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Acute Agitation: When to restrain someone for labs?

Discussion in 'Psychiatry' started by BobA, Apr 7, 2012.

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  1. BobA

    BobA Member

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    I was recently moonlighting a saw a woman with schizophrenia, alcohol dependence (+ h/o complex withdrawal), hepatitis who presented to the ED acutely psychotic. She denied any recent alcohol or other drug use. On my clinical exam, I did NOT see signs of intoxication. Her clinical presentation was highly consistent with acute exacerbation of schizophrenia rather than substance use or delirium - but that's only so good.

    I wanted to get labs to make sure there was a cause for delirium (he has been delirious from opioids/pancreatitis before). However, the patient refused labs at all. Would you restrain this woman to get labs? If not, what would your next step be?
  2. nitemagi

    nitemagi Senior Member

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    Tread carefully. Technically that's assault. You need to be able to justify that 1) they don't have capacity to refuse this, and probably 2) There may be an imminent risk to life by not performing this.
  3. notdeadyet

    notdeadyet Still in California Moderator

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    Yikes, on what grounds? It may vary by state (or not), but like nitemagi says, forcibly restraining a patient and drawing blood against their wishes is literally grounds for being charged with assault and battery.
  4. billypilgrim37

    billypilgrim37 Unstuck in Time

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    For one, restraining someone to obtain labs is almost impossible, as a little bit of wiggling makes taking blood pretty hard.

    It may be assault, but you have to make a clinical decision both of the patient's capacity as well as the dangerousness of the decision to refuse the labs. Would you rather explain to a jury how you let someone die that you could have saved, or would you rather explain why you had someone held down against their will? In some extreme cases, you'd be justified to have them held down for the labs. Given your low clinical suspicion of delirium or acute withdrawal, your best bet here is to treat the agitation as best you can, monitor the patient very carefully for clinical worsening, and hope you're right. While ideally you would want to treat the medical conditions ASAP, you are plenty justified in careful observation and re-evaluating the risk of proceeding without intervention in real time. If the AMS is from pancreatitis, it will show itself eventually.

    By asking the question, you're already being thoughtful. You really just have to be comfortable with why you would make either decision. I think having the conversation later with a patient like this wouldn't be the end of the world: "I'm really sorry I had you held down. I was really afraid if I didn't get that information, that I might be missing something that would have resulted in you dying or getting worse and getting hurt. From what I could tell, it didn't seem like you could really understand how dangerous it was to refuse, and I would rather see you alive and be able to explain to you how sorry I am that had to happened than I would see something terrible happen to you that I could have prevented." if you REALLY think they didn't have capacity and that you not proceeding was an unacceptable risk. Granted, your threshold for feeling this way would have to be REALLY high with good evidence that they lacked capacity and there was a high likelihood this was due to a life-threatening medical condition,
  5. whopper

    whopper Former jolly good fellow

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    I've done it before. It's something you'll likely not see unless you're in a long-term psychiatric facility, and even then it was rare.

    If you got a patient who will not cooperate with labs, lacks capacity, and needs labs, and you can see a realistic possibility where not doing labs will lead to a seriously bad outcome or does not meet the standard of care, it's justified, but then comes the question, do you tell staff members to go in their, guns blazing (not literally of course) and restrain this guy for labs? Usually not.

    If the situation could wait, it's better to bring it up in a forced-med hearing in court to cover your own butt. E.g if the only thing that stabilized the patient is Depakote, but he refuses Depakote labs, and he won't cooperate, and will be dangerous without it, and lacks capacity, that can wait for court. A person already on Depakote for weeks will likely not suffer permanent damage to wait a few more weeks for a court-hearing. If the situation can't wait (e.g .the patient is showing signs of delirium), I'd recommend telling your clinical supervisor--and even attendings have that. I have an attending up my chain of command, and he has one too, and tell them via beeping or calling them and tell them the situation over the phone and get an okay. You'll likely get a response within about 15 minutes. If it really can't wait, e.g. the patient is showing signs of DKA), and you really may just have to darned order it, documenting that you had little choice. The only thing I can think of off hand that would prevent me from taking action would be advance directives stating for no interventions but that hardly happens in our field and that's usually in the ICU.

    If courts approve forced labs (they usually pretty much always do in a forced-med hearing, simply include labs among the med request) the treatment team can get the labs at their discretion but they must do so under treatment guidelines. In most counties, the courts that handle the forced-med hearings have sat through these 10,000 times and know that you NEED LABS to perform the standard of care for forced meds. I have, however, sat through a few forced-med hearings where the court never went through one and the judge was very hesitant because he didn't want to violate prior case law. It's an ironic situation because the judge in a court is the final determiner of interpreting the law, but I've sat through these hundreds of times and knew it better than they did but I had to keep my mouth shut because I was just the expert witness.

    IMHO it's lesser restrictive to sedate the person first with meds than to restrain them for labs.

    A typical forced-lab case is a patient who is very very psychotic or manic, needs the labs, the court gives permission for forced-labs, medications haven't yet stabilized the patient to the point where he/she has capacity, and then the treatment team will politely ask the person. If the person refuses, I try to convince the patient. If the patient still refuses, and we need to get the labs for the patient's own good, I'd typically then order meds to sedate the patient and then order the labs be done. Of course, it could be a not-so-good idea to give sedating meds to a delirious patient depending on the situation.
    Last edited: Apr 7, 2012
  6. NJWxMan

    NJWxMan

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    I'm confused. If you saw this woman in the ED, you wold be consulting the ED staff. It is not your responsibility to make the call of whether she needs stat labs. You can recommend it, but it's not your issue. If this is in a psychiatric ED and the patient is acutely agitated, medicate them. You will have no problems getting labs from them after they get 10 mg of Zyprexa. I also question what you might be going after in terms of labs. What is it that you will be looking for? I realize that you could admit medically if you find something on labs, but without medicating her, how would she be going to the medical floor? I think the thing to do here is take vitals (rule out withdrawal), get a BAC, medicate her (offer PO first), have a nurse try to get a finger stick, and realize that more likely than not, she's simply psychotic and not delerious. To tell you the truth, after completing 72 calls in the psych ER, I think I have only seen a few truly decompensated schizophrenics come in alcohol intoxicated. I've seen many more manic patients come in intoxicated, however.
  7. BobA

    BobA Member

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    Thanks, everyone for your replies. Perhaps some more information would clarify things, although I do enjoy the discussion:

    The problem is that I was moonlighting at a community hospital whose inpatient psych unit doesn't accept involuntary patients. Insured + voluntary only. She was clearly involuntary. As part of the moonlighting deal I see floor and ED consults as well as manage the inpatient unit.

    I was going to have to transfer her somewhere else that did accept involuntary patients. In order for me to get the recieving hospital (called a Level 1 hospital in that state) to accept her I was afriad I'd have to get some labs. Would you accept a floridly psychotic patient with a h/o complicated withdrawal (e.g., serious DT's), and pancreatitis in transfer without labs? I wouldn't and don't!

    Thus, without the labs I was concerned that the patient was going to sit in the community hospital ER until she got better. Even after 20mg Geodon IM x2 + Ativan she wasn't willing to give vitals or labs. She was extremely psychotic. She certainly didn't have capacity to refuse labs if it were a question of delirium. But is it worth restraining her for? I don't know. The breathylzer is a good idea - less invasive and she'd be more likely to accept.

    So to summarize I saw myself as having two options:
    1) Keep her in the ED until something changed (she agreed to get labs or got better) - which could be >24hrs
    2) Restrain her to get the labs to facilitate the transfer


    Which one would you pick? Is there a third option?


    I'm putting this out there, and really enjoying everyone's advice, because I'm nearing the end of my residency and I feel as though I should have complete mastery over this situation by now. I've had plenty of ED docs restrain psych patients to get labs - but I've never been the one myself to do so. Of course, I'm just a consultant, but I feel like I should know the answer to this.
    Last edited: Apr 7, 2012
  8. strangeglove

    strangeglove

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    The lack of a unit that accepts involuntary admissions is not a good reason to restrain anyone for any reason. The only reason that matters is if not getting the labs would result in a threat of serious physical danger. If she needs to have her entire stabilization occur in the ED, so be it.
  9. billypilgrim37

    billypilgrim37 Unstuck in Time

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    110% agree.

    Unrelated note, the concept of a voluntary unit is so bizarre to me.
  10. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    As an EM doc, psychiatrists have never done the medical evaluation - ever - wherever I've been. Where I was a resident, they used to, until there was a bad miss. Then they didn't do it anymore.

    If I got such a floridly agitated patient, I would try some way (chemically) to bring them down, so that I could determine to the best of my ability that the cause wasn't something metabolic. I don't know specifically how someone could be so agitated without being a danger to others (if not simply because of swinging limbs or flailing about). That opens the door to restraint.

    And then what to use - 20mg Haldol will soak just about every single receptor, or 40mg or 80mg Geodon IM (although that 80 makes me a bit leery). I would posit that a patient without response to high dose antipsychotics and benzos deserves an even more involved search for sub-tentorial causes.
  11. kugel

    kugel

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    Couple of points:
    I agree completely with the other posts that this is one of the situations that can result in battery charges. In order to proceed with labs against her will, you would need to show that the pt. cannot consent (clearly does not understand the risks/benefits, documentation should probably show actual quotes from you and her after asking questions multiple ways) AND that the need for those labs is immediately life-threatening - not just might be life threatening if such and such condition possibly exists. For example, admitted massive overdose of lithium or acetaminophen.
    If you use sedation, you are no more permitted to do labs after sedation against her stated will than you were when awake. The principle of "presumed consent" does Not apply when you have stated refusal from someone capable of refusal before the sedation. Waiting for someone to go unconscious and then committing medical battery is still battery.

    On another issue:

    EMTALA regs apply to any hospital which receives any payments from Medicare or Medicaid, even free-standing psych hospitals. If you facility is licensed as a hospital and receives such funds, you are bound by EMTALA.
    EMTALA regs clearly state that whether a pt. is "medically stable" for transport is a decision made by the sending doc, NOT the receiving doc. If the sending doc feels the pt is medically stable (with or without labs), then the receiving doc cannot refuse the transfer. If you have capacity (beds) and capability (you have the needed program/facility), then you cannot refuse the transfer from a hospital that has identified a medical emergency (and psych emergencies do count) for which the sending hospital lacks either capacity or capability. If the pt has shown no signs of serious medical deterioration (and I would be admitting the pt to my own inpt psych unit if I had beds), then the receiving hospital cannot demand any particular medical interventions or tests before accepting the transfer. The Only acceptable reasons for refusing the transfer (per EMTALA regs) is lack of capacity or capability. And if you claim lack of either, and the feds find out you were less than truthful - you're in for a terrible headache and Could be fined personally as well as institutionally. For instance, if you claim you do not have the capability to accept pt's in ETOH w/d, but you have done so, even in rare circumstances, in the past, then you may have committed an EMTALA violation. Even in regards to capacity, if you have sometimes accepted pt's above your stated bed capacity for any reasons other than local disaster protocols, then the feds may well consider you to have the capacity you have used before. For instance, the feds have declared EMTALA violations against hospitals which refused a transfer on the grounds of lack of capacity, but which sometimes admit 5-6 pt's to a 4-person room when their own ER is overcrowded.

    Oh, BTW, not reporting an EMTALA violation (like a hospital refusing a transfer) is an EMTALA violation. So sending hospitals must report the EMTALA violation of a hospital that refuses transfer because "we don't think that patient is medically stable."

    See attachment for details.
    Don't take my word for it (ever). Look it up on the CMS website and talk to your facility's Risk Mgt attorney.

    So, you might just have to wait in the ER for 8-12 hrs to show the pt is not rapidly deteriorating, then transfer the pt.

    Attached Files:

  12. BobA

    BobA Member

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    This blows my mind. I was taught just the OPPOSITE in residency - that the reciving hospital decides if someone is medically stable and it's the job of the sending hospital to do enough of a work up to convince the recieving hospital of this. Clearly, you've backed up your facts well with the attachment. I'm going to have to talk to my PD about this. This, BTW, explains the ultimate outcome - the reciving hospital accepted the patient even without the medical work up. I was pleasantly surprised.

    It's a totally different ball game. It does create a nice therapeutic mileau and allows for groups that target a higher functioning population (people at least with enough insight to know they need to be in the hospital). The nurses spend more time meeting with patients for mini-therapy sessions and essentially no time on behavioral codes, etc.

    I agree - but it's tough to swallow that the patient has to remain in the ED indefinitely.
    Last edited: Apr 8, 2012
  13. BobA

    BobA Member

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    I always review the ED doc's medical clearance very carefully because I've been dumped on several times. I take a pretty hands-on approach because I know what's going to make me comfortable admitting a patient to a unit I'm responsible for.
  14. BobA

    BobA Member

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    I don't see where this is in that word document you posted. I do see that reciving facilities must accept "appropriate transfers", but I don't see where it outlines which doc decides what "appropriate" is.

    I can't imagine it'd be true anyway. For instance, just last night an ED doc tried to transfer me an elderly female patient who resides in assisted living and who happens to have schizophrenia for AMS without getting a UA. That's a completely inappropriate transfer and I felt justified saying "no" until they got a UA. (it turns out they didn't have a UTI and I accepted them once I got that information)

    Similarly, this patient I saw in the OP had both severe alcohol dependence with a h/o DTs and schizophrenia. The ED couldn't even get a BAL on her. I was surprised that the recieving facility accepted her (but at least they do have a full dual diagnosis detox unit) without that information. I would feel justified saying "no" to that transfer if I were the recieving facility -but I'm glad they didn't!
  15. splik

    splik

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    You said the patient was not delirious and then go on to say you want to look for a cause for delirium, something you believed not to be present in this patient?! Seeing as delirium is a clinical diagnosis, no labs would have helped you confirm or refute the diagnosis, and may have sent you on a wild goose chase. You diagnosis is as good as your clinical assessment is. No more, no less. This is regardless of whether you had labs or not. Pancreatitis does not present with psychosis (whilst delirium may be part of it, but the presentation would almost certainly be pain - it hurts A LOT), and you excluded acute intoxication thus there was no pressing need to get a BAL. I like having baseline labs on patients prior to admission to a psych i/p unit but there is nothing that was pressing here. It is very difficult to safely get labs from an acutely agitated patient - the last time i tried to restrain such a patient, he hit me, kicked a nurse, and I almost gave myself a needlestick injury.

    Now if the case was acute agitation and AMS in a transplant patient with no past psychiatric history (I had a patient like this once) then yes I would restrain with benzos and haldol and get labs, and do an LP under anesthesia if I had to before admitting to psych. (In this case the patient had CMV encephalitis so it was good we didn't just turf to psych).

    Quite apart from the legal issues, it would have been ethically questionable to restrain the patient in your case. It can be extremely distressing to be restrained and many patients report PTSD-like symptoms following forcible treatment/restraint. You have to have a very good reason for doing so such as in the above scenario where to have not restrained the patient for clinical investigation would have been disastrous.
  16. NJWxMan

    NJWxMan

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    20 mg of Haldol is wayyy too much. You are not doing a patient any good by going over 5 mg.

  17. kugel

    kugel

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    I had thought that provision was in the doc I attached. Sorry.
    But it is true. CMS has decided over and over that only the physician currently treating the patient has the ability (and responsibility) to decide if the patient is medically stable for transfer.
    I will track that down for you. Look for it soon.

    The term "appropriate transfer" has nothing to do with whether the receiving physician thinks more tests should have been done. It has to do with whether the pt requires specialized care that is not available at the sending hospital and whether the sending hospital has attempted to stabilize the emergency medical condition.
  18. NJWxMan

    NJWxMan

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    In my psychiatric ED, where we have approximately 20-30 patients at any given second of the day, there's a good reason that we get a BAC on most patients. If I had a nickel for every patient that said that they "didn't drink" or that "appeared to not be intoxicated" I could have retired this past year. I think a BAC and vitals on this woman would have been really helpful. Granted, the vitals might useless if she is running around the psych ED in an agitated state.

  19. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    10 is the max I give. 20 would be, as I said, soaking just about every receptor.
  20. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    Wait a minute - two things. First, "completely inappropriate" - hyperbole much? "Completely inappropriate" for a psych transfer would be a pt with no SI, no HI, not psychotic, no Ψ history, who is complaining of pain from their gall bladder. Not getting the UA is one item, and an incomplete workup. However, "completely"? Really?

    And, secondarily - I've never admitted AMS to anything but IM, never heard of anyone doing it, and don't know any psychiatrists that would accept undifferentiated AMS. Or was this patient, with a history of schizophrenia, psychotic? And, having worked coast to coast, I've never had a problem admitting to IM, save once - for a dextromethorphan intention overconsumption, which the senior resident, who was moonlighting doing admissions, was a Duke ├╝ber-brainy that would spend more time arguing admissions than it would take to actually do the admission. As an attending, no pushback at all.
  21. BobA

    BobA Member

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    Yes - it's inappropriate to not get a UA on a elderly female with an acute change in her cognition. Just because she has schizophrenia doesn't mean she can't become delirious like anyone else.
  22. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    That's some good concrete thinking there.

    I am not saying it is not inappropriate - again, read my post - but your assertion to throw the baby out with the bathwater sounds hyperbolic. People make mistakes - if one was forgotten to be ordered, would you get all bent out of shape and say that on the phone - "You didn't get a UA? This transfer is completely inappropriate." Really? Does not sound collegial. Or, is that your speed - "appropriate" or "completely inappropriate"?

    I mean, to belabor the point, a "completely inappropriate" transfer is one you can't make right, at all. If it's a forgotten test, then that's not "completely" anything. Get the UA, and, if negative, the transfer is on. Made right.
  23. BobA

    BobA Member

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    I think you're missing the point - I couldn't admit this patient to my unit (not that I would without a set of vitals, and BAL at the very least). I had to transfer her. A receiving hospital is unlikely to accept a transfer from another hospital without some objective measure of the patient's clinical status. The doc on the receiving end can't actually see the patient, has no idea who I or the ED docs are, and so the objective evidence becomes very important in these situations.
  24. BobA

    BobA Member

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    Thanks everyone for a lively discussion. I learned a lot and it was good to hear different perspectives!
  25. kugel

    kugel

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    EMTALA Transfers:
    So here are answers about who gets to decide what is "medically stable" for transport, from the CMS regs and guidelines, from US Circuit Court, and from a large professional organization.

    The obligations of receiving hospitals are found at 42 USC 1395dd(g), 42 CFR 489.24(f) and in the Interpretive Guidelines at tag no. A-2411/C-2411.

    In the case St. Anthony Hospital v. U.S Department of Health and Human Services, 309 F.3d 680 (a 2002 case for the 10th Circuit), an Oklahoma hospital got in trouble for refusing a trauma patient because the on-call thoracic and vascular surgeon refused to accept the case. The appellate court said:

    We note that a practical matter, however, any hospital with specialized capabilities or facilities that refuses a request to transfer an unstabilized patient risks violating (EMTALA) to the extent that it chooses to second-guess the medical judgement of the transferring hospital.

    The issue of conditioning the acceptance of a transfer on additional tests, etc. is discussed in a 2007 CMS memorandum (S&C 07-20) subsequently incorporated in tag. no A-2411/C-2411 of the Interpretive Guidelines..., CMS declared that placing conditions on the acceptance of transfers is disfavored by CMS, and will likely subject the receiving hospital to an EMTALA violation. In addition, CMS has cautioned hospitals against patient delays or disparate treatment of patients based on financial or insurance status...

    The California Hospital Association manual on EMTALA goes on to add a Compliance Tip:
    It is strongly recommended that conditions for accepting a transfer not be made on an ad hoc basis at the time of a requested transfer, because the discussions could delay an appropriate transfer of an emergency patient. Instead, arrangements should be handled in advance through transfer agreements between hospitals.

    And, most importantly, at page 7.11, describing tips for managing the transfer acceptance process:

    Do not place conditions on the transfer, including requests for the sending hospital to perform more tests, use a specific mode of transport, or take the patient back after the stabilizing services are performed.


    Where I work, I have NO lab/test capability, no IV's, etc., so I'm completely dependent on the ED workup in that regard. But I cannot demand any additional tests without risking an EMTALA violation on the hospital AND on myself.
    Therefore, when I'm faced with a transfer request that is missing some data I'd really like (Trazodone OD with only 1 EKG done 30min post OD, or 79 yo suddenly incoherent w/o any imaging) I can suggest the tests I'd like and the reasons why they would be very helpful. When I explain myself and make polite requests, I usually get the results I'm after.

    Hope this helps
  26. BobA

    BobA Member

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    Very helpful - thanks!

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