monetary penalties in a settlement agreement with the Office of Inspector General (OIG).6
Screening Psychiatric Patients
The most practical approach to ED screening of psychiatric patients is to divide the evaluation into a medical screen and a psychiatric, or "mental health," screen. The purpose of the medical exam is to diagnose and treat any underlying medical emergencies and to rule out potential organic causes of the patient's psychiatric symptoms. The purpose of the psychiatric exam is to determine if the patient has a psychiatric emergency, such as acute psychosis or suicidal intent, that requires immediate psychiatric intervention or civil commitment.
Typically, all of the patient's medical issues are addressed before the emergency physician evaluates, or asks a consultant to evaluate, the patient's psychiatric issues; thus, the term "medical clearance." Prior to referring the patient to a psychiatrist for a definitive evaluation of the patient's psychiatric disorder, medical clearance is obtained. The goal of the emergency physician is to adequately address all the medical issues prior to sending the patient off to the psychiatrist, since the patient usually receives no further medical evaluation after leaving the ED. The scope or extent of the medical workup is often difficult to judge and subject to wide variation among emergency physicians and psychiatrists in differing communities. An adequate history and appropriate physical exam, including neurological exam, is the expected minimum, but the extent of laboratory testing is controversial. Possible tests include CBC, electrolytes, glucose, urinalysis, thyroid studies, alcohol level, drug testing for substances of abuse, or toxicological screening. The necessity of any laboratory evaluation should depend upon the clinical presentation and the judgement of the examining physician rather than a set routine, such as lytes, glucose, and urine drug screen. The vast majority of medical problems in psychiatric patients are readily identifiable through vital signs, history, and physical examination.7,8 Routine screening is a waste of time, money, and man power; it also delays access to the psychiatric intervention the patient may desperately need.7
Testing Policies or Clinical Pathways
Many hospitals have policies or clinical pathways they follow in the medical workup of psychiatric patients, primarily because of longstanding expectations or demands from their psychiatric referral sources. Physicians and hospitals should consider the ramifications and drafting of such policies very, very carefully. If under your hospital policy all patients are supposed to get a CBC, urinalysis (U/A), and a thyroid test before transfer to psychiatric facility, then you will be held to that standard. What you say you will do becomes part of your standard screening process, and, thus, is subject to review by HCFA and plaintiff's attorneys. When HCFA or an attorney investigates screening cases, their first action is to demand a copy of the hospital's policies and procedures. If HCFA finds you're supposed to do a CBC and U/A, but you failed to do so, you have defacto violated federal law by "failure to follow your standard screening process." In dealing with HCFA, whether the test was actually clinically indicated, or whether any harm came to the patient is entirely irrelevant. This is strict liability, just like a speeding ticket: You violated the law, you pay the fine. It doesn't matter if anybody got hurt. You are held liable for what I call "failure to follow your own rules," even if your actions met the standard of care and were not negligent.
However, and fortunately, in civil cases brought under EMTALA, the plaintiff's attorney must prove your "failure to follow your own rules" caused the plaintiff personal harm, and that your failure was the proximate cause of that harm. For example, your policy requires a thyroid profile but you failed to do the thyroid test, and thus failed to detect the patient's severe hypothyroidism; therefore, you are legally responsible for the next 10 years he spent in a mental institution rather than as a productive member of society on synthyroid.
HCFA has taken some strange views on the scope of workup required in patients presenting with psychiatric complaints. In a recent investigation of a hospital in Richmond, VA, HCFA focused on four patients who presented with drug overdoses taken with intent to commit suicide.9 In one case, a 65-year-old woman was found lethargic by her son, allegedly after overdosing on alprazolam (Xanax). When the ambulance arrived, the patient was awake with normal vital signs and refused to go to the hospital. She claimed she took four or five pills of 0.5 mg of alprazolam with one glass of wine. The police were called, and after an hour and a half of squabbling, the patient ended up in the ED. Upon arrival at the ED, the patient's vital signs were normal, she had slurred speech and was lethargic, but was easily arousable. A complete physical, mental, and neurological exam was performed, and the patient was observed for another two hours and fifty minutes in the ED before transfer to an off-site affiliated mental health facility. During the patient's stay, her vital signs remained normal, her physical findings cleared, and she was independently evaluated by a crisis intervention professional who concurred that the patient was suicidal and needed inpatient treatment. HCFA claimed the patient's care violated EMTALA because the hospital failed to adequately evaluate her overdose. Specifically, HCFA stated the hospital failed to do an EKG, drug screen, alcohol and Xanax levels, and conduct decontamination procedures.9 The physician and hospital were entirely baffled; an alcohol level seemed fruitless, alprazolam levels worthless, and routine drug screening or an EKG entirely unnecessary. Clearly the risk of gastric lavage would have been much greater than its benefits, particularly since the overdose was almost two hours previously, alprazolam absorption peaks 1-2 hours after ingestion, and is very rarely fatal. One can argue about the value of giving activated charcoal, but the physician judged it unnecessary because of the patient's clinical condition.
In the other three cases against this hospital, HCFA also alleged that drug screening, drug levels, and even chest x-rays and ECGs should have been done in all patients who presented with suicidal ideation after a drug overdose.9 One patient admitted taking cocaine and heroine, so serum or urine screening for those chemicals would have been worthless. An alcohol level, a CXR, or an ECG should never be "mandatory," but left to the discretion of the physician after assessing the nature and circumstances of the patient's presentation. In one case, an acetaminophen level was indicated, since acetaminophen overdose is both potentially fatal and effectively treated with an antidote.
To present an acceptable plan of correction to HCFA, and thus avoid termination from Medicare and financial suicide, this hospital agreed to perform routine drug screening on all patients presenting with psychiatric and substance abuse complaints. The hospital hedged though, by agreeing to abide by such a policy until it could research the literature and then draft an "appropriate" policy regarding testing, drug screening, and toxicological evaluation of psychiatric patients.9 Ludicrous, but hospitals will do absolutely anything necessary to keep their Medicare funding.
Federal Courts' View on Testing Required as a Component of the Screening Exam
What's so frustrating to hospitals and physicians alike is that HCFA's enforcement stance is directly opposite the interpretation of the law by the U.S. Federal Courts. In the case of Vickers vs. Nash General Hospital, the Fourth Circuit Court of Appeals, which includes the State of Virginia, specifically addressed the issue of testing and evaluation of patients in the ED.10 The court held that the physician's judgment on whether tests are necessary for particular conditions does not fall under the purview of EMTALA, but rather is a question of medical malpractice to be addressed in state civil proceedings. In other words, if the physician perceives the patient's condition to be a non-emergency, and, thus, as not requiring drug screening or decontamination procedures, then it ends the EMTALA inquiry. Furthermore, the physician's judgment can be wrong, negligent, or even grossly negligent and not constitute an EMTALA violation.10,11 It's not the adequacy of the physician's judgment that's at issue under EMTALA, but whether the process was appropriate for that patient's complaint. If the hospital's standard process for managing patients with toxic ingestions and suicidal intent was triage, appropriate vital signs, complete history and physical by a physician, and physician judgment on what tests, what treatments, and what observation period were appropriate for that individual patient, then as long as the hospital followed this process, it didn't violate EMTALA, regardless if the physician's decision to not obtain an acetaminophen level failed to meet the standard of care.
The distinction between appropriate process and adequate medical care has been difficult for HCFA's investigators and decision makers to comprehend. Even well trained emergency physicians fail to understand it, as witnessed by the fact that the board certified emergency physician peer reviewer in these four cases initially agreed with HCFA.9 Most physicians understand standard of care/medical decision making much better than they do obtuse legal analysis.
Hospitals must address the issue of testing, drug screening, and toxicologic screening of psychiatric patients in ways that avoid hamstringing the physicians. In drafting such policies, the hospital should also take into account its accepting specialists and the expertise of the accepting facility. For example, if you admit the patient to your hospital's in-patient psychiatric unit and obtain an internal medicine and neurology consult, then your ED evaluation can be much different than if you're sending the patient to a state psychiatric facility that has little or no non-psychiatric expertise. If you refer the majority of your psychiatric patients to one physician group or to one psychiatric facility, then engage in a dialogue and mutually adopt an acceptable scope of the "medical clearance" before transferring patients to those physicians or facilities.
Who performs the psychiatric screen is an issue. HCFA specifically requires hospitals to formally designate, in writing, and approved by the Board of Trustees of the hospital, who can perform any screening exam on its behalf, including the psychiatric screen.12 Most hospitals designate credentialed physician members of its medical staff, though practically the duty falls to emergency physicians.
The psychiatric screening typically occurs after the patient has been medically screened, treated, and "medically cleared" (or simultaneously). Some hospitals either by choice, or because of county or state mandates, call in a quasi governmental crisis intervention team to evaluate the patient for admission to a psychiatric facility. In some areas of the country, state psychiatric facilities refuse to accept patients in transfer until this crisis team has evaluated the patient and blessed the admission decision. However, the hospital's or emergency physician's liability does not change one iota by the use of such teams. First, the team consists of nurses or social workers, usually quite experienced in the assessment of psychiatric patients, but they are not physicians. Second, they are not credentialed members of the medical staff of your hospital and have not been approved by the medical staff or the governing body of the institution to perform psychiatric screening; thus, they do not have privileges to make medical decisions on patients in your institution. Third, the EMTALA responsibility and the civil liability for the patient's care remains with the emergency physician. The hospital can not contract away its legal responsibilities under EMTALA. If the team only helps expedite a transfer to an appropriate facility within your community, and does not unduly delay or hinder appropriate care of the patient, that's fine. But if you allow their recommendations rather than your own to guide the patient's care, or if you allow them to chew up so much time that it jeopardizes the management of the patient, you will be held responsible. Frequently, such teams request additional blood or urine tests, particularly drug screening, prior to transfer to an accepting facility. Knowing whether the patient regularly ingests cocaine or THC may be helpful down the road to the psychiatrist's care of the patients; however, such tests are not necessary for the initial evaluation of the patient in the ED and only further delay their access to psychiatric intervention. This behavior is partly motivated by concern for the patients, but the crisis team may also be motivated to force the referring hospital to eat the costs for all these tests rather than the accepting facility, particularly if the accepting facility is a state institution or a managed care entity. If the team is delaying the transfer of an unstable psychiatric patient in order to check on the patient's insurance status, that is a direct violation of EMTALA.13
Holding a patient in four-point leather restraints in the ED for four hours while the crisis team fiddles around or argues about whether in-patient treatment is necessary, won't sit well with HCFA, and the liability rests solely with the physician and hospital, not with the crisis intervention team.
Must the hospital's on-call psychiatrist be called into the ED to evaluate, or "screen," a potentially suicidal patient? It depends. On-call physicians must come into the ED in two situations under EMTALA. First, the emergency physician requests the help of the on-call physician to determine if the patient has an emergency medical condition (EMC); and second, if the emergency physician diagnoses an EMC and needs the on-call physician to help stabilize the patient's condition.14 If a teenager took a few pills after breaking up with her boyfriend, and you decide it was a weak suicidal gesture, the patient is not actively suicidal, and feel comfortable sending her home with supportive parents, then you don't need the psychiatrist to help determine if the patient has an EMC. You already decided she does not. It's the same with abdominal pain. We send lots of patients with belly pain home without asking a surgeon to help us determine if the patient has acute appendicitis.
Similarly, if a deeply depressed 50-year-old man tried to commit suicide with a revolver, you already know the man is actively suicidal, truly an emergency medical condition. You don't need the on-call psychiatrist to help screen the patient; you need the psychiatrist's expertise to treat the emergency condition, the patient's suicidal intent, which is not the same as "to stabilize" the patient's emergency condition.
Reviewing the stabilization issues under EMTALA will explain these differences and address the involvement of on-call physicians and hospital in-patient psychiactric units in the management of the actively suicidal patient, or other patient with acute psychiatric illnesses. It will also answer the question of what to do about the patient on the fence, where you're not comfortable deciding whether or not the patient is suicidal, and do need help screening the patient for an EMC.
Stabilization and Transfer of Psychiatric
From this point forward it is assumed the patient is "medically clear," that any intoxication or medical emergency has been stabilized, and only the patient's psychiatric condition needs further attention.
Stabilization. In its governing regulations, HCFA specifically defines acute psychiatric manifestations as "sufficiently severe medical symptoms to warrant the label emergency medical condition."4 Thus, all patients with acute psychiatric symptoms have a legally defined EMC that must be stabilized before discharge or transfer. Previously, HCFA declared that for a patient to be psychiatrically stable, the psychiatric condition must be definitively treated (e.g., the suicidal patient cured of suicidal intent). In an advisory opinion, HCFA stated that the hospital's on-call psychiatrist must come into the hospital's ED to evaluate the patient and admit the patient for further treatment if the patient is indeed suicidal.15 This would mean that the actively or potentially suicidal psychiatric patient could never be transferred from that hospital until the patient was no longer suicidal. And, coincidentally, since EMTALA is federal law and preempts conflicting state laws, HCFA's interpretation would eviscerate state programs and institutions created for the commitment, assessment, and in-patient treatment of psychiatric patients.
However, HCFA's interpretation was inconsistent with the plain language of the statute that defines stabilized as "that no material deterioration of the emergency medical condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility."16 What is it about psychiatric patients that leads to the conclusion that they are suffering from an EMC? It is the fact that their condition represents a danger to themselves or others. If one renders the patient incapable of harming himself or others, then such individuals should be considered stable under the language of the law. Appropriately restraining the patient, either through chemical or physical means, clearly prevents such an individual from hurting himself or others. Therefore, if you can assure that the patient is properly restrained, chemically and/or physically, so that he/she cannot harm himself or others, then a reasonable interpretation of the law would hold that such a patient is stabilized.
In revising its EMTALA interpretive guidelines, now in effect since July 14th of this year, HCFA accepted an advisory committee's recommendation to change its interpretations of stability for psychiatric patients. The guidelines now read: "For purposes of discharge, the psychiatric patient is considered to be stable when he/she is no longer considered to be a threat to him/herself or to others;" and "For purposes of transferring a patient from one facility to a second facility, for psychiatric conditions, the patient is considered to be stabile when he/she is protected and prevented from injuring him/herself or others."5
Furthermore, HCFA now specifically agrees that being "stable" for either discharge or transfer does not require the final resolution of the emergency medical condition.5 And once a patient is stable, EMTALA no longer applies.
Return to our actively suicidal 50-year-old man who tried to kill himself with the revolver. Does the psychiatrist on-call have to come in to assess or treat the patient? Once you have treated his wounds, secured his handgun, and adequately restrained him to avoid further suicide attempts, the patient is legally stable. You now may admit the patient to your psychiatrist, who would not have to come in to evaluate the patient immediately, but, instead, could write some admitting orders and then see the patient in the morning. Or the hospital could transfer the patient, even for purely economic reasons, to a state mental health facility or to the patient's managed care plan hospital for further psychiatric treatment, without ever involving the psychiatrist on-call.
Transfers. The big question regarding psychiatric transfers is whether hospitals that have on-call psychiatrists and inpatient psychiatric units violate EMTALA if they admit only insured patients-transferring uninsured patients to a designated state or county psychiatric facilities. As long as the patient meets EMTALA's/HCFA's definition of stable for transfer, then it is legal to transfer the uninsured patients. Economic transfers are not illegal under EMTALA, as long as the patient does not have an EMC, or if the patient does have an EMC, it is stabilized before the transfer.
Reconsider the patient you're on the fence regarding his suicidality. You should demand your on-call physician to help you decide if the patient had an EMC (i.e., suicidal intent) because the law requires the hospital to perform the screening exam within the capability of the institution, including using the services of on-call physicians.3 If the on-call psychiatrist determined that the patient was not suicidal, the patient could be sent home and treated as an outpatient. If the psychiatrist determined that the patient was suicidal and stabilized the patient, as suggested above, then the patient could be admitted or transferred, again, even if that decision was economically based.
Many hospitals avoid on-call psychiatrist intervention by forcing the emergency physician to make only one of two decisions; either the patient is potentially suicidal or not. If not, discharge the patient, if yes, either transfer all patients to a state or county psychiatric evaluation intake center/hospital, or "stabilize" the patient and then do the financial dance to determine where the patient will be admitted. The emergency physician isn't allowed to sit on the fence and request screening assistance, as opposed to stabilizing or treatment help, from the psychiatry staff. It is an interesting legal position, but one not put to the crucible of a HCFA investigation or litigated in federal court yet, to my knowledge.
Recognize that there are pitfalls in transferring any patient for economic reasons, particularly psychiatric patients since they are essentially a protected class under HCFA's regulations. Both HCFA and the OIG have announced that they will closely scrutinize psychiatric transfers away from institutions capable of handling in-patient psychiatric emergencies. They will examine the methods and duration of restraints, how long it took to arrange the transfer, the duration of the transport itself, the security of the individual, the appropriateness of medical treatment, and any potential complications that could occur in route, especially if the patient was medicated just prior to transfer.
Appropriate attention to the patient's medical issues, aggressiveness, security, and medications is important, and, in some instances, may actually require sending the patient via ambulance with a nurse or paramedic in attendance to accomplish a safe transfer. Whether the transfer was appropriate will be judged under a reasonableness test, based on the individual facts and circumstances of the transfer.
However, compliance with EMTALA, or even ordinary malpractice, will be reviewed retrospectively, with the knowledge that the decision was based on the patient's lack of financial resources. Institutions should carefully select which patients are transferred for economic reasons, assuring that such transfers occur smoothly and without any substantial risk of harm to the patient.
Documentation is also crucial, and should track the language of the law. Even when claiming the patient to be stable, hospitals should still complete appropriate EMTALA transfer forms. Carefully drafted forms, which include sections outlining decisions regarding presence or absence of an emergency condition and whether or not the patient has been stabilized, can protect the hospital if the care rendered is retrospectively questioned by HCFA or plaintiff's attorneys.
It is paramount that the hospital reevaluate the patient at the time of transfer, document its findings at that time, and reconfirm that the patient is still stable for transfer.
Additional Issues in the ED Management of Psychiatric Patients Restraints and security search policies
Searching potentially suicidal patients for drugs or weapons they could use to kill themselves and properly restraining them to prevent further harm are both a form of stabilizing procedures, and thus are subject to EMTALA. As with testing policies in the medical screening exam, restraint and search policies will be subject to the "failure to follow your own rules test" both by HCFA and plaintiff attorneys. With HCFA, remember, no harm need come to the patient; if you failed to follow your restraint policy, you violated federal law (e.g., part of your legally created `stabilizing' [restraint] policy requires the ED to 2-point restrain all suicidal patients; if you failed to so restrain the patient, even if the patient never bolted, it is a violation). Same goes with your policies and procedures regarding searching potentially suicidal individuals. If the policy says all patients will be searched by security and placed under observation by a "sitter," but such search does not occur, and the patient seriously re-overdoses on medications stashed in her purse, then the hospital will be cited for failure to follow its own search policies by HCFA. It also can be successfully sued by the patient because she was harmed by the hospital's violation that resulted in her second overdose. Draft policies related to EMTALA very carefully!
Refusing the screening examination or stabilizing treatment
Can patients refuse offered medical and psychiatric screening evaluations and stabilizing treatment? Normally, patients can refuse screening; however, a patient who overdoses with the intent to commit suicide loses all rights to consent for examination and treatment.17,18 Laws in all 50 states not only allow but also mandate that the emergency physician take control of the patient to prevent the patient from harming himself or herself.2 Suicidal patients are not competent to accept or reject indicated medical intervention. Thus in the initial case scenario presented, it didn't matter whether the patient consented to treatment, or signed the appropriate consent form. The hospital and physician were obligated to take custody of the individual and provide appropriate medical evaluation and intervention. There is also one more twist in the example case. The patient was a prisoner; he was under arrest and in custody of police. Most state laws allow the correctional facility's medical officer to consent on the behalf of prisoners with intentional, self inflicted injuries or illness, regardless of whether the prisoner is mentally competent at the time.19
The best screening and stabilization policies state that all patients will be triaged, all patients will be examined by the emergency physician, and what tests, further evaluation, and stabilizing treatment required for that individual patient will be based on the patient's presenting complaints, history, physical findings, and the judgment of the examining physician. Policies should describe the process of screening and stabilization, and procedures should ensure all patients go through that process; both must leave room for physicians to use their head in deciding appropriate management of these patients.
The screening, stabilization, and transfer issues of handling psychiatric patients in the ED are difficult enough alone, and are even more complex when state referral systems and economic considerations are introduced into the decision making process. Emergency physicians and hospitals need to consider the issues diligently and thoughtfully before implementing management strategies for psychiatric patients in the ED.
1. Karzz A et al. Preventability of malpractice claims in emergency medicine - a closed claims study. N Engl J Med 1990;314:1557
2. Colucciello, SA. Civil Commitment: Medical, Legal, and Ethical Considerations. Emerg Med Reports 1997;18:55-64.
3. 42 USC 1395dd
4. 42 CFR 49.24(b)
5. HCFA's Revised Interpretive Guidelines: State Operations Manual Provider Certification, Dept. of HHS, HCFA, Transmittal No. 2, May 1998. Effective July 14, 1998; [pg V-25 includes definitions of stabilization of psychiatric patients and comment that stable does not require final resolution of the patient's EMC.]
6. HCFA 1997 EMTALA Citation vs. Bryan Memorial Hospital, Lincoln, Nebraska
7. Olshaker JS, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124
8. Henneman PL, Mendoza R, Lewis RS. Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994;24:672
9. HCFA 1997 EMTALA Citation vs. Stuart Circle Hospital, Richmond, Virginia
10. Vickers v. Nash General Hospital, 78 F3d 139 (4th Cir 1996)
11. Summers v. Baptist Medical Center Arkadelphia, 91 F3d 1132 (8th Cir 1996)
12. 42 CFR 489.24(a)
13. 42 USC 1395dd(h)
14. 42 USC 1395cc(a)(1)(I)(iii)
15. Frew, SA. Patient Transfers: How to Comply with the Law. Published by the American College of Emergency Physicians, Second Edition 1995; [private advisory letters from HCFA to Steven A. Frew, JD, December 1994. See pgs. 21-23.]
16. 42 USC. 1395dd(3)B
17. Korgaonkar G, Tribe D. Suicide and attempted suicide - a doctor's legal liability. Br J Hosp Med 1993;50:680
18. Parry JW. The supreme court fashions new boundaries for involuntary care and treatment. Ment Phys Disabil Law Rept 1990;14:198
19. E.g., North Carolina General Statutes Section 148-46.2.