How do you triage admissions/discharges from the ED?

[nexus73]

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My current inpatient job has social workers in the ED from 8AM-1130PM. The ED doctor sees the patient and determines if there is a primary mental health issue, then the social worker gathers a more in depth history and calls the on call psychiatrist to staff the patient. We discuss the patient and come up with a plan to either discharge with safety plan or admit to inpatient psych.

Is this standard practice? How much liability is the on call psychiatrist taking on with this practice?

I'm concerned we're essentially doing an over the phone consult for risk assessment. And I'm not sure this is up to or exceeding the standard of care. I've been thinking the ED doc and social worker (who is fully licensed) should be able to determine risk level on their own (after all they've actually seen and talked to the patient), and only the call the psychiatrist to staff likely admissions.

I was reviewing some of the ED notes for patients safety planned out and they use language like "patient cleared by on call psychiatrist and social worker for discharge" or "social work evaluated and patient does not meet inpatient psych criteria." The social worker notes are much more descriptive, but it is frustrating the ED doctors for the most part seem to be documenting in such a way to try and sidestep any responsibility for discharging these patients, and document as though sole decision making rests with the on call psychiatrist and social worker.

Any advice? Or is this just a typical setup and I shouldn't be concerned.

 

[splik]

Any time you are supervising someone you are taking on ALL of the liability. This is not a normal set up. The social workers, if they are LCSWs with a psychiatric background, should be deciding admit/discharge without a psychiatrist's input. I personally would never agree to this set up. I wouldn't even do this for an NP (in fact when we had a psych NP in the ED I insisted on seeing all the patients I was going to be "supervising" myself and billing under my name and refused to provide any "supervision" without seeing the patient personally). The doctrine of respondeat superior is very clear: (it's latin for "why go after the monkey when you can go after the organ grinder".) In malpractice, it's always gonna be the MD who they go after. And in this case, it's very clear you are supervising the social workers if they are calling you to discuss the case.

When I trained the SWs would see all the ED patients themselves without involvement from psychiatry. Definitely no supervision. If the patient was on a hold, or needed admission then psych would get involved. If there were medication issues, or they wanted a second opinion then we would personally examine the patient. Also if the ER docs disagreed with the SW assessment then the pt would be seen by psychiatry. In my current setting, SW sees some psych pts by themselves without involving us. If they are on a hold, or present with SI/HI then they have to have to have a psychiatric evaluation and would not have a SW eval.

From a cost perspective it also doesnt make sense for psychiatry to be discussing pts by phone since none of this is billable. All it does is expose you to major liability. The ER is one of the few settings whether the liability is high in psychiatry. If a pt is discharged and commits suicide or harms someone, that is a lawsuit you likely can't win.

 

[Merely]

Any time you are supervising someone you are taking on ALL of the liability. This is not a normal set up. The social workers, if they are LCSWs with a psychiatric background, should be deciding admit/discharge without a psychiatrist's input. I personally would never agree to this set up. I wouldn't even do this for an NP (in fact when we had a psych NP in the ED I insisted on seeing all the patients I was going to be "supervising" myself and billing under my name and refused to provide any "supervision" without seeing the patient personally). The doctrine of respondeat superior is very clear: (it's latin for "why go after the monkey when you can go after the organ grinder".) In malpractice, it's always gonna be the MD who they go after. And in this case, it's very clear you are supervising the social workers if they are calling you to discuss the case.

When I trained the SWs would see all the ED patients themselves without involvement from psychiatry. Definitely no supervision. If the patient was on a hold, or needed admission then psych would get involved. If there were medication issues, or they wanted a second opinion then we would personally examine the patient. Also if the ER docs disagreed with the SW assessment then the pt would be seen by psychiatry. In my current setting, SW sees some psych pts by themselves without involving us. If they are on a hold, or present with SI/HI then they have to have to have a psychiatric evaluation and would not have a SW eval.

From a cost perspective it also doesnt make sense for psychiatry to be discussing pts by phone since none of this is billable. All it does is expose you to major liability. The ER is one of the few settings whether the liability is high in psychiatry. If a pt is discharged and commits suicide or harms someone, that is a lawsuit you likely can't win.

How could you not win? If you document everything that explains your reasoning and you did the proper evaluation that indicated he could be discharged, you still lose the suit? If that’s the case why would you ever discharge someone since on the off chance they do commit suicide you’re guaranteed to lose the suit..

 

[hamstergang]

Any advice? Or is this just a typical setup and I shouldn't be concerned.

This is the set up at my current 2 hospitals and at least 1 other in my system. We always have the option to hold the patient over night until a psychiatrists shows up the next morning. How well this works, from my view, depends a lot on the quality of the social worker.

 

[hamstergang]

How could you not win? If you document everything

If this consultation is being done by phone, you're not documenting anything.

 

[nexus73]

If this consultation is being done by phone, you're not documenting anything.

This is correct, so entirely relying on social worker and ED doctors notes.

 

[calvnandhobbs68]

Our hospital actually has two different systems.

On the adult side, there are a team of social workers 24hrs a day that typically see patients in the adult EDs and decide on inpatient admission or not....they tend to err pretty strongly on the admit side.

On the child side, there are social workers during the days/early evenings that typically see the consults in the ED during that time and staff with the fellows over the phone (who will also typically quickly discuss the cases with the attending on call). They typically have an idea if they want to admit or discharge. As noted above, you don't document anything, the SW do all the documentation...so it does rely on the SW documentation quality if you're discharging a patient.

And yeah, ED always does that with all the consults anyway though. "Ortho cleared for discharge, Cardiology read EKG and okay'd discharge, etc, etc". I mean they call the consults to cover their butts...

 

[NickNaylor]

We have a few different systems at different hospitals.

At the children's hospital, there is a social worker in the ED 24 hours a day who sees all patients presenting with psychiatric complaints. During business hours, the psychiatry consult service will also see ED patients. Overnight, the social worker staffs the consult by phone with the on-call C&A fellow, and the fellow will document in the patient's chart that they have discussed the case and confirm the disposition. If needed, the fellow can come in to actually see the patient, but I've never heard of that actually happening. Decisions to admit are made by the fellow after talking with the social worker.

At the county hospital, there are psychiatrists and social workers in the ED 24 hours a day. The hospital has a very busy PED service, so there are dedicated teams to seeing consults in the medical ED as well as teams in the actual psychiatric ED 24/7. There are clearly defined patients that social workers can see and "clear" independently - basically low-risk patients presenting with things that really do not be seen in the ED (for example, a voluntary patient who comes to the ED with a medical complaint and "wants to see psych" while they're at the hospital) - though they can always escalate the case to a psychiatrist if they feel that there is something going on or if medications may be indicated. This doesn't happen too often. By default, however, most patients are seen by a psychiatrist and social worker. The decision to admit vs. not admit is made by the psychiatrist in all cases, not the ED attending or the social workers. Social workers can, however, recommend that a patient be transferred to one of the dedicated PED services for further observation.

At the university (private) hospital, social workers are in the ED 24 hours a day. The consult psychiatry service will see patients during business hours. Overnight, the decision to pursue admission is made by the ED attending. The social worker will also see the patient and, as long as the patient meets medical necessity criteria, the social worker will facilitate admission. Patients that need to be admitted involuntarily will remain in the ED until the morning when the consult psychiatry service can see them and, if needed, file involuntary paperwork.

While not ideal, what you're doing doesn't seem to be markedly out of line with what happens at our hospitals. The key, of course, is having good social workers that are experienced and have sound clinical judgment.

 

[Merovinge]

So I actually think this is a very complicated topic, but have absolutely zero forensic or JD experience, so I would be very interested in those who know the case law well. In other fields, rural/low level of care OSH EDs call specialty physicians, who does not have access to labs/imaging/seeing the patient and ask if they will accept the patient for transfer based on their verbal story (which may or may not be accurate); if you do not accept the transfer and your facility has the capability to care for the patient, they essentially document that said specialist does not feel the patient needed transfer and will DC home. These ED docs are able to essentially consult any specialty physician at a higher level of care institute, for free, and the receiving MD has to decide with paltry information. Sure you can accept every one as a transfer to your ED but then every call you become the dumping ground at 0200h and goodbye sanity; that and your ED will not get pleased if you routinely accept transfers just to discharge home when you come in the next morning to round. All this to say ED dispo is clearly an area wrought with liability issues that seem very unresolved in the world of medicine.

I've seen a lot of EDs staffing with LCSWs in my area and while they may independently make a decision for the patient and never contact the MD (clearly no liability as best I can tell), others are doing things like calling a child fellow who is not in house to see the patient (as described above, as done by some major child fellowships) to "staff" the case. This model is clearly similar to many residencies where a similar thing is done, and lets be honest, not every pgy-1 psychiatry resident is doing a great job verbally staffing their cases with attending who is then making the decision.

To summarize my points: 1) Not every ED patient can feasibly be seen by an attending of the appropriate specialty in every situation 2) Attendings are clearly making decisions without being able to see the patient (and in some cases not even supporting vitals/labs/imaging) 3) What practical ways can this situation be approached that promotes appropriate care of patients without erroneous liability?