Do psychiatric cases risk EMTALA violations?
Do psychiatric cases risk EMTALA violations?
A confused woman who can’t remember what day it is. A man who says he "doesn’t feel himself" lately. A teenager who admits he’s considered suicide.
Would each of these patients receive a medical screening examination (MSE) in your ED, as required by the Emergency Medical Treatment and Labor Act (EMTALA)?
Psychiatric patients can present risks for violations of EMTALA, due to confusion about what is required for MSEs, warns Denise Atwood, RN, trauma coordinator at Maricopa Medical Center in Phoenix.
If a psychiatric patient doesn’t receive a complete MSE, this is a violation of EMTALA, which applies to all patients who present to the ED seeking care, including psychiatric patients, says Atwood.
"A patient with a psychiatric issue needs medical care just like a diabetic with an extremely high glucose level," she says. "Their needs may be different, but they have the same right to seek and receive treatment."
Nurses must understand that triage and an MSE are different things, says Heather Freiheit, RN, BSN, EMT-P, clinical manager for emergency services at Rogue Valley Medical Center in Medford, OR. "Not understanding this can lead to potential EMTALA violations and more importantly, an adverse patient outcome," she says.
Triage is the rapid assessment of a patient’s chief complaint, vital signs, overall appearance, level of consciousness, pain level, and psychosocial state in order to decide the patient’s acuity and assign a priority level of care, while an MSE determines whether the patient has an emergency medical condition, says Freiheit. If an emergency condition exists, the patient must be treated and cannot be transferred or referred to another hospital until they are stabilized, she says.
"EMTALA mandates that an MSE be completed to protect patients with life-threatening illness or injury from being refused medical treatment by ED because of the patient’s lack of insurance coverage or inability to pay," Freiheit says. "Behavioral health patients can be challenging because they may not receive an adequate MSE."
Triage not a substitute for an MRE
Triage is not a substitute for an MSE, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. The goal at triage is only to determine the order that the MSE takes place, he says. "What constitutes an MSE is determined by the patient’s presenting signs and symptoms," he adds. "Your aim is always to determine whether an emergency exists."
Under EMTALA, an emergency is a medical condition that, in the absence of immediate medical attention, would reasonably result in placing the health of the individual in serious jeopardy, with serious impairment to bodily functions or serious dysfunction of any bodily organ or part. "Certainly if a patient is threatening suicide, you could reasonably conclude there is a threat to this person’s life," says Lawrence. However, there are gray areas for psychiatric complaints — a patient who says, "I’m so depressed that want to kill myself" is clearly a suicide risk, whereas a delusional patient may be less clear cut, he adds.
If the patient has a psychiatric emergency, you must provide stabilizing treatment within the capability of your facility, says Atwood. This treatment may consist of an evaluation by a psychiatric provider, administration of medication, and 1:1 monitoring by a health care professional before a patient can be transferred to an appropriate level of care, she adds.
If the patients are a danger to themselves or others and your hospital doesn’t provide behavioral health or psychiatric services, you are required to transfer the patients as needed to another facility that can provide short-term or long-term psychiatric treatment, says Atwood.
If a patient has no known psychiatric diagnosis and the family states the patient is having a "nervous breakdown," you must first provide an adequate MSE to rule out life-threatening causes of this personality change, says Freiheit. The work-up may include lab draws, drug screens, computerized tomography scan, or lumbar punctures, she says.
Look for other causes of behavioral changes and rule out medical or pathological events, says Freiheit. "Frequently, behavioral health patients are well known to the ED staff." she says. "At times, staff may be a little too quick to assume the patients are acting abnormal because they stopped taking their medication."
Sources
For more information about psychiatric patients, contact:
- Denise Atwood, RN, Trauma Coordinator, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008. Telephone: (602) 344-5670. E-mail: [email protected].
- Heather Freiheit, RN, BSN, EMT-P, Clinical Manager, Emergency Services, Rogue Valley Medical Center, 2825 E. Barnett Road, Medford, OR 97504. Telephone: (541) 608-4768. E-mail: [email protected].
- Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 30813. Telephone: (562) 491-9090. E-mail: [email protected].
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