New requirement for psych admission: Lipid Panel

[Boatswain2PA]

Guy BIBPD for supposed homocidal/suicidal ideation, tele-psych screener (the low IQ "mental health counselor) supposedly already screened him in jail but needed medical clearance for psych admit. Pt denies SI/HI to me but whatever. Quick typical workup normal and I clear him.

Psych calls back and they want a lipid panel before they accept to an inpatient hospital. Try to explain that this is tiny hospital and that's a sendout with 3 day turnaround, plus we wouldn't get paid for it being ordered through the ED. But low IQ is low IQ and they wouldn't budge.

D/c to PD who isn't happy, but whatever.

WTF?

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[Mount Asclepius]

Psychiatric resources are significantly constrained so these facilities’ lower level staff have become massively obstructionist. They quickly cave when you ask to speak to their medical director or ask for their name/credentials for reporting purposes even if a mostly idle threat.

 

[Boatswain2PA]

Psychiatric resources are significantly constrained so these facilities’ lower level staff have become massively obstructionist. They quickly cave when you ask to speak to their medical director or ask for their name/credentials for reporting purposes even if a mostly idle threat.

Agree with first part, but so far I've found psych medical directors generally give their staff their full support as well.

Can't admit for a K of 3.2? (another one I had recently at busier shop with an inpatient psych unit). Easier to replete orally and recheck to prove it's trending up so they will accept than it is to explain to them that I would send 3.2 home every day.

 

[Mount Asclepius]

Agree with first part, but so far I've found psych medical directors generally give their staff their full support as well.

Can't admit for a K of 3.2? (another one I had recently at busier shop with an inpatient psych unit). Easier to replete orally and recheck to prove it's trending up so they will accept than it is to explain to them that I would send 3.2 home every day.

I hear you. Sometimes it’s not worth the fight. Sometimes it is. You put on your boxing gloves and punch it out with the psychiatry medical director asking how many times they’ve seen a K of 3.2 cause acute psychosis in a decompensated schizophrenic, bring up EMTALA, and ask why if they have bed availability and staff are they declining transfer of a medically cleared psychiatric patient. People will cave. It’s worth not tying up an ED bed instead of appropriately and safely dispositioning a psychiatric patient that is being held up by an obstructionist.

 

[Pudortu]

I hear you. Sometimes it’s not worth the fight. Sometimes it is. You put on your boxing gloves and punch it out with the psychiatry medical director asking how many times they’ve seen a K of 3.2 cause acute psychosis in a decompensated schizophrenic, bring up EMTALA, and ask why if they have bed availability and staff are they declining transfer of a medically cleared psychiatric patient. People will cave. It’s worth not tying up an ED bed instead of appropriately and safely dispositioning a psychiatric patient that is being held up by an obstructionist.

Are these psych facilities bound by EMTALA?

 

[Boatswain2PA]

Are these psych facilities bound by EMTALA?

I've been told they are not, but like all things guvment it all seems to depend on which bureaucrat you talk to.

 

[southerndoc]

Are these psych facilities bound by EMTALA?

Yes

 

[Mount Asclepius]

Are these psych facilities bound by EMTALA?

Our hospital system has determined that EMTALA forms are required for inpatient psychiatry admissions/transfers with EPs being notified of forms with deficiencies. I’ve found receiving facilities to change their tune when EMTALA mentioned.

 

[southerndoc]

Asking for a lipid panel for a psych admission would be a hindrance to the acceptance policy and would run afoul of EMTALA obligations.

 

[TooMuchResearch]

Asking for a lipid panel for a psych admission would be a hindrance to the acceptance policy and would run afoul of EMTALA obligations.

Ha. I've got an entire state that doesn't believe you.

 

[Brigade4Radiant]

Asking for a lipid panel for a psych admission would be a hindrance to the acceptance policy and would run afoul of EMTALA obligations.

Really in Georgia and Tennessee they fight and fight potassium or wbc is 12. So these outside psych facilities must accept the patient if they have space and not a vague medical clearance?

 

[CajunMedic]

Dealt with this yesterday. Type two diabetic that hasn’t taken their medicine in three months and had a fingerstick of 280 with nothing else abnormal. Restarted all their medications. Refused to take them until their blood sugar was 100 or below. Spent an extra 12 hours in the department on a diabetic diet, fluids, and insulin before the facility would take them

 

[PianoMedic]

Dealt with this yesterday. Type two diabetic that hasn’t taken their medicine in three months and had a fingerstick of 280 with nothing else abnormal. Restarted all their medications. Refused to take them until their blood sugar was 100 or below. Spent an extra 12 hours in the department on a diabetic diet, fluids, and insulin before the facility would take them

That seems like an arbitrarily chosen number… Obviously tough to fight this, but if an A1c of 7 is an avg sugar of 140, and 6-7 is target range, 100 seems awfully low. And for some diabetics could be close to causing symptoms of hypoglycemia…

 

[thegenius]

Guy BIBPD for supposed homocidal/suicidal ideation, tele-psych screener (the low IQ "mental health counselor) supposedly already screened him in jail but needed medical clearance for psych admit. Pt denies SI/HI to me but whatever. Quick typical workup normal and I clear him.

Psych calls back and they want a lipid panel before they accept to an inpatient hospital. Try to explain that this is tiny hospital and that's a sendout with 3 day turnaround, plus we wouldn't get paid for it being ordered through the ED. But low IQ is low IQ and they wouldn't budge.

D/c to PD who isn't happy, but whatever.

WTF?

There is nothing you can do. Just discharge the guy. If he's on a 5150 then you are stuck. You either have to have your social worker there clear him, or he sits in your ER for 3 days, let it expire, and then let him go.

So much of our health care field is just nonsense.

 

[southerndoc]

Really in Georgia and Tennessee they fight and fight potassium or wbc is 12. So these outside psych facilities must accept the patient if they have space and not a vague medical clearance?

Correct. If they have an unstable psychiatric condition, they are obligated to accept them if you have medical cleared them. No unnecessary testing or excuses.

 

[thegenius]

Psychiatric resources are significantly constrained so these facilities’ lower level staff have become massively obstructionist. They quickly cave when you ask to speak to their medical director or ask for their name/credentials for reporting purposes even if a mostly idle threat.

I've had this happen several times too. The medical director gets on the phone, I say "I'm sorry we cannot run a lipid panel" and the patient is accepted.

I've had countless pushbacks from crisis psych nurses and a simple phone call with the medical director cleared things up:
- 5150 guy dx with DVT 3 days ago and is on treatment. They wouldn't accept pt because "it was a fresh DVT." I explained that there is no such medical concept as a "fresh" DVT. A DVT isn't a piece of fruit.
- 5150 guy they wanted an EEG. I said no. it's not a service we offer in our ER.
- K+ 3.2. Pt is eating food. I spoke to the medical director. Pt accepted
- Stable Hgs of 12, 10, 8.
- They didn't like that the MCHC was abnormal. After a very short conversation, patient accepted.

 

[southerndoc]

Dealt with this yesterday. Type two diabetic that hasn’t taken their medicine in three months and had a fingerstick of 280 with nothing else abnormal. Restarted all their medications. Refused to take them until their blood sugar was 100 or below. Spent an extra 12 hours in the department on a diabetic diet, fluids, and insulin before the facility would take them

Also an EMTALA violation. They cannot refuse based on a glucose of 280. Too few people file EMTALA complaints which is why they get away with this crap. Patient has an unstable condition -- a psychiatric condition -- that requires hospitalization for stabilization. They cannot refuse something that you would normally discharge if they didn't have a psychiatric condition.

 

[thegenius]

I hear you. Sometimes it’s not worth the fight. Sometimes it is. You put on your boxing gloves and punch it out with the psychiatry medical director asking how many times they’ve seen a K of 3.2 cause acute psychosis in a decompensated schizophrenic, bring up EMTALA, and ask why if they have bed availability and staff are they declining transfer of a medically cleared psychiatric patient. People will cave. It’s worth not tying up an ED bed instead of appropriately and safely dispositioning a psychiatric patient that is being held up by an obstructionist.

Unfortunately many of these places are not bound by EMTALA. They can do whatever they want and are not required to take patients (under that statute)

 

[thegenius]

Yes

Not in CA

 

[DocEspana]

Guy BIBPD for supposed homocidal/suicidal ideation, tele-psych screener (the low IQ "mental health counselor) supposedly already screened him in jail but needed medical clearance for psych admit. Pt denies SI/HI to me but whatever. Quick typical workup normal and I clear him.

Psych calls back and they want a lipid panel before they accept to an inpatient hospital. Try to explain that this is tiny hospital and that's a sendout with 3 day turnaround, plus we wouldn't get paid for it being ordered through the ED. But low IQ is low IQ and they wouldn't budge.

D/c to PD who isn't happy, but whatever.

WTF?

do you work at my facility? Thats a new thing we have had to do the last few months.

I haven't read all the responses yet, but here is the reason why. CMS requires that psychiatric patients on certain medications have their lipid panel checked every 6 months. Multiple facilities by work at have stated that the having a severe difficulty actually getting these tests performed as psychiatric patients are not exactly the most reliable for regular outpatient blood draws. CMS has not been particularly sympathetic to this argument and is chewing out various psych departments. I know of at least 2 different medical systems in my area that have decided that the best way to handle this is to have the emergency department run this test every time they see the patient that way there is a random collection of lipid panels, essentially re setting that 6 month clock every single time they show up for some psychiatric complaint.

 

[DocEspana]

Unfortunately many of these places are not bound by EMTALA. They can do whatever they want and are not required to take patients (under that statute)

Also an EMTALA violation. They cannot refuse based on a glucose of 280. Too few people file EMTALA complaints which is why they get away with this crap. Patient has an unstable condition -- a psychiatric condition -- that requires hospitalization for stabilization. They cannot refuse something that you would normally discharge if they didn't have a psychiatric condition.

They are 100% bound by EMTALA. What most of us run into is that if they are part of our hospital, they may have circumvented emtala. for example I'm at one campus of a multi-campus county system. As a legal design, all of the campuses are considered 'one hospital' but very clearly are multiple hospitals. This is designed for (among other things) making sure transfers for psych fall into the legal category of inter-departmental transfers (that require an ambulance and a 15 mile ride) and not EMTALA hospital-to-hospital transfers. I find I get 7,000x more resistance transferring inside of my own system than when all the beds are full and i need to send the patient to another hospital system, where immediately EMTALA would come into play and they bend over backwards to make it work out so they can address the psych issue.

 

[thegenius]

They are 100% bound by EMTALA. What most of us run into is that if they are part of our hospital, they may have circumvented emtala. for example I'm at one campus of a multi-campus county system. As a legal design, all of the campuses are considered 'one hospital' but very clearly are multiple hospitals. This is designed for (among other things) making sure transfers for psych fall into the legal category of inter-departmental transfers (that require an ambulance and a 15 mile ride) and not EMTALA hospital-to-hospital transfers. I find I get 7,000x more resistance transferring inside of my own system than when all the beds are full and i need to send the patient to another hospital system, where immediately EMTALA would come into play and they bend over backwards to make it work out so they can address the psych issue.

In my county, the crisis center is not part of a hospital system. It is not an emergency department for psychiatric patients. It is in a separate small building downtown and is funded by county tax dollars. One of our ER docs in the past asked our legal team whether they have to accept patients under EMTALA and the response was no.

I'm happy to revisit this especially if there is new case law suggesting otherwise.

 

[DocEspana]

In my county, the crisis center is not part of a hospital system. It is not an emergency department for psychiatric patients. It is in a separate small building downtown and is funded by county tax dollars. One of our ER docs in the past asked our legal team whether they have to accept patients under EMTALA and the response was no.

I'm happy to revisit this especially if there is new case law suggesting otherwise.

Nah, I'm referring to psych departments with affiliated EDs. The big loophole of requirement to get out of EMTALA is to not be an ED or not be attached to one in any meaningful way. A crisis unit set up by the county would definitely count as one of the exceptions to EMTALA. But most psych facilities are, one way or another, directly affiliated with someplace with an ED which catches them up in EMTALA.

Memorial Sloan Kettering Cancer center famously does not have to abide by EMTALA because they have an emergency center that is not open to the public, only to patients that already have an existing relationship with them. That's my favorite work around I've ever heard.

 

[thegenius]

Nah, I'm referring to psych departments with affiliated EDs. The big league of requirement to get out of EMTALA is to not be an ED or be attached to one in any meaningful way. A crisis unit set up by the county would definitely count as one of the exceptions to EMTALA.

Memorial Sloan Kettering Cancer center famously does not have to abide by EMTALA because they have an emergency center that is not open to the public, only to patients that already have an existing relationship with them. That's my favorite work around I've ever heard.

I remember reading on here that USC has something like an ER but they don't call it an ER, it's instead called something else and that pseudo-ER is not registered as an ER, despite the fact that it basically does everything that an ER does. They get to redirect ambulances too.

 

[RuralEDDoc]

Not in CA

Plural

openstates.org

TL;DR: Yes EMTALA applies to psych hospitals in CA

 

[thegenius]

Plural

openstates.org

TL;DR: Yes EMTALA applies to psych hospitals in CA

We don't directly interact with psych hospitals though in most counties where there are ER hospitals. There are numerous counties where there is a "crisis center" which interfaces with all of the psych hospitals. We never really know where our psych patients end up, as they are transferred directly to the crisis center.

 

[John Rawls]

Also an EMTALA violation. They cannot refuse based on a glucose of 280. Too few people file EMTALA complaints which is why they get away with this crap. Patient has an unstable condition -- a psychiatric condition -- that requires hospitalization for stabilization. They cannot refuse something that you would normally discharge if they didn't have a psychiatric condition.

It's a cultural thing that WE as a specialty have enabled. Same reason why docs on the receiving end of transfer calls expect you to bend over backwards and accommodate every tom dick and harry test they expect you to obtain before they actually evaluate the patient. Call CMS guys, it's not a big deal, and it's the right thing to do.

 

[John Rawls]

Not in CA

Federal law doesn't apply in CA? I guess if it's true for stoners, it's true for everyone.

 

[thegenius]

Federal law doesn't apply in CA? I guess if it's true for stoners, it's true for everyone.

No of course it does (I actually thought about editing my prior post.) see my other ones about the actual process many counties use in CA

 

[RuralEDDoc]

We don't directly interact with psych hospitals though in most counties where there are ER hospitals. There are numerous counties where there is a "crisis center" which interfaces with all of the psych hospitals. We never really know where our psych patients end up, as they are transferred directly to the crisis center.

Now I understand and agree with your assessment.

 

[Boatswain2PA]

We don't directly interact with psych hospitals though in most counties where there are ER hospitals. There are numerous counties where there is a "crisis center" which interfaces with all of the psych hospitals. We never really know where our psych patients end up, as they are transferred directly to the crisis center.

Same here, except one hospital with an inpatient psych unit. However they still find every way possible to decline acceptance.

 

[southerndoc]

Not in CA

EMTALA is a federal law. California isn't exempt to it. I can quote cases tomorrow if you want. Currently at work and have to give an early morning lecture.

 

[southerndoc]

In my county, the crisis center is not part of a hospital system. It is not an emergency department for psychiatric patients. It is in a separate small building downtown and is funded by county tax dollars. One of our ER docs in the past asked our legal team whether they have to accept patients under EMTALA and the response was no.

I'm happy to revisit this especially if there is new case law suggesting otherwise.

There are three provisions for EMTALA to apply, but in most circumstances they do:

(1) Psychiatric facility must receive emergency/unstable patients (this does not require a dedicated emergency department),
(2) Psychiatric facility must be licensed as a hospital under state law (a psychiatric facility license qualifies),
(3) Psychiatric facility must participate in Medicare and/or Medicaid.

If all 3 apply, then the psychiatric facility is bound by EMTALA.

Regarding #1, if more than 1/3 of their patients are not scheduled for admission, then #1 applies. This is almost every psych facility in existence.

Sorry I did not explain this in further detail.

 

[Brigade4Radiant]

Wow so if doctors ever get screwed and forced to be let go by admin the can cite various EMTALA violations good to know

 

[GonnaBeADoc2222]

This thread makes me thankful that I don't have to get labs on my psych patients before clearance.

 

[CoolDoc1729]

do you work at my facility? Thats a new thing we have had to do the last few months.

I haven't read all the responses yet, but here is the reason why. CMS requires that psychiatric patients on certain medications have their lipid panel checked every 6 months. Multiple facilities by work at have stated that the having a severe difficulty actually getting these tests performed as psychiatric patients are not exactly the most reliable for regular outpatient blood draws. CMS has not been particularly sympathetic to this argument and is chewing out various psych departments. I know of at least 2 different medical systems in my area that have decided that the best way to handle this is to have the emergency department run this test every time they see the patient that way there is a random collection of lipid panels, essentially re setting that 6 month clock every single time they show up for some psychiatric complaint.

I’m sure OP would be fine with drawing the lipids and sending it wherever though .. just not holding the patient in the ED for 3 days waiting for results that won’t affect anything

 

[CoolDoc1729]

Dealt with this yesterday. Type two diabetic that hasn’t taken their medicine in three months and had a fingerstick of 280 with nothing else abnormal. Restarted all their medications. Refused to take them until their blood sugar was 100 or below. Spent an extra 12 hours in the department on a diabetic diet, fluids, and insulin before the facility would take them

A) I wonder what proportion of their psych inpatients meet this criteria? Probably less than half depending on what they served for breakfast?
B) I’d worry more about bottoming the person out… almost never give insulin to anyone under 350 in the ER unless they’re dka and still gapped getting d5… I’d bump that up to my director TBH

 

[DocEspana]

I’m sure OP would be fine with drawing the lipids and sending it wherever though .. just not holding the patient in the ED for 3 days waiting for results that won’t affect anything

My facility *used* to have this as a send out. The deal we cut was that as long as it was sent, the psych department would stop putting up a fight because their 'need' for it was more bookkeeping and appeasing CMS rather than actual "oh no this patient has a cholesterol emergency!". The psych department did still push the larger system enough until we could do the test in-house and get results in approximately 1 hour, but that all happened behind the scenes and didn't stop us back when it was still a send out.

 

[John Rawls]

Wow so if doctors ever get screwed and forced to be let go by admin the can cite various EMTALA violations good to know

Gotta have a little black book, names are not HIPAA compliant, but times and dates are. Document when it's fresh in your mind, take it out when needed.

 

[rokshana]

A) I wonder what proportion of their psych inpatients meet this criteria? Probably less than half depending on what they served for breakfast?
B) I’d worry more about bottoming the person out… almost never give insulin to anyone under 350 in the ER unless they’re dka and still gapped getting d5… I’d bump that up to my director TBH

Gap won’t close without insulin, doesn’t matter what the sugar is.

 

[rokshana]

My facility *used* to have this as a send out. The deal we cut was that as long as it was sent, the psych department would stop putting up a fight because their 'need' for it was more bookkeeping and appeasing CMS rather than actual "oh no this patient has a cholesterol emergency!". The psych department did still push the larger system enough until we could do the test in-house and get results in approximately 1 hour, but that all happened behind the scenes and didn't stop us back when it was still a send out.

What is a cholesterol emergency?

 

[DocEspana]

What is a cholesterol emergency?

I don't know but the psych intern on the other side of the phone says lets get some crestor STAT on this person.

 

[CoolDoc1729]

Gap won’t close without insulin, doesn’t matter what the sugar is.

Well that’s what I mean. If the sugar is 250 and they’re gapped and on insulin gtt and d5 that’s one thing..

to give an asymptomatic psych patient with a bs of 280 enough insulin to get them under 100 seems actually dangerous.

 

[PianoMedic]

What is a cholesterol emergency?

Significant hypertriglyceridemia causing acute pancreatitis is the only one that jumps to mind. IIRC it’s a triglyceride level above 1000, but the two or three cases at my facility I’ve heard about were several thousand each. They get emergent plasmapheresis in the ICU where I’m at.

 

[southerndoc]

Significant hypertriglyceridemia causing acute pancreatitis is the only one that jumps to mind. IIRC it’s a triglyceride level above 1000, but the two or three cases at my facility I’ve heard about were several thousand each. They get emergent plasmapheresis in the ICU where I’m at.

Probably get the same benefit by reducing their carbs and putting them on a treadmill.

 

[thegenius]

There are three provisions for EMTALA to apply, but in most circumstances they do:

(1) Psychiatric facility must receive emergency/unstable patients (this does not require a dedicated emergency department),
(2) Psychiatric facility must be licensed as a hospital under state law (a psychiatric facility license qualifies),
(3) Psychiatric facility must participate in Medicare and/or Medicaid.

If all 3 apply, then the psychiatric facility is bound by EMTALA.

Regarding #1, if more than 1/3 of their patients are not scheduled for admission, then #1 applies. This is almost every psych facility in existence.

Sorry I did not explain this in further detail.

I don't think you read my prior posts on this. Our ER doesn't interface with psychatric hospitals. There is a middle man. It's the county crisis services center. It's a small building in the middle of our town and our medicaid patients with psych emergencies go there. These crisis centers do not #1,2,3 above. They are not hospitals. We never talk to the psych hospitals ever.

Perhaps a middle man doens't invalidate EMTALA and that could very well be the case, but procedurally it would be extremely difficult to prove.

 

[rokshana]

Significant hypertriglyceridemia causing acute pancreatitis is the only one that jumps to mind. IIRC it’s a triglyceride level above 1000, but the two or three cases at my facility I’ve heard about were several thousand each. They get emergent plasmapheresis in the ICU where I’m at.

Yes but then they would be quite symptomatic if a problem.
Have uncontrolled diabetes pts with fat globules in their blood walking around with triglycerides in the 800-2000 range.

 

[TooMuchResearch]

Sir or ma'am, we both know they're not walking.

I honestly don't know how people don't exercise or move. After I work a few 12s in a row, I'm so stiff, sore, and tired.

 

[aim-agm]

@southerndoc while EMTALA applies to psychiatric hospitals and preempts state law, it's application is not simple since commitment involves curtailment of liberty and attendant constitutional protections. Do you have citations for EMTALA applying in cases involuntary treatment and transfer? Specifically, court findings that "refuses to consent" to treatment or transfer does not include when such refusal is product of mental illness or incapacitated?

 

[HemorrhagicShock]

It's a cultural thing that WE as a specialty have enabled. Same reason why docs on the receiving end of transfer calls expect you to bend over backwards and accommodate every tom dick and harry test they expect you to obtain before they actually evaluate the patient. Call CMS guys, it's not a big deal, and it's the right thing to do.

Good luck keeping a job if you're the doc that's raising the EMTALA-violation flag