Sorry about the wall of text.
I'm currently embroiled in a tense debate with our hospital ED due to boarded patients. Unfortunately our inpatient psych service is understaffed so we can't always get to the patients in the ED waiting on inpatient care (sometimes we can't get to all the patients on the psych unit due to pressure beyond our control). Our hospital is trying to hire more doctors, but who knows how long that will take.
One of the points at issue is the term "decision to admit". When we staff a patient with the ED and advise the patient needs inpatient care, they state there has been a "decision to admit", they then enter an admit order and list the on call psychiatrist as the attending. When we have open psych beds it's no problem, we just transfer them over. But, this creates problems for boarded patients, because now we're listed as the attending for a patient stuck in the ED who we may or may not be able to see that day, or the next day if it's an overnight call. When patients are boarding the psych unit is at capacity, so we're less able to see any patients off the psych unit at these times. In addition, the ED docs now want us to essentially take over as attending and manage every aspect of the patient's care
The ED has tried to argue this as an EMTALA issue, and psychiatry is obligated to be the attending doctor for patients in the ED and enter all med orders, diet orders, etc. But as far as I can tell, EMTALA no longer applies once a patient is stable; which for psychiatric patients does not mean for example that their SI has resolved, but rather they are in a safe environment and prevented from harming themselves or others.
My contention is that when we don't have an inpatient unit bed for the patient we are not "deciding to admit" them. Rather we are advising they need inpatient care, but we cannot accept them for admission due to lack of facility capacity. At that point there would be a consult request and we would try to see the patient in consultation as soon as reasonably possible, but given staffing limitations, there are often delays. In the meantime I'd argue the ED doctor needs to maintain responsibility as the attending physician while the patient remains in the ED, make sure they are at least on home meds.
The frustrating part is we don't have the provider bandwidth to take on all ED boarders all the time. And the ED is trying to strong arm us with threats of EMTALA into taking on this responsibility.
Has anyone been through this? Any advice?
I'm currently embroiled in a tense debate with our hospital ED due to boarded patients. Unfortunately our inpatient psych service is understaffed so we can't always get to the patients in the ED waiting on inpatient care (sometimes we can't get to all the patients on the psych unit due to pressure beyond our control). Our hospital is trying to hire more doctors, but who knows how long that will take.
One of the points at issue is the term "decision to admit". When we staff a patient with the ED and advise the patient needs inpatient care, they state there has been a "decision to admit", they then enter an admit order and list the on call psychiatrist as the attending. When we have open psych beds it's no problem, we just transfer them over. But, this creates problems for boarded patients, because now we're listed as the attending for a patient stuck in the ED who we may or may not be able to see that day, or the next day if it's an overnight call. When patients are boarding the psych unit is at capacity, so we're less able to see any patients off the psych unit at these times. In addition, the ED docs now want us to essentially take over as attending and manage every aspect of the patient's care
The ED has tried to argue this as an EMTALA issue, and psychiatry is obligated to be the attending doctor for patients in the ED and enter all med orders, diet orders, etc. But as far as I can tell, EMTALA no longer applies once a patient is stable; which for psychiatric patients does not mean for example that their SI has resolved, but rather they are in a safe environment and prevented from harming themselves or others.
My contention is that when we don't have an inpatient unit bed for the patient we are not "deciding to admit" them. Rather we are advising they need inpatient care, but we cannot accept them for admission due to lack of facility capacity. At that point there would be a consult request and we would try to see the patient in consultation as soon as reasonably possible, but given staffing limitations, there are often delays. In the meantime I'd argue the ED doctor needs to maintain responsibility as the attending physician while the patient remains in the ED, make sure they are at least on home meds.
The frustrating part is we don't have the provider bandwidth to take on all ED boarders all the time. And the ED is trying to strong arm us with threats of EMTALA into taking on this responsibility.
Has anyone been through this? Any advice?
