ED boarders

[nexus73]

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Hypothetical case example:

Setting: Community hospital ED with inpatient adult psych unit attached.

39 year old male with psychosis presents to ED with law enforcement, off meds x 2 weeks he is hallucinating, delusional, agitated. Medically evaluated and cleared by ED doctor. ED doctor provides one time Zyprexa 10 mg PO and patient calms some, PRN Zyprexa available for agitation which helps overnight. Patient meets criteria for psych admission at 10 pm, but no beds, so patient is boarding in ED, psych consult order is entered. ED doctor starts patient's established home meds, or if questions discusses over the phone with on call psychiatrist. Next day, psychiatry sees patient for consult and follows them daily while boarding in ED, with transfer to psych unit once bed available.

Per policy psychiatry must see patient within 24 hours of consult order, but will typically see patient before noon, on rare circumstances seen by 2-3 pm depending on unit acuity and other patient needs.

====================================================================================================================


To me this seems like a reasonable process for boarded patient care.

Am I missing any gaps where improvement could reasonably be made.

 

[Sushirolls]

1) State laws impact these situations of what can and can't be done.
2) Hospital bylaws impact nature of consultant role and timing of consults, etc.

3) If psychosis improves, discharge? Ideally have on LAI, so you can just give the LAI in the ED and hopefully expedite discharge? Have an understanding of patient baseline functioning so you know if achieved in the ED? Know your hold/detention laws, and if can't justify, discharge. Maybe there is a better IM floor than the ED to temporary transfer to just to get out of ED, if you know you have a long wait to transfer? Are the ED SW calling BID or per shift, every single admitting facility in state to assess their access? Even if a facility on other side of state 5 hours away has a bed, do the transfer and call for transport.

Could even keep it as a true consultant role, put recs in chart, then verbally discuss with EM of record (attending) and be sure they place the orders, and document who/when you verbally discussed with. I've seen some EDs not even register the patient with an EM. They are 'attendingless' so force/remind the EM that it is their patient, and they need to do their job.

 

[Sushirolls]

Fiji water.
PRN restaurant food service, gratis of hospital.
Single room, no roommate, customizable heat/cold controls.
Quality speakers in room with Bluetooth capability to play what you want.

 

[comp1]

It sounds reasonable, sure. But I second that this specifics of this are going to be state law based.

 

[Merovinge]

Fiji water.
PRN restaurant food service, gratis of hospital.
Single room, no roommate, customizable heat/cold controls.
Quality speakers in room with Bluetooth capability to play what you want.

So my local dollar tree actually sells Fiji water, I could not believe it. I go for the staples of shaving cream and $1 fanciest crest toothpaste (it may do the same thing to my teeth but man does it taste great) and was wondering who falls into the crossover of Fiji water drinker and dollar tree consumer.

 

[nexus73]

It sounds reasonable, sure. But I second that this specifics of this are going to be state law based.

Can you expand and give me worst case scenario for the psychiatrists depending on state law? I don’t understand how state law effects management of boarders. Maybe my state doesn’t have specific legislation or case law in this area.

 

[comp1]

Well, in California the ED doctor just on their say so can hold a patient involuntarily for 24 hours on something called a 1799. I'm not sure how exactly this could go wrong in terms of a worst case scenario.

 

[Sushirolls]

Can you expand and give me worst case scenario for the psychiatrists depending on state law? I don’t understand how state law effects management of boarders. Maybe my state doesn’t have specific legislation or case law in this area.

Some states forbid boarding, unless a state issued hold is done. So you either have to discharge after X time or start the process to get that type of hold...

 

[erg923]

I go for the staples of shaving cream

Does it feel like you are cutting barbed wire with that "goo in a can" stuff? Cant you docs afford some Saville Row, Truefitt & Hill, etc.... or at least Cremo for that pretty face of yours?! Jeez.

 

[nexus73]

Thanks, sorry for not being clear.

Assuming this patient was somehow voluntary or on a legal hold and boarding them in the ED wasn't illegal. Does the response time for a psych consult seem reasonable? Is this a standard setup for community hospitals with an inpatient psych unit? Is this hypothetical psych consult service waiting too long to see the boarded patient, eg should psychiatrist be coming in at 10 pm or arriving at 6am, 7am and seeing boarded patient first thing in the morning?

 

[comp1]

Oh okay, I get it. So...if you want to keep psychiatrists actually continuing to work for you, they should not be called in overnight. That's not standard and any psychiatrists asked to do this would need to be paid significantly more than normal. I know some residencies make their residents do it, but even that is on the decline. A curbside in the situation you described seems very appropriate.

 

[Merovinge]

Does it feel like you are cutting barbed wire with that "goo in a can" stuff? Cant you docs afford some Saville Row, Truefitt & Hill, etc.... or at least Cremo for that pretty face of yours?! Jeez.

Something that reminds me of childhood using Barbasol, I've never noticed a difference but maybe I should branch out at this point...

 

[erg923]

Something that reminds me of childhood using Barbasol, I've never noticed a difference but maybe I should branch out at this point...

The face skin should be actually moisturized and lubricated before shaving...is all I am saying 🙂

 

[nexus73]

Oh okay, I get it. So...if you want to keep psychiatrists actually continuing to work for you, they should not be called in overnight. That's not standard and any psychiatrists asked to do this would need to be paid significantly more than normal. I know some residencies make their residents do it, but even that is on the decline. A curbside in the situation you described seems very appropriate.

How early the next day do you think a psychiatrist should see boarders? Noon, 7am?

 

[Sushirolls]

24 hours from time stamp of order on the EMR to consult being started is probably routine.

Anything faster than that the hospital needs to penny up for 24/7 locums coverage, or have resident coverage, or moonlighting coverage, etc.

The tricky thing is... ED docs will some times place the order as soon as the patient gets brought back, but then they don't call for the actual consult until 5 hours later. So you think you have 24hrs, but you actually have 19hrs, and once you finally do the consult you realize time just lapsed.... thank you ED docs for that...

 

[comp1]

Unless the psychiatrists are salaried, I'm not sure you'll get to pick exactly what time they see the consults. At my salaried positions, it depended on the work schedule. Some physicians have a 4 day 10 hour week, so they would see the consult at 7 AM. And some are on a more regular 8-4:30 kind of schedule, so the consult would be seen around 8 AM.

 

[Sushirolls]

I once interviewed at a place where the Psych med dir went and told the rest of the hospital, Psychiatry was no longer doing C/L consults nor ED consults. Merely IP and OP - take it or leave. This med dir got his wish.

 

[Mass Effect]

Thanks, sorry for not being clear.

Assuming this patient was somehow voluntary or on a legal hold and boarding them in the ED wasn't illegal. Does the response time for a psych consult seem reasonable? Is this a standard setup for community hospitals with an inpatient psych unit? Is this hypothetical psych consult service waiting too long to see the boarded patient, eg should psychiatrist be coming in at 10 pm or arriving at 6am, 7am and seeing boarded patient first thing in the morning?

No, I don't think it's reasonable. For one, patients on legal hold (even if compliant with state laws) should be evaluated faster than 24 hours to determine if the hold is necessary. It may be by a max of 24 hours, but that should be due to volume rather than just giving the consultant the time. No other consultant would say "give me 24 hours and I'll see the patient". Now if the patient is completely 100% voluntary, maybe, but even then, I think it's bad for the hospital and other patients.

Second, the ED should not have psych patients boarding just because you can't get a psychiatrist there for 24 hours. That's horribly inefficient and just a bad service overall. Yes I know that technically that's the rule legally but psych services that actually run well don't do that, especially in the ED. If the patient is on medicine, it's easier to justify given that the patient will be there tomorrow too.

Oh okay, I get it. So...if you want to keep psychiatrists actually continuing to work for you, they should not be called in overnight. That's not standard and any psychiatrists asked to do this would need to be paid significantly more than normal. I know some residencies make their residents do it, but even that is on the decline. A curbside in the situation you described seems very appropriate.

I disagree. I have never worked at any hospital that didn't dispo ED patients overnight. The patients on the med/surg wards can wait, but ED patients should be evaluated. In some cases they're evaluated by a psych social worker if it's voluntary and they just need to be triaged and bed search started. In other cases, it's by a psychiatrist either in person or via telemedicine.

 

[nexus73]

No, I don't think it's reasonable. For one, patients on legal hold (even if compliant with state laws) should be evaluated faster than 24 hours to determine if the hold is necessary. It may be by a max of 24 hours, but that should be due to volume rather than just giving the consultant the time. No other consultant would say "give me 24 hours and I'll see the patient". Now if the patient is completely 100% voluntary, maybe, but even then, I think it's bad for the hospital and other patients.

Second, the ED should not have psych patients boarding just because you can't get a psychiatrist there for 24 hours. That's horribly inefficient and just a bad service overall. Yes I know that technically that's the rule legally but psych services that actually run well don't do that, especially in the ED. If the patient is on medicine, it's easier to justify given that the patient will be there tomorrow too.



I disagree. I have never worked at any hospital that didn't dispo ED patients overnight. The patients on the med/surg wards can wait, but ED patients should be evaluated. In some cases they're evaluated by a psych social worker if it's voluntary and they just need to be triaged and bed search started. In other cases, it's by a psychiatrist either in person or via telemedicine.

I know it's hard to convey things clearly thru text only. In my example, the patients don't sit and wait for a psychiatrist. There is psych triage overnight with social workers and if someone needs admitted and there is a bed, the patient is admitted to the psych unit (seen next morning by psych MD). It's only the people meeting admit criteria and there isn't a bed who become boarders. If someone goes thru psych triage and can discharge they discharge.

My question is to see what people think is a reasonable amount of time to pass between the 10pm decision to admit (but no beds so pt is boarding) until a psychiatrist gets down to the ED to do the psych admission/consult? And remember this is for a community hospital, not an academic center with PES and/or pysch residents in house 24/7. Do you think psychiatrist should come in at 10pm, 7am next day, by noon next day, etc? Current policy is up to 24 hours, but it would rarely if ever take that long.

 

[Mass Effect]

I know it's hard to convey things clearly thru text only. In my example, the patients don't sit and wait for a psychiatrist. There is psych triage overnight with social workers and if someone needs admitted and there is a bed, the patient is admitted to the psych unit (seen next morning by psych MD). It's only the people meeting admit criteria and there isn't a bed who become boarders. If someone goes thru psych triage and can discharge they discharge.

My question is to see what people think is a reasonable amount of time to pass between the 10pm decision to admit (but no beds so pt is boarding) until a psychiatrist gets down to the ED to do the psych admission/consult? And remember this is for a community hospital, not an academic center with PES and/or pysch residents in house 24/7. Do you think psychiatrist should come in at 10pm, 7am next day, by noon next day, etc? Current policy is up to 24 hours, but it would rarely if ever take that long.

So if there is a bed on the psych unit, can the patient be admitted overnight? I mean, if what you're saying is that if a patient goes through triage, it's determined they meet IPLOC and there's no bed, is it ok to wait until the next day for a psych consult in the ED? The answer to that is yes (but it should be the first/one of the first things the psychiatrist does in the am; no reason to wait "up to 24 hours.") But if the patient can't be admitted to the unit even if there's a bed available, no, this isn't ok.

 

[nexus73]

So if there is a bed on the psych unit, can the patient be admitted overnight? I mean, if what you're saying is that if a patient goes through triage, it's determined they meet IPLOC and there's no bed, is it ok to wait until the next day for a psych consult in the ED? The answer to that is yes (but it should be the first/one of the first things the psychiatrist does in the am; no reason to wait "up to 24 hours.") But if the patient can't be admitted to the unit even if there's a bed available, no, this isn't ok.

If patient requires inpatient level of care and there's a psych unit bed available the patient is admitted into it anytime of day, even overnight. They don't wait in the ED in that scenario.

And I agree that sooner is better for psych to get to the ED boarder. For example, psych would typically prioritize ED boarder the next morning, but if a patient on the unit was highly agitated, psychiatrist might see that patient first thing. Or if there is a patient who will discharge to make room for the ED boarder, they could see that person first so there is actually a bed for the patient in the ED to admit into.

Just curious, are you an inpatient psychiatrist?

 

[Mass Effect]

If patient requires inpatient level of care and there's a psych unit bed available the patient is admitted into it anytime of day, even overnight. They don't wait in the ED in that scenario.

And I agree that sooner is better for psych to get to the ED boarder. For example, psych would typically prioritize ED boarder the next morning, but if a patient on the unit was highly agitated, psychiatrist might see that patient first thing. Or if there is a patient who will discharge to make room for the ED boarder, they could see that person first so there is actually a bed for the patient in the ED to admit into.

Just curious, are you an inpatient psychiatrist?

I just left an inpatient job. I'm now in a model that's outpatient with CL split between several of us so I do CL one week a month, including ED.

 

[hebel]

I just left an inpatient job. I'm now in a model that's outpatient with CL split between several of us so I do CL one week a month, including ED.

Is your outpatient load lighter or clear during the CL week?

 

[Mass Effect]

Is your outpatient load lighter or clear during the CL week?

Yes for the most part. It's blocked, but if I have a patient I'm worried about or a patient I'd like to see, I can ask for it to be opened for that specific patient.

 

[nexus73]

I just left an inpatient job. I'm now in a model that's outpatient with CL split between several of us so I do CL one week a month, including ED.

How is your service staffed? We've considered a consult/ED position, either assigned to one person or rotating, but volume is pretty low so not necessarily 1.0 FTE. Plus nobody has been interested in that role.

 

[Mass Effect]

How is your service staffed? We've considered a consult/ED position, either assigned to one person or rotating, but volume is pretty low so not necessarily 1.0 FTE. Plus nobody has been interested in that role.

We have about 8 general adult attendings. 4-5 of us take turns doing CL because we like it. Volume is hit or miss. Some weeks, it's dead and other weeks, it's too much for one person so we have a backup system if it gets crazy. My colleague worked a day when he got 12 consults so someone else went in to see 3 of them that afternoon. Other days, we'll be lucky to get 2 consults the whole day.

 

[robellis]

We have about 8 general adult attendings. 4-5 of us take turns doing CL because we like it. Volume is hit or miss. Some weeks, it's dead and other weeks, it's too much for one person so we have a backup system if it gets crazy. My colleague worked a day when he got 12 consults so someone else went in to see 3 of them that afternoon. Other days, we'll be lucky to get 2 consults the whole day.

You’re paid on wrvu?

 

[Mass Effect]

You’re paid on wrvu?

Base salary plus rvu.

 

[Psych19]

A related billing question--

If the patient is sitting in the ED for several days, you see them as a consult, and then you see them daily thereafter until a bed becomes available...

For the initial consult I imagine you can bill either 90792 or 99203/4/5.

What about subsequent days the patient is still in ED waiting for a bed. 99213/4/5?

I know that the day they come up to the psych unit, even if they are seen in the ED earlier in the day, you would choose an admission code (i.e. 99223)

 

[robellis]

Base salary plus rvu.

How much per wrvu after base

 

[splik]

A related billing question--

If the patient is sitting in the ED for several days, you see them as a consult, and then you see them daily thereafter until a bed becomes available...

For the initial consult I imagine you can bill either 90792 or 99203/4/5.

What about subsequent days the patient is still in ED waiting for a bed. 99213/4/5?

I know that the day they come up to the psych unit, even if they are seen in the ED earlier in the day, you would choose an admission code (i.e. 99223)

You would use 90792 for the initial visit (you could technically use outpatient codes but it rarely makes sense). You use emergency codes 99281-99285 for follow ups for boarding pts. It will usually be a level 3 or level 4 follow up.

 

[hebel]

You would use 90792 for the initial visit (you could technically use outpatient codes but it rarely makes sense). You use emergency codes 99281-99285 for follow ups for boarding pts. It will usually be a level 3 or level 4 follow up.

I typically work outpatient, so am less familiar with inpatient and don't trust what I've been told to bill.

So from what your wrote...

For ED: consults can be 90792 and f/u are 99281-99285.

Would this be the same for CL?

 

[splik]

I typically work outpatient, so am less familiar with inpatient and don't trust what I've been told to bill.

So from what your wrote...

For ED: consults can be 90792 and f/u are 99281-99285.

Would this be the same for CL?

99281-99285 are ED codes so can only be used in the ED. They cant be used on day one if the ER doc is also seeing the patient (only one per day) but can be used for follow up.

For floor consults you would use the inpatient codes. 90792 is best for initial evals, and 99231-99233 for follow ups. There are inpatient consult codes but medicare doesn't pay for them and as of last year almost all payers stopped paying for them too and for those in a wRVU position, 90792 now worth more wRVUs than a level 5 consult code anyway. That said, I do not recommend doing C-L on a RVU basis, because of the variability and time spent in uncompensated activities (if doing the job well). Instead it should be on a flat salary, per hour, or per shift basis.

 

[hamstergang]

What about subsequent days the patient is still in ED waiting for a bed. 99213/4/5?

I, and others at my hospital, use these outpatient E&M codes for ED consult follow ups (the ED docs remain primary each day and bill their ED codes).

 

[hebel]

99281-99285 are ED codes so can only be used in the ED. They cant be used on day one if the ER doc is also seeing the patient (only one per day) but can be used for follow up.

For floor consults you would use the inpatient codes. 90792 is best for initial evals, and 99231-99233 for follow ups. There are inpatient consult codes but medicare doesn't pay for them and as of last year almost all payers stopped paying for them too and for those in a wRVU position, 90792 now worth more wRVUs than a level 5 consult code anyway. That said, I do not recommend doing C-L on a RVU basis, because of the variability and time spent in uncompensated activities (if doing the job well). Instead it should be on a flat salary, per hour, or per shift basis.

What do you think of the 99221-99223 codes for CL consults? Looks like 90792 is simpler to document and higher wRVU.

And for the forum, to sum up and make sure I understand this correctly:

ED Initial Consult: 90792
ED Boarding F/U: 99281-99285 or 99213-99215

CL Initial Consult: 90792
CL Follow-Up: 99231-99233

Inpatient Psych unit: same as CL?

For the codes other than the 90792 (and maybe 99213-99215), I assume most people bill by time?

 

[Stagg737]

That said, I do not recommend doing C-L on a RVU basis, because of the variability and time spent in uncompensated activities (if doing the job well). Instead it should be on a flat salary, per hour, or per shift basis.

Can you elaborate on this? I can see this being reasonable on relatively easy C/L services, but for busy services where there's a constant stream of new consults seems like at least having some available Bonus after hitting base RVUs would still be preferable.

 

[splik]

Can you elaborate on this? I can see this being reasonable on relatively easy C/L services, but for busy services where there's a constant stream of new consults seems like at least having some available Bonus after hitting base RVUs would still be preferable.

Each to their own I guess, but I would not want to work on a service where the volume was so high you don’t have a chance to spend time doing the important stuff like the liaison roles which is where a lot of the fun of working in this setting comes from. Another model that can be used is getting paid per consult either for additional work or just in general with a baseline daily rate for being available.

 

[nexus73]

Each to their own I guess, but I would not want to work on a service where the volume was so high you don’t have a chance to spend time doing the important stuff like the liaison roles which is where a lot of the fun of working in this setting comes from. Another model that can be used is getting paid per consult either for additional work or just in general with a baseline daily rate for being available.

In your expert witness work have you seen any liability for psychiatrists when it comes to boarded ED patients?

 

[Stagg737]

Another model that can be used is getting paid per consult either for additional work

Wouldn't this just be the same as a base salary + RVU bonus though? If not, then I'm not sure what you're saying. Also curious what you're referring to specifically with "liaison roles". Just the discussion with other physicians and healthcare professionals? Because I also agree that a caseload busy enough to prohibit this (in the worthwhile cases) would not be a position I would want.

 

[robellis]

In your expert witness work have you seen any liability for psychiatrists when it comes to boarded ED patients?

What kind of liability could there be? Liability is so overblown people are so paranoid when it comes to actual lawsuits that occur and real payouts and such

 

[ridethecliche]

Does it feel like you are cutting barbed wire with that "goo in a can" stuff? Cant you docs afford some Saville Row, Truefitt & Hill, etc.... or at least Cremo for that pretty face of yours?! Jeez.

Something that reminds me of childhood using Barbasol, I've never noticed a difference but maybe I should branch out at this point...

The face skin should be actually moisturized and lubricated before shaving...is all I am saying 🙂

I just use conditioner.

Come at me.

 

[Merovinge]

Wouldn't this just be the same as a base salary + RVU bonus though? If not, then I'm not sure what you're saying. Also curious what you're referring to specifically with "liaison roles". Just the discussion with other physicians and healthcare professionals? Because I also agree that a caseload busy enough to prohibit this (in the worthwhile cases) would not be a position I would want.

No it's not. In base salary + RVU bonus (say for >4000 for a CL job as a semi-random approximation) if you see enough patients to generate 3999 RVUs you got paid exactly 0 dollars extra per patient for that year. In Splik's example you got paid $xx to be available and then $yy per case which would be more like a case of a salary and then RVU bonus set at 0 RVUs (which is not how most RVU bonuses are structured).

Regardless of above, CL work is miserably time consuming per RVU generated and easily the least lucrative way a person can spend time in psychiatry if you want to do anything resembling a quality job. There's a reason everyone says to only take these jobs on flat salary or per hour/shift basis. I suppose you do 15 minute evals, talk to no one, and bill level 5's often to make it worthwhile, then just not answer your phone from the 4 other people trying to get ahold of you (not that I know of any doc's who have done this...) but I cannot imagine anyone recommending that type of care.

 

[Sushirolls]

No, I don't think it's reasonable. For one, patients on legal hold (even if compliant with state laws) should be evaluated faster than 24 hours to determine if the hold is necessary. It may be by a max of 24 hours, but that should be due to volume rather than just giving the consultant the time. No other consultant would say "give me 24 hours and I'll see the patient". Now if the patient is completely 100% voluntary, maybe, but even then, I think it's bad for the hospital and other patients.

Second, the ED should not have psych patients boarding just because you can't get a psychiatrist there for 24 hours. That's horribly inefficient and just a bad service overall. Yes I know that technically that's the rule legally but psych services that actually run well don't do that, especially in the ED. If the patient is on medicine, it's easier to justify given that the patient will be there tomorrow too.



I disagree. I have never worked at any hospital that didn't dispo ED patients overnight. The patients on the med/surg wards can wait, but ED patients should be evaluated. In some cases they're evaluated by a psych social worker if it's voluntary and they just need to be triaged and bed search started. In other cases, it's by a psychiatrist either in person or via telemedicine.

Actually other consultants have and do. Waiting 23.5 hours to do the consult is completely Okay.

There is nothing wrong with taking the full 24 hours. A smaller hospital that doesn't have a designated C/L service simply won't prioritize the ED over everything else. People won't be coming in extra early before their usual IP or OP schedule just to see a patient in the ED who is on an admission track. These types of smaller hospitals typically strive to see these patients after Unit discharges / Admits are completed, or even after all IP duties are completed, then C/L, and then possibly head off to OP clinic for few hours.

Logistically the decision for admission was already made, and if the EM docs put in a modicum of thought they would continue the home meds - if they were compliant - or do a temporary cocktail of their usual. The Psychiatrist has no real added value for a patient in ED 9 out of 10 times. Rushing down there won't make a difference. Can't tell you how many times I had rushed down to the ED in one of these types of hospitals, to do a consult, and before I got around to finishing up my note later in the day, the patient was already transferred out and a bed was found some place else. Had I waited, the consult never would have happened and the same result would have come about. You need to know your hospital, your unit, your outside units and the general flow of things to further prioritize your time and that resource.

Take the 24 hours if needed. If this is an issue, then the ED and Psych medical directors need to hash things out in committees behind the scenes and consider even changing the hospital bylaws.

 

[Sushirolls]

There is no liability for a patient boarding in the ED.
The patient is the "ward" of the EM attending.
Psychiatry has no admitting privilege's to an ED unit, we are merely consultants.
All liability for the patient rests with the EM Attending Physician mid-level.

 

[Mass Effect]

Actually other consultants have and do. Waiting 23.5 hours to do the consult is completely Okay.

There is nothing wrong with taking the full 24 hours. A smaller hospital that doesn't have a designated C/L service simply won't prioritize the ED over everything else. People won't be coming in extra early before their usual IP or OP schedule just to see a patient in the ED who is on an admission track. These types of smaller hospitals typically strive to see these patients after Unit discharges / Admits are completed, or even after all IP duties are completed, then C/L, and then possibly head off to OP clinic for few hours.

Logistically the decision for admission was already made, and if the EM docs put in a modicum of thought they would continue the home meds - if they were compliant - or do a temporary cocktail of their usual. The Psychiatrist has no real added value for a patient in ED 9 out of 10 times. Rushing down there won't make a difference. Can't tell you how many times I had rushed down to the ED in one of these types of hospitals, to do a consult, and before I got around to finishing up my note later in the day, the patient was already transferred out and a bed was found some place else. Had I waited, the consult never would have happened and the same result would have come about. You need to know your hospital, your unit, your outside units and the general flow of things to further prioritize your time and that resource.

Take the 24 hours if needed. If this is an issue, then the ED and Psych medical directors need to hash things out in committees behind the scenes and consider even changing the hospital bylaws.

Has there ever been a time that 24 hours has been necessary? I think it's a very, very rare occasion that someone legitimately can't see a consult before 24 hours.

There is no liability for a patient boarding in the ED.
The patient is the "ward" of the EM attending.
Psychiatry has no admitting privilege's to an ED unit, we are merely consultants.
All liability for the patient rests with the EM Attending Physician mid-level.

Of course there's liability. PD brings in a patient for suicidal statements. You see the patient, tell ED to discharge, and patient kills himself within an hour. It isn't the ED attending who's carrying the bag on that.

 

[Sushirolls]

Has there ever been a time that 24 hours has been necessary? I think it's a very, very rare occasion that someone legitimately can't see a consult before 24 hours.

Yes, and quite often for these smaller hospitals and how they do their staffing levels.

Looks like we agree to disagree.

 

[splik]

In your expert witness work have you seen any liability for psychiatrists when it comes to boarded ED patients?

Not sure what liability you are thinking about. The main thing that has come up is the constitutionality (at the state level at least) of keeping patients boarded in the ED, and whether it constitutes the "least restrictive" level of care. This does not pose any liability for the psychiatric consultant (if there even is one) but may to the hospital or local government agencies for failure to provide adequate psychiatric care or bed availability etc.

Actually, keep the patient boarding in the ED is lower liability for the psychiatric consultant than discharging a patient in crisis due to lack of beds or pressure to get patients out of the ED from on high if the patient then dies by suicide or kills someone. I have reviewed too many cases of patients being discharged from the ED and then killing a parent the next day...

 

[psychacad]

Not sure what liability you are thinking about. The main thing that has come up is the constitutionality (at the state level at least) of keeping patients boarded in the ED, and whether it constitutes the "least restrictive" level of care. This does not pose any liability for the psychiatric consultant (if there even is one) but may to the hospital or local government agencies for failure to provide adequate psychiatric care or bed availability etc.

Actually, keep the patient boarding in the ED is lower liability for the psychiatric consultant than discharging a patient in crisis due to lack of beds or pressure to get patients out of the ED from on high if the patient then dies by suicide or kills someone. I have reviewed too many cases of patients being discharged from the ED and then killing a parent the next day...

Out of curiosity, is it usually missed psychosis? I've seen many attendings discharge acutely psychotic patients who are not on meds or connected with treatment "because there is no dangerous behavior"; which is sort of like waiting for it to happen.

 

[Mass Effect]

Out of curiosity, is it usually missed psychosis? I've seen many attendings discharge acutely psychotic patients who are not on meds or connected with treatment "because there is no dangerous behavior"; which is sort of like waiting for it to happen.

Whoa, let's back up here. First, it's difficult to "miss" acute psychosis. Seeing it and still discharging is a thing. If there's no dangerous behavior and the patient doesn't want to go inpatient, you legally cannot force them to. I'm not aware of any state that will allow you to commit someone just because they're psychotic and not on meds. Holds and commitment involves some type of imminent danger. Absent that, no dice.

 

[Mass Effect]

Not sure what liability you are thinking about. The main thing that has come up is the constitutionality (at the state level at least) of keeping patients boarded in the ED, and whether it constitutes the "least restrictive" level of care.

This is why I was saying 24 hours is ridiculous. But the OP said that they're triaged and discharged before that if deemed to be not dangerous, so I'm ok with that. But the above would be my concern too. I've seen many patients in the ED who were put on a psych hold for absurd reasons (one just last week - pt at the PCP's office with acute GI illness, vomits and says he feels terrible and "I just want to die". Sent to ED for psych eval.). and if those patients had to wait 24 hours to be able to return to their lives, that wouldn't be ok, imo.