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[psychacad]

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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.

No kidding. Don't think anyone needs this med2 lecture. But the devil is in the detail. There's almost universally a decline in function (poor self hygiene, isolation, poor eating..etc) for first episode psychotic pts who make it to the ER, as well as disorganized/erratic behavior and that is admittable. I've seen pts though who were discharged because, as splik said for administrative pressure, because they didn't straight up say they would hurt themselves or others. Psychosis is tricky; when you're psychotic enough that it is significantly influencing your behavior, there's a valid argument for dangerousness. Psychosis is not always difficult to miss. Sometimes it will only show up with anxiety. Some patients are really good at hiding it and present very well, and all you would depend on is collateral.

 

[nexus73]

No kidding. Don't think anyone needs this med2 lecture. But the devil is in the detail. There's almost universally a decline in function (poor self hygiene, isolation, poor eating..etc) for first episode psychotic pts who make it to the ER, as well as disorganized/erratic behavior and that is admittable. I've seen pts though who were discharged because, as splik said for administrative pressure, because they didn't straight up say they would hurt themselves or others. Psychosis is tricky; when you're psychotic enough that it is significantly influencing your behavior, there's a valid argument for dangerousness. Psychosis is not always difficult to miss. Sometimes it will only show up with anxiety. Some patients are really good at hiding it and present very well, and all you would depend on is collateral.

At our hospital in a mid size town we have the luxury of a smaller homeless population, so if a person with psychosis comes in and is clearly not doing well, but may not be SI/HI, or not clearly gravely disabled, we're still able to get them into the hospital as we usually have enough beds. Versus big city hospital where I trained, people are chronically psychotic, and would probably be better off coming in and getting on meds (and they might even say they're glad they were forced into the hospital once their symptoms reduce), but they were sent back to the street due to more strict interpretation of admission criteria and not having enough psych beds to accommodate.

 

[nexus73]

At our hospital in a mid size town we have the luxury of a smaller homeless population, so if a person with psychosis comes in and is clearly not doing well, but may not be SI/HI, or not clearly gravely disabled, we're still able to get them into the hospital as we usually have enough beds. Versus big city hospital where I trained, people are chronically psychotic, and would probably be better off coming in and getting on meds (and they might even say they're glad they were forced into the hospital once their symptoms reduce), but they were sent back to the street due to more strict interpretation of admission criteria and not having enough psych beds to accommodate.

In the big city we also had a lot of lawyers graduating from school who couldn't find work 7-8 years ago, so these really smart people were basically Johnny Cochran at the commitment hearings, which meant your hold paperwork and process had to be perfect or they could get holds dropped (sometimes really sick people were released because a very effective lawyer was working for them through the public defenders office). In our smaller town, the lawyers are still good, but generally not quite as strong.

 

[psychacad]

At our hospital in a mid size town we have the luxury of a smaller homeless population, so if a person with psychosis comes in and is clearly not doing well, but may not be SI/HI, or not clearly gravely disabled, we're still able to get them into the hospital as we usually have enough beds. Versus big city hospital where I trained, people are chronically psychotic, and would probably be better off coming in and getting on meds (and they might even say they're glad they were forced into the hospital once their symptoms reduce), but they were sent back to the street due to more strict interpretation of admission criteria and not having enough psych beds to accommodate.

I've seen that dynamic play out as well in some of the places I work at. Luckily I can just ignore the administrative nonsense and do what's right. An ex, just last week a young pt who said some delusional stuff to the family, had some bizarre behavior (but nothing totally outright dangerous), hasn't been working for a few months, presented really well in the ER, d/ced because family didn't want them admitted and there was no 'dangerous behavior'. Comes back two days later, and I admit them. Now needing IMs/restraints on the unit, tried to jump from a window, underlying depression. If we kept with discharging them the risk of doing something outright dangerous is actually very high. Insight is also very important. I don't mess with untreated psychosis if there's clear evidence that it is changing their behav.

 

[Mass Effect]

No kidding. Don't think anyone needs this med2 lecture. But the devil is in the detail. There's almost universally a decline in function (poor self hygiene, isolation, poor eating..etc) for first episode psychotic pts who make it to the ER, as well as disorganized/erratic behavior and that is admittable. I've seen pts though who were discharged because, as splik said for administrative pressure, because they didn't straight up say they would hurt themselves or others. Psychosis is tricky; when you're psychotic enough that it is significantly influencing your behavior, there's a valid argument for dangerousness. Psychosis is not always difficult to miss. Sometimes it will only show up with anxiety. Some patients are really good at hiding it and present very well, and all you would depend on is collateral.

I can't argue against things you haven't yet said. I was responding to the following:

"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."

Your argument now is taking into account things that CAN make someone dangerous. But if there is no imminent danger at time you see them (even if they are eating poorly), state laws are pretty clear on this.

 

[Mass Effect]

At our hospital in a mid size town we have the luxury of a smaller homeless population, so if a person with psychosis comes in and is clearly not doing well, but may not be SI/HI, or not clearly gravely disabled, we're still able to get them into the hospital as we usually have enough beds. Versus big city hospital where I trained, people are chronically psychotic, and would probably be better off coming in and getting on meds (and they might even say they're glad they were forced into the hospital once their symptoms reduce), but they were sent back to the street due to more strict interpretation of admission criteria and not having enough psych beds to accommodate.

Having beds does not determine commitablility either way and practicing in such a manner is the biggest risk in terms of liability. You can't just force someone into the hospital because you have beds. Likewise, you shouldn't just discharge people because there are no beds.

 

[Mass Effect]

I've seen that dynamic play out as well in some of the places I work at. Luckily I can just ignore the administrative nonsense and do what's right. An ex, just last week a young pt who said some delusional stuff to the family, had some bizarre behavior (but nothing totally outright dangerous), hasn't been working for a few months, presented really well in the ER, d/ced because family didn't want them admitted and there was no 'dangerous behavior'. Comes back two days later, and I admit them. Now needing IMs/restraints on the unit, tried to jump from a window, underlying depression. If we kept with discharging them the risk of doing something outright dangerous is actually very high. I don't mess with untreated psychosis if there's clear evidence that it is changing their behav.

Orrr, the guy decompensated and is acting out because his civil rights have been violated. We don't pre-emptively admit patients and I'm actually shocked by your attitude about this.

 

[psychacad]

Orrr, the guy decompensated and is acting out because his civil rights have been violated. We don't pre-emptively admit patients and I'm actually shocked by your attitude about this.

I don't want to reveal clinical information, but no this is wrong. Criteria for admission in my state is 'substantial risk' and 'likelihood to result in serious harm to self or others.' I also don't know what you mean by "we don't pre-emotively admit patients". Of course we do. The whole point is to mitigate risk. and pre-empt them hurting themselves or others.

 

[Mass Effect]

I don't want to reveal clinical information, but no this is wrong. Criteria for admission in my state is 'substantial risk' and 'likelihood to result in serious harm to self or others.' I also don't know what you mean by "we don't pre-emotively admit patients". Of course we do. The whole point is to mitigate risk. and pre-empt them hurting themselves or others.

Not if they're not at imminent risk. We don't say "well, you're low risk now, but chances are that will change in the future, so admit". If you're going to take away someone civil rights, they better be at risk of harming themselves or others right then, not a week later.

 

[psychacad]

Not if they're not at imminent risk. We don't say "well, you're low risk now, but chances are that will change in the future, so admit". If you're going to take away someone civil rights, they better be at risk of harming themselves or others right then, not a week later.

huh? This isn't making any sense. The argument is that they ARE at a substantial risk even if they haven't actually done yet something that is seriously harmful to themselves or others. Of course this is about pre-emption.

 

[Mass Effect]

huh? This isn't making any sense. The argument is that they ARE at a substantial risk even if they haven't actually done yet something that is seriously harmful to themselves or others. Of course this is about pre-emption.

There has to be evidence of imminent risk. If there isn't, I don't know how you get away with forcefully hospitalizing them. Even first break psychosis does not mean they will be danger to themselves or others, certainly not imminently which would be a reason for containment.

 

[psychacad]

There has to be evidence of imminent risk. If there isn't, I don't know how you get away with forcefully hospitalizing them. Even first break psychosis does not mean they will be danger to themselves or others, certainly not imminently which would be a reason for containment.

I do no know about your state laws, but there's no 'imminent risk' anywhere in the state laws I'm working in. As I mentioned there is substantial risk and likelihood for serious harm to self or others if the patient is not hospitalized. Of course there has to be 'evidence' for that. And no where did I say that first episode psychosis is a criterion for hospitalization. You're grasping at straws here. I'm done.

 

[Mass Effect]

I do no know about your state laws, but there's no 'imminent risk' anywhere in the state laws I'm working in. As I mentioned there is substantial risk and likelihood for serious harm to self or others if the patient is not hospitalized. Of course there has to be 'evidence' for that. And no where did I say that first episode psychosis is a criterion for hospitalization. You're grasping at straws here. I'm done.

Substantial risk when? Where? I'd argue someone who is acutely manic has a substantial risk of harming himself or others too, but do we force hospitalization on everyone who is manic? No, we don't. Same with psychosis. If someone is hearing voices or is paranoid and withdrawn, they may be at substantial risk down the line, but we don't hospitalize them just because they're paranoid or withdrawn. There has to be concern that at this moment, the patient is not safe.

As to the word imminent, even if that specific word is not in your state law, I would bet money it is mentioned in some other way. That's the point of commitment law. You cannot make a case that someone is at substantial risk just based on the fact that they're psychotic unless they're demonstrating behavior or symptoms that make them imminently higher risk and therefore they need containment for safety and stabilization.

"The term “dangernousness” refers to one’s ability to hurt oneself or others physically or mentally within an imminent time frame,"

"Opponents worry an obligatory dangerousness criterion might lead individuals without a serious mental illness to be involuntarily hospitalized, or that individuals without a serious mental illness will be involuntarily hospitalized as a "preventative" means.[4"

Obligatory Dangerousness Criterion - Wikipedia

en.wikipedia.org

Now, I don't oppose the dangerousness criteria, but only as it applies to an imminent time frame. Your comment that this psychotic guy re-presented to the ER and you hospitalized him because...psychosis, and then after you forcefully hospitalized him, he had to be restrained and tried to jump out a window as vindication for what you did rubs me wrong in so many different ways.

 

[psychacad]

Substantial risk when? Where? I'd argue someone who is acutely manic has a substantial risk of harming himself or others too, but do we force hospitalization on everyone who is manic? No, we don't. Same with psychosis. If someone is hearing voices or is paranoid and withdrawn, they may be at substantial risk down the line, but we don't hospitalize them just because they're paranoid or withdrawn. There has to be concern that at this moment, the patient is not safe.

As to the word imminent, even if that specific word is not in your state law, I would bet money it is mentioned in some other way. That's the point of commitment law. You cannot make a case that someone is at substantial risk just based on the fact that they're psychotic unless they're demonstrating behavior or symptoms that make them imminently higher risk and therefore they need containment for safety and stabilization.

"The term “dangernousness” refers to one’s ability to hurt oneself or others physically or mentally within an imminent time frame,"

"Opponents worry an obligatory dangerousness criterion might lead individuals without a serious mental illness to be involuntarily hospitalized, or that individuals without a serious mental illness will be involuntarily hospitalized as a "preventative" means.[4"

Obligatory Dangerousness Criterion - Wikipedia

en.wikipedia.org

Now, I don't oppose the dangerousness criteria, but only as it applies to an imminent time frame. Your comment that this psychotic guy re-presented to the ER and you hospitalized him because...psychosis, and then after you forcefully hospitalized him, he had to be restrained and tried to jump out a window as vindication for what you did rubs me wrong in so many different ways.

Man, you're making s*** up. No one said that psychosis is enough for hospitalization. I'm really intrigued by your persistence, almost with a toxic, malignant quality. I'm not going to reveal a full clinical case for you on the forum. If you're arguing to win the internet, congrats, you did it.

 

[Mass Effect]

Man, you're making s*** up. No one said that psychosis is enough for hospitalization. If you're arguing to win the internet, congrats, you did it.

Ok, tell me how I'm making **** up. This is exactly what you said:

"An ex, just last week a young pt who said some delusional stuff to the family, had some bizarre behavior (but nothing totally outright dangerous), hasn't been working for a few months, presented really well in the ER, d/ced because family didn't want them admitted and there was no 'dangerous behavior'. Comes back two days later, and I admit them. Now needing IMs/restraints on the unit, tried to jump from a window, underlying depression. If we kept with discharging them the risk of doing something outright dangerous is actually very high. Insight is also very important. I don't mess with untreated psychosis if there's clear evidence that it is changing their behav."

That is not how I interpret dangerousness criteria in commitment law.

 

[Merovinge]

Ok, tell me how I'm making **** up. This is exactly what you said:

"An ex, just last week a young pt who said some delusional stuff to the family, had some bizarre behavior (but nothing totally outright dangerous), hasn't been working for a few months, presented really well in the ER, d/ced because family didn't want them admitted and there was no 'dangerous behavior'. Comes back two days later, and I admit them. Now needing IMs/restraints on the unit, tried to jump from a window, underlying depression. If we kept with discharging them the risk of doing something outright dangerous is actually very high. Insight is also very important. I don't mess with untreated psychosis if there's clear evidence that it is changing their behav."

That is not how I interpret dangerousness criteria in commitment law.

There are clearly details missing from the short blurb, but presumably the family (or worse, the police) is bringing him back in after 2 days despite not wanting him initially hospitalized due to worsening symptoms. When then observed on the locked unit his behavior was dysregulated enough to generate marked symptoms. Blaming this on inappropriate commitment really seems to be stretching it when presumably his own family is trying to get him help. I'm not sure about you, but if I get locked up on an inpatient psychiatric unit, my first move is not going to be physical aggression towards others or an attempt to elope.

I find much more difficulty with doctors who aren't willing to do involuntary work (particularly when family are asking/begging) due to a distaste for it, the legal process, desire for easier patients//more money, or whatever else is holding them back. I highly recommend every aspiring resident to ask about how many involuntary patients move through their main inpatient unit/year and would not recommend training at programs that do not provide exposure to this critical role of the psychiatrist.

 

[Mass Effect]

There are clearly details missing from the short blurb, but presumably the family (or worse, the police) is bringing him back in after 2 days despite not wanting him initially hospitalized due to worsening symptoms. When then observed on the locked unit his behavior was dysregulated enough to generate marked symptoms. Blaming this on inappropriate commitment really seems to be stretching it when presumably his own family is trying to get him help. I'm not sure about you, but if I get locked up on an inpatient psychiatric unit, my first move is not going to be physical aggression towards others or an attempt to elope.

I think you're making a lot of assumptions there. I'm going by what the poster said. That's all I can comment on. I'm not a mind reader and I'm not going to assume things he didn't say. You're assuming he was brought in by family or police. You're assuming the family changed their mind. So I reject your premise that I'm the one stretching.

I find much more difficulty with doctors who aren't willing to do involuntary work (particularly when family are asking/begging) due to a distaste for it, the legal process, desire for easier patients//more money, or whatever else is holding them back. I highly recommend every aspiring resident to ask about how many involuntary patients move through their main inpatient unit/year and would not recommend training at programs that do not provide exposure to this critical role of the psychiatrist.

I don't think anyone here voiced any unwillingness to do involuntary work. The advice is fine and I'd echo it as well, but knowing when not to involuntarily commit is just as important as knowing when to do it.

 

[psychacad]

I think you're making a lot of assumptions there. I'm going by what the poster said. That's all I can comment on. I'm not a mind reader and I'm not going to assume things he didn't say. You're assuming he was brought in by family or police. You're assuming the family changed their mind. So I reject your premise that I'm the one stretching.



I don't think anyone here voiced any unwillingness to do involuntary work. The advice is fine and I'd echo it as well, but knowing when not to involuntarily commit is just as important as knowing when to do it.

You're going by the 'poster said' to make conclusions about a case you hardly know anything about? These details are crucial, yet you felt free to reach conclusions. As I said, your persistence in this thread has a very malignant flavor.

 

[Mass Effect]

You're going by the 'poster said' to make conclusions about a case you hardly know anything about? These details are crucial, yet you felt free to reach conclusions. As I said, your persistence in this thread has a very malignant flavor.

Dude, I'm going directly by what YOU said. I even highlighted the relevant parts. You, yourself, admitted there was no dangerous behavior. When you put something out there, don't expect that people won't comment on it on a forum. There's nothing malignant at all about me commenting on what I consider to be inappropriate use of involuntary commitment based on the information provided.

 

[psychacad]

Dude, I'm going directly by what YOU said. I even highlighted the relevant parts. You, yourself, admitted there was no dangerous behavior. When you put something out there, don't expect that people won't comment on it on a forum. There's nothing malignant at all about me commenting on what I consider to be inappropriate use of involuntary commitment based on the information provided.

But the information provided is not enough to reach a conclusion on the merits of an involuntary hospitalization and it wasn't the point of the post. Any reasonable psychiatrist would conclude the same thing. There was literally zero said about how the pt presented the second time. It's not like that small blurb is a legal rational for an involuntary hosp.

I do find your persistence on this throughout the thread is frankly ranging on malignant behavior. Maybe you don't mean it that way. But I am not going to belabor this any longer. Have a nice day.

 

[Mass Effect]

But the information provided is not enough to reach a conclusion on the merits of an involuntary hospitalization and it wasn't the point of the post. Any reasonable psychiatrist would conclude the same thing. There was literally zero said about how the pt presented the second time. It's not like that small blurb is a legal rational for an involuntary hosp.

I do find your persistence on this throughout the thread is frankly ranging on malignant behavior. Maybe you don't mean it that way. But I am not going to belabor this any longer. Have a nice day.

In a court of law? No, it's not. But this is an informal message board. We're having a conversation and based on the information you stated, I drew a conclusion. Your wording and choice of phrase gives a very clear hint that psychosis can become dangerous, which is not the same as is imminently dangerous. That is what I'm commenting on. It's a nuance, but a very important one in our field. Whether it was the point of the post or not doesn't really matter when we're in a public forum discussing topics. If it was, then half the discussions here would end. Conversations evolve and points come up that were not initially highlighted.

As for my persistence, again, it's a conversation. I resent your accusation of malignancy when I dare to respond to your public posts on a forum.

 

[hamstergang]

I'd actually be interested in exploring this topic further, though maybe it should get its own thread? I often struggle with patients who have psychosis but no clear dangerous behaviors (to others or self) and so I feel that I must discharge them despite the benefit inpatient hospitalization would provide.

I'm in NJ. The law here defines dangerousness as there being "substantial likelihood that the person will inflict serious bodily harm upon another person or cause serious property damage within the reasonably foreseeable future. This determination shall take into account a person's history, recent behavior, and any recent act, threat or serious psychiatric deterioration." Further, "reasonably foreseeable future" is "a time frame that may be beyond the immediate or imminent, but not longer than a time frame as to which reasonably certain judgments about a person's likely behavior can be reached."

So if someone is hallucinating, delusional, and acting in a bizarre manner but isn't acting dangerously, isn't endangering their own life, and doesn't have a substantial history of violence during prior psychotic episodes, can you really justify committing them based on these criteria?

 

[Mass Effect]

I'd actually be interested in exploring this topic further, though maybe it should get its own thread? I often struggle with patients who have psychosis but no clear dangerous behaviors (to others or self) and so I feel that I must discharge them despite the benefit inpatient hospitalization would provide.

I'm in NJ. The law here defines dangerousness as there being "substantial likelihood that the person will inflict serious bodily harm upon another person or cause serious property damage within the reasonably foreseeable future. This determination shall take into account a person's history, recent behavior, and any recent act, threat or serious psychiatric deterioration." Further, "reasonably foreseeable future" is "a time frame that may be beyond the immediate or imminent, but not longer than a time frame as to which reasonably certain judgments about a person's likely behavior can be reached."

So if someone is hallucinating, delusional, and acting in a bizarre manner but isn't acting dangerously, isn't endangering their own life, and doesn't have a substantial history of violence during prior psychotic episodes, can you really justify committing them based on these criteria?

I agree that I'd like to discuss this further in its own thread. I think this is a very important topic and I'm guessing many of us are uncomfortable either committing or not from time to time.

I used to live in NJ. It's interesting that NJ's law also takes property into consideration. This is something that is nationally frowned upon when it comes to involuntary commitment. So says whatever advocacy group it's supposed to be based on physical harm to people (self or others) and not property. Wonder if it's ever been challenged?

 

[psychacad]

I'd actually be interested in exploring this topic further, though maybe it should get its own thread? I often struggle with patients who have psychosis but no clear dangerous behaviors (to others or self) and so I feel that I must discharge them despite the benefit inpatient hospitalization would provide.

I'm in NJ. The law here defines dangerousness as there being "substantial likelihood that the person will inflict serious bodily harm upon another person or cause serious property damage within the reasonably foreseeable future. This determination shall take into account a person's history, recent behavior, and any recent act, threat or serious psychiatric deterioration." Further, "reasonably foreseeable future" is "a time frame that may be beyond the immediate or imminent, but not longer than a time frame as to which reasonably certain judgments about a person's likely behavior can be reached."

So if someone is hallucinating, delusional, and acting in a bizarre manner but isn't acting dangerously, isn't endangering their own life, and doesn't have a substantial history of violence during prior psychotic episodes, can you really justify committing them based on these criteria?

It's interesting that the NJ law explicitly mentions that imminence is not the sole criteria in regards to the time frame. It's the same in the other states I practiced in (though not explicitly defined). I think there's quite some leeway there in regards to 'serious psychiatric deterioration' , 'recent behavior'. In general I think it depends on a case by case basis of the behavior we're describing; if their behavior is being seriously compromised by their psychosis, it's hard to argue that it will not affect their safety in society, especially when they are deteriorating in front of your eyes, their family is concerned and they are not connected to treatment (all factors that considerably increase the likelihood of inflicting harm on self or others). We don't need to wait till they actually commit harm to hospitalize them. Of course there are exceptions, pts with delusional disorder, chronic psychosis, pts who you familiar with their history...etc, where you can make a good risk assessment for their discharge.

This is a really long, but very good read: https://www.samhsa.gov/sites/default/files/civil-commitment-continuum-of-care_041919_508.pdf

I'm quoting some relevant parts:

"Dangerousness may be defined as some level of risk that a person, at some point in the future, will act in a way that causes a harm of some sort, to a sufficient degree that a particular intervention (here, commitment) is justified. Dangerousness does not require prediction that an individual will act in a way that results in harm, only that there is some risk he or she will. The degree of risk that is necessary is not settled, nor, in most states, is the immediacy of the risk or even the type of harm the individual is at risk for. There are no bright lines delineating dangerousness. Certainly an argument can be made that a person who is experiencing a deterioration in his or her functioning due to a mental illness, making it likely that, without treatment, the person’s risk of harm will become significant, is dangerous. The legislature in Arkansas would seem to agree"

--------

Now, some states permit inpatient commitment on grounds of deterioration. For example, in Oregon, a person may be committed who is dangerous (paragraph A of the statute), who is gravely disabled (paragraph B), or “who, unless treated, will continue, to a reasonable medical probability, to physically or mentally deteriorate so that the person will become a person described under subparagraph (A) or (B) of this paragraph or both” [i.e., dangerous and/or gravely disabled] (OR. Rev. Stat., § 426.005(1)(f)).

------

Although dangerousness continues to serve as a commitment criterion in nearly every state, what must be shown to establish dangerousness has changed. In many states, the risks presented no longer need be imminent or immediate. The requirement of a recent overt act has been removed in some states. In others, the law now speaks of recent “acts or omissions.” Finally, dangerousness need not always mean risk of violent behavior. In Iowa, a person may be committed who “is likely to inflict serious emotional injury on members of the person's family or others who lack reasonable opportunity to avoid contact with the person…if the person…is allowed to remain at liberty without treatment.”

So basically this remains a very gray area, and there is considerable variation from state to state. To me the rational thing is to prioritize your clinical judgement in how you appraise risk in a certain case and see how that works out with your state laws.

 

[hebel]

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?

Sorry to bump, but wanted to confirm my summary was accurate. Does this look correct to everyone?

 

[GUH]

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.

Just to make sure I understand you, how long is a reasonable amount of time to wait for a psychiatrist? Do you propose that every ED have a psychiatrist in-house 24/7 to do these assessments, and if not, how would you obtain coverage to ensure that all patients are seen by the psychiatrist within your proposed time frame?

 

[Stagg737]

Your argument now is taking into account things that CAN make someone dangerous. But if there is no imminent danger at time you see them (even if they are eating poorly), state laws are pretty clear on this.

Just as an aside, in our state we can admit involuntarily for "profound lack of self-care". I had an acutely psychotic patient we admitted because he'd only been drinking olive oil and water for the past 4-5 days and his landlord was very concerned. No SI/HI or particularly dangerous behaviors, just inability to function. Involuntary was upheld in court. I've seen several similar cases with the same outcome in our hospitals. So imminent danger is not a requirement in every state for admission.

 

[Mass Effect]

Just to make sure I understand you, how long is a reasonable amount of time to wait for a psychiatrist? Do you propose that every ED have a psychiatrist in-house 24/7 to do these assessments, and if not, how would you obtain coverage to ensure that all patients are seen by the psychiatrist within your proposed time frame?

When consulting for level of care in a patient on an involuntary hold, yes, I propose that every ED have someone (psychiatry, psychology, or SW) who can answer this question 24/7. It is not ok to make a patient wait 24 hours to be told they don't require involuntary admission.

 

[Mass Effect]

Just as an aside, in our state we can admit involuntarily for "profound lack of self-care". I had an acutely psychotic patient we admitted because he'd only been drinking olive oil and water for the past 4-5 days and his landlord was very concerned. No SI/HI or particularly dangerous behaviors, just inability to function. Involuntary was upheld in court. I've seen several similar cases with the same outcome in our hospitals. So imminent danger is not a requirement in every state for admission.

I mean that is dangerous behavior due to impairment. Dangerousness doesn't just refer to SI/HI, but it also refers to patient's lack of ability to care for themself. Some states are more lenient on what that means than others (hence why some states have lower threshold than others for eating disorder commitments), but I'm not aware of any state that doesn't have this as a criteria for involuntary commitment.