ED called with an admission...

[nexus73]

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I got called today while covering an inpatient unit. It was about a mid 30's male in the emergency room. The ED physician said the patient was psychotic and needed psych admission. The patient had no psych history, and was doing fine until 4 days ago when he stopped going to work, stopped showering, developed latent responses and "memory problems." I told the ED doc the time course and age were atypical of new onset schizophrenia, and memory problem definitely aren't expected in schizophrenia. The patient had no hallucinations or delusions, and he wasn't disorganized. The ED then said the patient looked "catatonic" to him. I suggested that given the atypical presentation he should call internal medicine or neurology for further workup of organic causes, or possible admission to one of their services with psych consulting. The ED doc said thanks and discharged the patient.

 

[shan564]

Sounds like encephalitis. Or really really bad MDD. Most likely drugs, of course. I probably wouldn't discharge the patient without an LP (and a UDS, of course).

 

[strangeglove]

Did you see the patient? You are being called as a consultant to make an evaluation. You can't really do that over the phone.

 

[shan564]

Did you see the patient? You are being called as a consultant to make an evaluation. You can't really do that over the phone.

It sounds like the ER doctor was calling more to say "I'm admitting this patient to your service" rather than "please consult."

 

[Doctor Bagel]

Did you see the patient? You are being called as a consultant to make an evaluation. You can't really do that over the phone.

Was he being called as a consultant or being called just to accept a patient? I think these two things can be different. I'm assuming the op assumed the ED doc wouldn't discharge the patient and would get an appropriate workup. It sounds like the op was willing to consult and just saying admission straight to psych didn't seem appropriate.

 

[Bartelby]

That sounds like malpractice on the ER physician's part (I'm presuming that he did not do a thorough workup on his own, make a diagnosis, and come up with an adequate treatment plan that did not involve hospitalization). I don't think you did anything wrong. It creates a curious liability situation though. If you didn't document anything the ER physician could document something like "psych consult placed, states psychiatric hospitalization not indicated." And since you were the consultant on call I don't think it counts as a 'curbside' even though you didn't see the patient.

If you did see the patient I hope you documented a differential with a number of the nasty things this could have been and recommended further consultation v inpatient workup.

Overall though just a sad situation.

 

[PikminOC]

UDS?

 

[notdeadyet]

UDS?

And basic labs. From a forensic standpoint, curb siding psych with concerns for catatonia and subsequently sending someone home without extensive medical work-up is dodgy.

 

[thoffen]

This depends on a lot of variables, but I might have been willing to take a patient like that knowing it would be the wrong place, just to ensure they get the workup and treatment they needed.

 

[Doctor Bagel]

This depends on a lot of variables, but I might have been willing to take a patient like that knowing it would be the wrong place, just to ensure they get the workup and treatment they needed.

Sadly that's not an unheard of situation. I think we've all been there.

 

[PikminOC]

And basic labs. From a forensic standpoint, curb siding psych with concerns for catatonia and subsequently sending someone home without extensive medical work-up is dodgy.

ER's do this to me. I will send a patient there for admission. They will say the patient doesn't meet criteria (they don't want to do the immense paperwork, keep the patient there forever for medical clearance etc).

 

[Shikima]

Usual ER nonsense.

 

[PistolPete]

Ouch. OP, you did the right thing, this patient didn't belong on the psychiatric floor.

I had a similar case a few years ago, surgery consulted us for suspected NMS. Young black male had gotten surgery for something, got agitated so they gave IV haldol, then temp went up, he became stiff and altered, CK was high, etc. We called it NMS and recommended the appropriate treatment, including close, daily follow-up by psychiatry. What does surgery do? Discharge him home the next day.

 

[cbrons]

Did you see the patient? You are being called as a consultant to make an evaluation. You can't really do that over the phone.

Do psychiatrists ever come to the ED? Or is always the "psych assessor" (usually a nurse from what I have seen).

 

[Shikima]

Do psychiatrists ever come to the ED? Or is always the "psych assessor" (usually a nurse from what I have seen).

In residency? Always.

Post-residency, depends.

 

[milesed]

You may want to read #11 if you are covering as the specialist for psychiatry for the hospital the ED is in.
http://www.emtala.com/faq.htm

 

[nexus73]

So I didn't see the patient. There is a social worker in our ED that does the initial assessment for psych patients. All the typical blood tests were normal and urine drug screen was completely negative, though that doesn't come close to ruling out all the drugs people use around here. I typically don't dictate a note, but in this case I will so there is a record of my concerns and specific recommendations to get IM and/or neurology involved and admit with a psych consult.

 

[nexus73]

This depends on a lot of variables, but I might have been willing to take a patient like that knowing it would be the wrong place, just to ensure they get the workup and treatment they needed.

I agree. I didn't find out until later in the shift he discharged the patient. He never told me. The social worker called and said he didn't consult anyone and then sent the patient home.

 

[michaelrack]

To go off on an EMTALA tangent, does it apply for nonvoluntary pts (is it ok to decline a patient from another hospital's ER if the patient refuses hospitalization and has been put on a 72 hour hold by the ER doc)? My understanding is that EMTALA doesn't apply in these situations

 

[strangeglove]

Was he being called as a consultant or being called just to accept a patient? I think these two things can be different. I'm assuming the op assumed the ED doc wouldn't discharge the patient and would get an appropriate workup. It sounds like the op was willing to consult and just saying admission straight to psych didn't seem appropriate.

They can be different, but how do you know a patient is appropriate for admission, consult medicine or neurology or discharge without an initial consult? Otherwise, you get into a situation where it is the ED doctor's judgement that you rely on to determine this, with the result you see here.

 

[Bartelby]

To go off on an EMTALA tangent, does it apply for nonvoluntary pts (is it ok to decline a patient from another hospital's ER if the patient refuses hospitalization and has been put on a 72 hour hold by the ER doc)? My understanding is that EMTALA doesn't apply in these situations

You mean for the psychiatric unit to decline a transfer from an outside ER (or even its own ER)? I think that is fine, and it's certainly standard practice whether the patient wants hospitalization or not. I think EMTALA just obligates the ER to hold on to and appropriately treat the unstable patient until an accepting facility with appropriate treatment resources relieves them of that obligation.

 

[FlowRate]

I came across this article recently.

Applying the guidelines from that article, it seems you may have entered a doctor-patient relationship, as you gave specific advice regarding a particular patient. However, the ED physician did not follow your advice or relay that information directly to the patient, which dose raise the question (as mentioned by others ITT) of what that means for your liability?

Did you keep at least informal written documentation of the consult? Did the ED physician include your name in his or her documentation?

 

[thoffen]

This is an interesting legal question with a lot of face validity.

But...I'm gonna get all analytical on you guys and challenge you to think about this.

I'm worried that we are significantly interested in making this an EMTALA discussion instead of a clinical discussion because we are defending against the cumulative reality that we can't always help our patients even if we know how, and even worse the reality that sometimes we can help them but fail to do so.

Edit: Of course it's never the reality that we're afraid of. It's what it represents (i.e. the powerlessness of not being able to help and the guilt of being able but failing to do so).

 

[milesed]

The EMTALA link refers to you seeing the patient if the ER is in your hospital. Most ER requests from your own hospital's ER are done as a consult and the ER doc is the attending (responsible) MD for the patient. Your input on a consult can be used or ignored by the attending ER doc. This may vary by state and hospital policy. You don't have to accept the pt as a psyc floor admit if you feel they are inappropriate (and I agree that the example you gave sounds more like a delerium of unknown etiology).