Failure to Keep Boarded Psych Patients Safe Is Med/Malpractice Risk
Patient safety is EP’s primary concern
Psychiatric patients boarded in EDs awaiting available beds present significant liability risks for emergency physicians (EPs) for several reasons, according to Leslie Zun, MD, MBA, chair of the Department of Emergency Medicine at Mount Sinai Hospital in Chicago, IL.
"We are the provider of last resort for many of these patients," he says. "We have to do medical clearance, determine if the problem is medical or psychiatric, and determine if the patient needs to be hospitalized."
The major liability risks for EPs involve failure to keep patients safe, including suicide in the ED, escape followed by suicide, and assault of staff or other patients, says Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine, & Law and director of the Division of Law, Ethics, and Psychiatry at Columbia University’s College of Physicians & Surgeons in New York, NY.
"Patient safety should be the primary concern while awaiting transfer to an inpatient bed," he underscores.
Alternatives to Hospitalization
Part of the problem is many chronically mentally ill individuals are uninsured, "which makes the matter even worse," says Zun, because the burden then gets placed on the EP as the safety net provider.
"It’s rare that you see institutions or programs being added to serve the mentally ill," says Zun. "Rather, you quite frequently see reductions in services. That is quite concerning."
Trying to identify a site that can take the patient is often difficult or impossible for EPs. "All too often, EDs have a large population of psychiatric patients who have nowhere to go but the ED, and the patients are boarded in the ED for days," says Michael Turturro, MD, associate professor of emergency medicine at the University of Pittsburgh and chief of emergency Services at UPMC — Mercy Hospital in Pittsburgh.
Turturro urges EPs to partner with mobile crisis teams, or outpatient centers, and to look for alternatives to hospitalization when that is appropriate.
"Many EDs don’t realize the type of resources that may be available, such as county and state programs," he says. Turturro recommends having someone specifically trained in managing behavioral health emergencies do a structured risk assessment to determine if the ED patient can be safely managed without hospitalization.
"EPs tend to be risk-averse," says Turturro. "They will assume hospitalization is always required if a patient expresses a fleeting thought of suicide. But in fact, that may not always be necessary."
UPMC — Mercy Hospital’s ED brought in employees from a local outpatient crisis center to help determine which patients need hospitalization and which can be connected to outpatient resources.
"It’s important to know they do have a safe environment to land in. But it’s still a high-risk population, no matter what you do," Turturro says. "A structured risk assessment, while not foolproof, can be very helpful in finding the best environment for the patient."
Standard of Care
The legal standard of care does not change for an EP if the patient is a psychiatric patient — the EP still has to do what the typical EP would do in similar clinical circumstances, says Joshua M. McCaig, JD, a shareholder with Polsinelli in Kansas City, MO.
While psychiatric unit providers are held to a higher standard of care for psychiatric treatment than the EPs, the EP should, at a minimum, take the necessary steps to make sure that psychiatric patients are protected, safe, and not a danger to themselves or others, advises McCaig.
With regard to patient safety and treatment of general medical issues, the applicable standard is likely to be that of a reasonable EP, says Appelbaum. However, when EPs undertake treatment of conditions outside their specialty, they could be held to the higher standard of a specialist in that area.
"Thus, to the extent that treatment is initiated in the ER, especially during prolonged boarding episodes, [EPs] may be held to a standard consistent with psychiatric practice," says Appelbaum. "Malpractice risk can be mitigated by psychiatric consultation or participation in the patient’s treatment."
At Mount Sinai Hospital, the hospital’s psychiatric service rounds on psychiatric patients boarded in the ED and makes treatment recommendations to ensure the patient is properly assessed and cared for. Dr. Zun says he believes this decreases legal risks.
If the patient’s condition were treated in the ED, there’s a possibility the patient would not need admission at all, says Zun, which raises the question as to whether EDs should do some acute stabilization or observation care for psychiatric patients.
"We would never let a medical patient sit in the ED without any treatment until they get a bed upstairs," says Zun. "Why is it O.K. for a psychiatric patient to sit there for days, getting minimal, if any, treatment for their illness?"
EPs should document the patient’s condition upon arrival, document the circumstances in the facility at that time and why the patient could not be admitted, and order a psychiatric consultation, advises McCaig.
"Even if the consultation does not take place right away, at least it is ordered and shows a level of concern on the part of the physician," he says. "If there are no psychiatric services in the emergency department, document that and the steps taken to keep the patient safe."
The EP’s documentation does not have to be extensive, but should include an evaluation of the patient’s condition, including risk of harm to self or others; rationale for any treatment initiated, including decisions to defer treatment until transfer to an inpatient bed; and steps taken to ensure patient safety, says Appelbaum.
"If a decision is made not to initiate psychiatric treatment, the reasons should be documented, along with the measures taken to keep the patient safe in the interim," he says.
For more information, contact:
• Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine, & Law, Director, Division of Law, Ethics, and Psychiatry, Columbia University College of Physicians & Surgeons, New York, NY. Phone: (212) 543-4184. E-mail: email@example.com.
• Joshua M. McCaig, JD, Polsinelli PC, Kansas City, MO. Phone: (816) 395-0651. E-mail: JMcCaig@Polsinelli.com.
• Michael Turturro, MD, Associate Professor of Emergency Medicine, University of Pittsburgh. E-mail: tuturoma@ upmc.edu.
• Leslie Zun, MD, MBA, Chair, Department of Emergency Medicine, Mount Sinai Hospital, Chicago, IL. Phone: (773) 257-6957. E-mail: firstname.lastname@example.org.