Addressing the challenges behavioral health patients present when in crisis

Access to proper treatment for patients with behavioral and mental health issues has become a major issue in the United States and has received attention from the public and Congress. But, there are unique issues when a behavioral health patient appears at a hospital emergency room and the hospital must abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 U.S.C. §1396dd). Catherine M. Greaves, counsel, and Kristin M. Roshelli of King & Spaulding, LLC addressed the challenges hospitals face in emergency situations with behavior health patients in a Health Care Compliance Association webinar held on July 25, 2017.

The behavioral health patient and EMTALA

When a patient comes to the hospital’s emergency department (ED) with a behavioral health condition and requests emergency treatment, the patient (1) may be a danger themselves or to others, (2) may lack orientation, which is interfering with his or her ability to meet basic needs such as nutrition or safety, or (3) may have an underlying mental illness. Patients may be suicidal or homicidal, assaultive or combative, delusional or psychotic, or experiencing withdrawal from drugs or alcohol.

Hospitals must ensure that EMTALA requirements are met, including conducting a medical screening as well as a psychiatric evaluation, properly stabilizing the behavioral health patient if a n emergency medical condition (EMC) exists, and addressing transfer issues, including the vehicle used to transfer have been addressed. In addition, the hospital must have policies and procedures that adequately reflect EMTALA requirements and must provide education and training on serving behavioral health patients for the ED and other hospital staff, including security. If the hospital is in a state that has laws requiring mental health patients to be evaluated and treated at designated facilities may clash with or be more stringent than EMTALA. Hospitals must not disregard EMTALA requirements.

Concerns specific to behavioral health patients

Greaves said that EDs have become the “de facto dumping grounds for psychiatric patients.” One out of 8 ED visits are for mental health disorders or substance abuse, which represents a large percentage when compared to the population as a whole. In addition, she pointed out a 2008 survey conducted by the American College of Emergency Physicians that found that 99 percent of emergency physicians reported admitting behavioral health patients daily. According to Greaves, much of this is due to the lack of available designated psychiatric hospital beds and the decrease in state facilities for behavioral health patients. Currently, there are only 14 beds available per 100,000 people, which represents a decrease of 90 percent since the 1990’s, and is the number of beds available in 1850. The optimal number of beds is 50 per 100,000.

MSE for behavioral health patients

MSE for behavioral health patients consists of two steps, an initial medical screening to rule out underlying medical/organic causes for symptoms followed by a psychiatric review once medical clearance has been determined. Greaves stressed the importance of conducting the medical screening examination before doing a psychiatric evaluation to rule out medical conditions that can trigger behavioral symptoms. As examples, she noted that drugs and alcohol can mask underlying medical conditions and infections, especially in the elderly, can trigger psychiatric behavior. She also emphasized that appropriate hospital personnel conduct screening.

Stabilization

Greaves noted that patients with behavioral health conditions are not quickly stabilized. Patients must be stabilized enough to tolerate a transfer or be discharged. Hospitals should consider whether the patient is protected and prevented from injuring or harming self or others; when using chemical or physical restraints, and is the underlying EMC stabilized. Although some patients refuse treatment, suicidal patients may not refuse medical and psychiatric evaluations and stabilizing treatment. If the patient is being transferred with restraint for stabilization, how long will the stability last and how long is the trip.

If the ED decides to transfer a patient that is not stable, the physician must explain the reason for the transfer and certify that the benefits outweigh the risk. The transfer, however, must comply with all of the other EMTALA regulations. Within the hospital’s capabilities, treatment must be provided to minimize the risk of harm, the receiving facility that agrees to accept the transfer must be contacted, and appropriate information must be sent to the receiving facility.

Transfer challenges

Behavioral health patients are transferred at higher rates than nonpsychiatric patients with much longer wait times for the transfer because of issues locating an available bed in a national shortage, insurance acceptance and prior authorization delays, and arranging transportation. When it comes to choosing the vehicle to transport behavioral health patients, there is no single method that is full proof. Hospitals should balance minimal interference with the patient’s dignity and self-respect, reduce the likelihood of harm to self or others, and prevent the transport experience from being perceived as a traumatic event.

Options for transportation include ambulance, police care, private vehicle, and a hybrid, but all present problems. An ambulance may not be a good choice because it is filled with objects that can be utilized to harm self or others and there is no barrier to protect the driver. A police car may traumatize the patient, a support person is not allowed, there is no established protocol for safe transport of behavioral health patients, and there is limited ability to intervene if a medical emergency occurs during transport. In addition, both ambulances and police vehicles brings a public cost. Private vehicles should not be used because family are generally not capable of providing appropriate care. Some states laws allow variations that make up a hybrid that may include the involvement of Mental Health Crisis Teams or unmarked police vehicles.