involuntary holds and transportation services

[Suedehead]

Hey, everyone!

So, here's my deal. I've had a great difficulty transporting patients from our emergency department to our psych facility (about 2 miles away). Ambulance and security services refuse to do it unless the patient is placed on an involuntary hold.

But most patients are willing to come to the psych unit voluntarily, and in that case, I CAN'T write an involuntary hold.

The solution, per ED staff, security, etc, is that the patient drive him or herself. And that drives me nuts... just because the patient is voluntary doesn't mean he/she is stable.

It gets weirder. If there are no beds at our affiliated psych facility then we get case management or social work to find another accepting facility, and there's NO way that patient will be accepted, let alone transported, without an involuntary hold.

So, I know of residents writing involuntary holds on patients in order to make the machine run smoother, to ensure transportation or acceptance to a facility, and I don't blame them. The justification I hear is that we may be liable if the patient changes his/her mind in the middle of transport, decides to leave, jump out of the car, etc... but hell. it's illegal and unethical.

Anyone else getting this? Is this America? Psych patients won't be taken seriously by transport or insurance unless they're on a 5150?

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[whopper]

Same thing happened where I did residency.

On the side: the hospital was trying to move the location of the inpatient unit to the same hospital as the psychiatric crisis stabilization unit to prevent this problem.

That was, until the hospital took over the ambulances that drove the patients over. Then they seemed to content to keep everything where it was because the hospital was making the money off the transportation.

IMHO the situation is ridiculous, more so when you consider that the cost between one hospital to another which is just a few miles away could well be over $1000.

In NJ, the thing that made it easy for the people in the crisis unit was it was state law that the patients be transported if they wanted hospitalization. The person couldn't just drive to the hospital and admit themselves. No, they had to go through the crisis stabilization unit. It made it easier only because the patient knew it wasn't us imposing the rule on them.

Some ambulance drivers didn't want to transport people that they thought might become agitated, but the person didn't want medication, nor met the emergency guidelines for it. We've had a few situations where the ambulance driver refused to transport the person.

So, I know of residents writing involuntary holds on patients in order to make the machine run smoother, to ensure transportation or acceptance to a facility, and I don't blame them.

Technically that is an abuse of power unless the person truly meets the criteria where a doctor believes they should be involuntarily committed. I know the laws do not always assist in the reality of the situation.

E.g. what if there's someone who wants to commit suicide, yet wants to be hospitalized? OK that person should not be involuntarily committed and held by the doctor. How about if that same person wants to drive to the hospital because they want to avoid the $1000 ambulance fee? Technically you can't let them avoid the ambulance, now that person does not want to be hospitalized.

In that instance you can hold them for hospitalization, though IMHO though this is not an ideal situation. It's unfair in that person's mind to be slapped an additional $1000 charge, and I'd feel the same way if I were the patient.

 

[Suedehead]

E.g. what if there's someone who wants to commit suicide, yet wants to be hospitalized? OK that person should not be involuntarily committed and held by the doctor. How about if that same person wants to drive to the hospital because they want to avoid the $1000 ambulance fee? Technically you can't let them avoid the ambulance, now that person does not want to be hospitalized.

In that instance you can hold them for hospitalization, though IMHO though this is not an ideal situation. It's unfair in that person's mind to be slapped an additional $1000 charge, and I'd feel the same way if I were the patient.

So, what would you do? Last night, I let the pt's husband drive her to the psych hospital - he seemed like reasonable guy. And the hospital/ambulance was absolutely unwilling to help. They said things like "if she's voluntary, she can take herself," or "why don't you take her over there youself, Doctor?" Again, they think "voluntary" means "stable."

Last night, I didn't have the heart to abuse my power to make things convenient for the 'system.' I mean, this lady's looking for work, doesn't want the consequences of an involuntary hold.

But what if there's no husband? If the pt has no one to take her but still wants to go to the hospital, do I place an involuntary hold??? Feels sleezy.

 

[Doc Samson]

So, what would you do? Last night, I let the pt's husband drive her to the psych hospital - he seemed like reasonable guy. And the hospital/ambulance was absolutely unwilling to help. They said things like "if she's voluntary, she can take herself," or "why don't you take her over there youself, Doctor?" Again, they think "voluntary" means "stable."

Last night, I didn't have the heart to abuse my power to make things convenient for the 'system.' I mean, this lady's looking for work, doesn't want the consequences of an involuntary hold.

But what if there's no husband? If the pt has no one to take her but still wants to go to the hospital, do I place an involuntary hold??? Feels sleezy.

This should be a fight your hospital administration is having, not you. Bring it up with your PD - if that fails, a chat with the hospital attorney pointing out how the status quo is encouraging residents to break the law (i.e., write holds when they are actually forbidden) would likely gain a lot of ground.

 

[Suedehead]

This should be a fight your hospital administration is having, not you. Bring it up with your PD - if that fails, a chat with the hospital attorney pointing out how the status quo is encouraging residents to break the law (i.e., write holds when they are actually forbidden) would likely gain a lot of ground.

Love it. That's exactly what I'll do. I'll get back to you guys on how it goes. and if anyone else has had this issue, let me know. thanks again.

 

[michaelrack]

It gets weirder. If there are no beds at our affiliated psych facility then we get case management or social work to find another accepting facility, and there's NO way that patient will be accepted, let alone transported, without an involuntary hold.

?

Though I don't agree with it, I can see the rationale behind that. All of us attendings and many residents have been in the situation of receiving a voluntary transfer who then decided they didn't want to be hospitalized anymore- this patient typically arrives in the middle of the night, denies all symptoms, and the clinicians who originally dealt with the patient are no longer available.

 

[kugel]

At my CA county, our Medical Director found out about this same practice here and wrote a memo to all staff stating clearly that it is illegal and unethical to write a hold for the purpose of getting the pt accepted to an inpt hospital. And we are absolutely NOT permitted to do that. He wanted to be notified ANY time a hospital or ambulance made that request, and he backed it up by calling the admin at any hospital that had "capacity and capability" (EMTALA language) and stated they could not accept the pt unless he/she was put on a Hold. He apparently did call those hospitals. The problem has largely subsided.

 

[whopper]

I let the pt's husband drive her to the psych hospital - he seemed like reasonable guy.

Where I did residency, that would've been a no-no. It would've violated state law.

So--you're either going to force them to take the ambulance if they meet commitment criteria, or your going to persuade them to take the ambulance. Of they don't meet commitment criteria, you leave the choice up to the patient. If they don't want hospitalization, then so be it--you let them go.

Mind you, I don't agree with it, but that's the situation the state laws put the doctors in.

I agree with Doc Samson. It's not an issue you can fix on your own. You have to work with the system. In my case, I and several nurses brought up that this was a problem. We didn't get anything we could work with back. As upsetting as that was, it really was a problem with the state laws. It could take years to fix that, and I'm not going to break HIPAA and call the local news in. If a patient wants to do that fine, I'm not going to violate HIPAA.

On the side, but similar, occasionally we'd get someone who ended up in the psych crisis unit because the poor guy waited in the ER over 8 hrs without any service and decided to leave. In NJ, no one can leave without the doctor's ok from an ER. Yes, the person can sign out A.M.A. but only after the doctor talks to them.

So once in awhile you'd get someone who tried to leave and ER doctor didn't have the time to talk to the person yet. So then the person starts screaming that this was a violation of their rights. Then security comes in, and within a few minutes the ER doctor's dosed up the guy on Haldol or Thorazine, and labelled them as psychotic, when in fact it really was just a very frustrated person who waited several hours in the ER.

IMHO the NJ law I mentioned really should be struck down as unConstitutional, but it'd really take a lawsuit for that to happen. I'm not going to volunteer myself to be the guy who has to wait in the ER, then try to leave without permission and then launch a lawsuit.

 

[Suedehead]

So--you're either going to force them to take the ambulance if they meet commitment criteria, or your going to persuade them to take the ambulance. Of they don't meet commitment criteria, you leave the choice up to the patient. If they don't want hospitalization, then so be it--you let them go.

That's the conundrum. The ambulance refuses to take the patient unless he/she is on a hold. So, I see people all the time in the ED who'd willingly be admitted, but how will they get there?

And you're all right. We're going to hit up the hospital lawyer. See what's up.

 

[Suedehead]

Though I don't agree with it, I can see the rationale behind that. All of us attendings and many residents have been in the situation of receiving a voluntary transfer who then decided they didn't want to be hospitalized anymore- this patient typically arrives in the middle of the night, denies all symptoms, and the clinicians who originally dealt with the patient are no longer available.

I've been in this situation before, too. In fact, the patient I admitted WAS placed on a hold the following morning because she wanted to leave (I could've predicted this, too -very cluster B).

But I feel I just have to cross that bridge when I come to it. If the pt in front of me says she agrees with admission, I can't write a hold, even if I'm afraid she'll change her mind later. When she changes her mind at 3am, then I can write the hold.

I don't know.

 

[Suedehead]

At my CA county, our Medical Director found out about this same practice here and wrote a memo to all staff stating clearly that it is illegal and unethical to write a hold for the purpose of getting the pt accepted to an inpt hospital. And we are absolutely NOT permitted to do that. He wanted to be notified ANY time a hospital or ambulance made that request, and he backed it up by calling the admin at any hospital that had "capacity and capability" (EMTALA language) and stated they could not accept the pt unless he/she was put on a Hold. He apparently did call those hospitals. The problem has largely subsided.

Love it! I love a champion of worthy causes. How long ago was this?

 

[kugel]

Love it! I love a champion of worthy causes. How long ago was this?

Just a few months back. And we're getting good results so far.

 

[michaelrack]

If the pt in front of me says she agrees with admission, I can't write a hold, even if I'm afraid she'll change her mind later. When she changes her mind at 3am, then I can write the hold.

If a person is already admitted (signed the paperwork and is on the unit), and then requests to leave AMA, the doc doesn't have to make a decision right away. Although it makes administrators nervous, in Mississippi psychiatrists legally have up to 72 hours after the patient makes a request to leave before we have to either discharge them or file for a hold (in general, psychiatrists in MS will do this within 24 hours).

The big problem is if a patient is transferred from an ER to a psych hospital and then changes their mind about admission prior to signing the paperwork and before being taken from the admission office to the psych unit.

 

[whopper]

Did you ever have the patient who decides to go to the hospital, then changes his mind, then changes his mind again?

If people followed the letter of the law, the doctor and staff would have to redo the paperwork each time!

 

[kugel]

Did you ever have the patient who decides to go to the hospital, then changes his mind, then changes his mind again?

If people followed the letter of the law, the doctor and staff would have to redo the paperwork each time!

Assuming this is a patient who meets the criteria for a hold and needs inpatient psychiatric treatment...
At that point the pt has not been discharged and the hold has not yet been dropped, so it is still in force. I then write a note stating that the pt's behavior has demonstrated that he is not capable of making a decision about whether to accept services voluntarily and his ambiguity makes it unlikely that he will follow-through with the recommendations for outpatient treatment - so involuntary admission will be necessary. I then write an order canceling the discharge and that the pt remains on a hold.

No more waffling. For now.