Emergency physicians (EPs) face significant legal risks if psychiatric patients are boarded for long periods due to a lack of inpatient beds, warns Scott L. Zeller, MD, chief of psychiatric emergency services at the John George Psychiatric Hospital of the Alameda Health System in Oakland, CA. “This is a major issue around the country,” he says.
The average boarding time for patients with mental health issues ranges from seven to 34 hours, according to recent studies.1,2
Most EDs are not suited to handle psychiatric emergencies, according to Zeller.
“Unfortunately, too often the most common options for treatment are to either restrain and sedate the patient, or have the patient wait with a sitter until the patient can be sent to an inpatient hospital,” he says.
Zeller recommends creating a dedicated psychiatric ED or a separate section of the ED with a psychiatric focus.
“It’s much better for patients if you actually get them the care they need immediately,” he says. “Otherwise, quite frequently, by the time actual definitive treatment begins, it’s often three or four days from the emergency.”
Zeller and colleagues reported that psychiatric patient boarding times were reduced with a system allowing mental health services to be accessed either by ambulance or direct transfers from EDs.3
“It’s really time to look at an alternative approach and make sure the patient is receiving an evaluation that’s consistent with community standards,” he says.
EPs also face legal exposure due to the possibility of a psychiatric patient’s symptoms worsening during long waits.
“Patients can become aggressive and that can lead to injuries,” says Zeller. “If it’s deemed that the ER staff was not doing enough to treat that patient’s symptoms, they could probably be held liable for whatever happens.”
An ED chart showing no evidence that the patient’s vital signs were reassessed can quickly complicate the EP’s defense.
“There is a risk to assuming that somebody is ‘all done’ and just waiting for a bed,” Zeller says.
Patients with serious psychiatric illnesses often have medical comorbidities and have higher levels of asthma, diabetes, and seizure disorders than the general population, he notes.
“As long as the patient is in your ER, they are still your responsibility,” Zeller says. “It’s easy to forget that, if you think your part has been completed.”
Discharge Without Consult
Zeller once testified as an expert witness in a case against an EP who discharged a patient waiting for a psychiatric consult.
“The EP was waiting so long, he finally got frustrated and discharged the patient. The patient ended up in a skirmish with police and got killed,” he says. The family sued, claiming the EP breached the standard of care by failing to perform a proper psychiatric evaluation.
“It’s not uncommon for EPs to discharge emergency psychiatric patients without a psychiatry consult, typically because of the difficulty accessing such consults in a timely fashion,” Zeller says. “That’s where the risks come in.”
Telepsychiatry is one possible solution.
“Anything we can do to actually get a psychiatrist to the patient, whether in a special section of the ER or by videoconferencing, will alleviate a lot of legal concerns,” Zeller says.
Some EPs, frustrated with long wait times for psychiatric consults, argue that they should be allowed to discontinue involuntary psychiatric holds and create space in the ED.
“EPs should be able to determine if an involuntary psychiatric hold is inappropriate and discontinue those, such as a psychiatric hold placed on a patient whose behavior was due solely to delirium or head trauma,” Zeller says. But for true psychiatric emergencies, he says, “there needs to be a much greater degree of trepidation.”
Some EPs believe they should be able to release involuntary holds when they see a drunk patient is sober and no longer suicidal.
“Those are the ones that are going to get you,” Zeller warns. “You may have been lucky so far, but a suicidal threat should always be explored further.”
If the patient does harm himself or others and the EP was the one to release the involuntary psychiatric hold, Zeller adds, the EP could be held to a higher standard of care.
“One of the ideas has been, ‘Why don’t we get a law passed where we can get legal authority to discontinue these holds?’” Zeller says. “Board-certified EPs feel they should be considered qualified to do this, which does make a lot of sense.”
The question is whether the EP has the time and ability to conduct a comprehensive psychiatric evaluation that meets the community standard of what a mental health provider’s evaluation would be.
“Discontinuation of a psychiatric hold requires a comprehensive evaluation, including making phone calls to obtain collateral history,” Zeller notes. “It can be a difficult and intricate process.”
An EP might take the view that a patient appears to be doing well, discontinue the involuntary hold, and discharge the patient. If a bad outcome occurs, the EP will likely be compared against what a psychiatrist would have done in that situation.
“If the EP did nothing more than a cursory evaluation and documentation, he or she could be accused of an inadequate exam, and could be liable for malpractice,” Zeller says.
REFERENCES
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Tuttle GA. Report of the Council on Medical Service, American Medical Association: Access to psychiatric beds and impact on emergency medicine. AMA, Chicago; 2008.
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Weiss AP, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012;60:162-171.
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Zeller S, et al. Effect of a regional dedicated psychiatric emergency service on boarding and hospitalization of psychiatric patients in area emergency departments. West J Emerg Med 2014;15:1-6.
SOURCE
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Scott L. Zeller, MD, Chief, Psychiatric Emergency Services, John George Psychiatric Hospital of the Alameda Health System, Oakland, CA. Phone: (510) 346-7500. E-mail: [email protected].
