From: Keith Conover <kconover@pitt.edu>
To: emap@list.pitt.edu
Subject: psych transfers
Date sent: Sat, 09 Aug 2003 09:38:46 -0400
Send reply to: kconover@pitt.edu
As someone mentioned in the ED recently, in the summary about psych
transfers I sent by email and posted on the DEM website, I left out
an important point, that we had discussed before.
If a facility's psychiatrist seems to be inappropriately refusing a
transfer, an option is to get the emergency physician on duty at the
facility to accept the transfer.
This is certainly a possibility,but given Becky O'Connor's working
with institutions to get them to accept transfers appropriately, this
should be a last resort. An example might be when the patient has been in
the ED at Mercy for hours, and the facility that is inappropriately
refusing has the only available psych bed in the county. Given recent
psych overcrowding in this area, this is not entirely to be unexpected at
some point.
I will add this to the note about psych transfers posted on the DEM
website:
<a href= "http://www.pitt.edu/~mercyres/psych_transfers.htm" > Click Me
</a>
Thank you.
From: Keith Conover <kconover@pitt.edu>
To: emap@list.pitt.edu
Subject: psych transfers--the final word?
Date sent: Mon, 21 Jul 2003 12:52:13 -0400
After many discussions over the past several years, I hope that this
summary will prevent any misunderstandings about psych transfers and
smooth the process.
1. PSYCH TRANSFERS, MERCY MAIN > PROV
Patients can go from the ED at Mercy Main directly to one of the
psych floors, rather than to the ERC, provided patient meets all the
requirements for moving from the ERC to the psych floor. Specifically: a.
The patient must be medically suitable for direct admission to a psych
floor. Doesn't need IVs, and doesn't need any urgent medical workup that
can't wait for a day or so. b. The patient is sober (alcohol under 100, or
will be by the time the patient gets there) and not intoxicated from other
substances. c. You've spoken with the psychiatrist on call for Prov.
If for some reason you think it's appropriate to send the patient
before the patient is suitable for a direct admission, you can always call
the emergency physician in the Prov ED to accept the patient in the main
ED there. Note that a psychiatrist might not want a particular patient as
a direct admission to the psych unit. This is _not_ an EMTALA violation as
you can always send the patient to the ED and get the emergency physician
to accept the patient. However, it's usually best for the patient and for
the ERC staff and for the emergency physician at Prov if you left the
patient sober at Mercy Main prior to transfer.
2. PSYCH TRANSFERS MERCY MAIN > OTHER PLACES
If you trying to transfer a psych patient from Mercy Main to another
institution with a psych unit, then any transfer is governed by EMTALA as
we don't have a psych unit at Mercy Main. Thus, the receiving institution
is not permitted, under EMTALA, to condition the acceptance on alcohol
levels or drug screens. Under EMTALA, it is the responsibility of the
sending physician to make sure the patient is stable for transfer.
What if an institution refuses such a transfer, demanding that you
perform a drug screen or alcohol level prior to transfer? Or, the
institution says "we don't do dual-diagnosis, we're refusing this
transfer." Conditioning a transfer on results of testing, or based
on "not having a dual-diagnosis psych unit" is, to the best of our
knowledge, and after confirmation with the state and federal
governments, a violation of EMTALA.
Some people are maudlin when drunk, and not really suicidal one
sober; so, allowing a potentially suicidal patient to sober and
reassessing often makes sense. It may be that, once sober, the
patient may be suitable for outpatient psych referral, and the psych
nurses or social workers can help with this. However, if a patient has
made a suicidal attempt (a real one, not just a minor gesture) while
drunk, then it doesn't really matter if the patient is drunk.
However, if a psychiatrist or other emergency physician suggests
additional workup, perhaps doing an alcohol level or drug screen or
other labwork, but accepts the transfer regardless, that's another
matter. And if the receiving psychiatrist suggests that, based on
his or her experience with this type of patient, it would be wise to check
something before transferring the patient (for instance, electrolytes in
an elderly patient who isn't eating due to depression) then it would be
wise to take advantage of the psychiatrist's experience and do these
things before transferring.
However, if it's a flat out refusal, you should inform the physician who
is refusing the transfer "From my understanding, your refusal to accept
this patient is a possible EMTALA violation, and thus, if you do refuse, I
will be reporting this to the PMHS legal counsel for investigation." Don't
get excited, don't get mad, this is likely to happen and we have a plan to
deal with it. It may take months or years to get it all settled out so
psych transfers are accepted appropriately, but we're working on it.
Then, you should do what seems best for the patient. If this means
doing a drug screen and an alcohol level, and calling again with this
information, then do it. If it means transferring somewhere else, then do
it.
3. DUAL DIAGNOSIS?
The term "dual diagnosis" means nothing to the state or federal
government, to them, any psych unit should accept patients with true psych
emergencies regardless of whether they have drug problems too. any place
with a psych unit is appropriate to take someone with
However,. some places are better than others at taking care of people with
drug and alcohol problems, specifically, withdrawal. Some hold that any
psych unit should take such patients, and if they don't know how to deal
with withdrawal, then they should learn. Others point out that, from a
purely patient care perspective, it's better patient care to send a
patient to where their problems will be better cared for. But simply
having some alcohol or drugs on board doesn't mean that withdrawal is
likely. So, you need to make a good assessment of whether withdrawal is
likely. If it is, then it makes sense to call first to places that are
likely to be able to take good care of the patient.
Mary Ann Foley, I'm told, has a listing of which places are good at
taking care of those with withdrawal, posted in the ERC at Prov, and we
may be able to make this available to the physicians and others at Mercy
Main, too.
Regardless, at this point, if a place refuses a patient due to "dual
diagnosis" or a positive alcohol level or drug screen, please report it
for investigation.
4. REPORTING POSSIBLE EMTALA "REVERSE DUMPING" (REFUSALS)
Note that reporting to the PMHS legal counsel is _not_ equivalent to
reporting the case to the feds or the state. Our legal counsel, Becky
O'Connor, will be collecting these cases and then using them to discuss
issues with the institutions involved. We want all the area institutions
to play by the rules, but we don't want to get into a tit-for-tat battle
where all the hospitals are calling the government about EMTALA violations
all the time.
To report a possible inappropriate refusal, _or_ a possible
inappropriate transfer from somewhere else, please refer to the PMSH
Administrative Policy: REQUESTS FOR TRANSFER TO MERCY HOSPITAL OR MERCY
PROVIDENCE HOSPITAL (�MERCY�), which provides a reporting form. This is
available on the PMHS Intranet. From outside the Intranet, I have posted a
copy on the PMHS Emergency Medicine website; look on the "Misc
Information" page. If you'd like to look at this the direct link is:
http://www.pitt.edu/~mercyres/mercy-transfer.pdf
Also, you can compile the information into an email and send directly to
Becky:
"Mercy Legal, Rebecca C. O'Connor, Esq." <roconnor1@mercy.pmhs.org>
I sincerely hope that, after many years of confusion over EMTALA,
alcohol, and psych patients (a deadly combination) we have a plan
that will work relatively well, make your overnights more efficient, and
provide better patient care.