PART II: So, What Happens in the ER?
Many practitioners will find in the course of their career that they have a client in need of emergency psychiatric hospitalization or evaluation. However, if you were to explain the process by which this happens to a layperson, say the parent of a client, could you do it? Many practitioners, if they are being honest, might not be able to. In fact, most attorneys and the general public, especially, have no inkling of how this process works. Hopefully, after reading this blog and going forward you will have an understanding of the process and you will feel confident explaining it to others.
In Part I, I discussed the emergency petition process and how a client of yours in a psychiatric emergency might get to a local hospital for treatment. In this second part, I will now cover what happens from the moment your client enters through the doors of the emergency room (ER) to when they leave the ER, either to be discharged or to be transferred to a psychiatric facility.
Previously, I discussed a situation where a client who is having a psychiatric emergency and needs to be brought to an ER for evaluation. For this second part, the same client has now been transferred or arrived at their local hospital’s ER, either brought by police on an emergency petition (EP), brought by a family member or friend, or came to the ER alone. It is of critical importance that practitioners understand that almost all psychiatric emergencies are a high stress situation for both the individual and their family and preparing a client for the process can help.
The Emergency Medical Treatment and Labor Act (EMTALA) requires anyone coming to an emergency department to be accepted and stabilized and treated. This is regardless of whether the hospital has an inpatient psychiatric unit on site. Did you know that not all of our local hospitals have inpatient psychiatric units and not all have ones that are appropriate for the concerns bringing the individual to the hospital (i.e. child/adolescent unit, neuropsychiatric unit, geriatric unit, dual diagnosis unit, etc. )? However, in an emergency situation it is most important that the individual get to a safe place regardless of whether the hospital has an inpatient unit. Therefore, clients should always be told to go to the closest ER.
Upon arrival, your client will be evaluated by emergency room personnel. Based on the presenting problem, it will be determined if there is a need for a psychiatric evaluation. If an individual comes to the ER, but not on an EP, they do not have to be evaluated psychiatrically if the ER physician feels they can treat the problem and safely discharge. For example, an individual who presents with panic attacks might be given medication and discharged. An individual who is detoxing from alcohol or heroin might never see a mental health practitioner.
The first concern when an individual comes to the ER is to address any significant medical concerns. Individuals will be medically stabilized and medical issues will first be ruled out as the cause of the psychiatric emergency. For example, a patient who has overdosed must be medically stable before psychiatry can step in for an evaluation. A person who self-injures and cuts too deep might need stitches or other medical intervention. A geriatric patient with a mental status change might have medical causes ruled out such as a urinary tract infection.
Some hospitals have psychiatric hold areas within their emergency department; some hospitals like Johns Hopkins have larger psychiatric ER’s. Some ER’s place psychiatric patients in regular rooms and may or may not assign a sitter to watch the individual during their stay. Additionally, some hospitals staff their ER’s with psychologists and psychiatrists, and others may staff their ER with psychiatry residents or social workers.
Practitioners and clients should also be aware that this process is not instantaneous nor is it particularly speedy. Depending on how the individual arrives at the hospital, there could be a significant wait in the waiting room. A physician generally does their medical exam pretty quickly after the individual is placed in a room; however the time it takes getting into a room varies drastically day to day and hour by hour. Once the individual is cleared for the psychiatric evaluation, the individual may then sit several more hours before they are seen by a mental health professional. Most emergency departments don’t provide psychiatric evaluations 24/7 and depending on how many others are waiting for evaluations, there could be a long wait. The medical staff will often attempt to keep the individual comfortable and safe by providing medications but it can be a stressful time for the individual and their family.
Eventually, your client will be evaluated by two healthcare professionals, generally an ER physician and a mental health professional. If brought to the ER by EP, the ER physician has six hours to evaluate your client (Maryland Ann. Code Health-General Section 10-624(b)(2)). This means that if the ER physician does the first evaluation within six hours they are in compliance, the second evaluation has to be completed within 30 hours (Maryland Ann. Code Health-General Section 10-624(b)(4)).
Therefore, an individual brought to the ER on an EP can only remain an “emergency evaluee” for up to 30 hours; however, this does not mean their stay in the ER caps at 30 hours. Once evaluated, the client is either discharged or stays as a voluntary or involuntary patient. It is important to know that an individual who is brought by police to the ER on an EP cannot leave until they are evaluated. On the other hand, an individual who comes to the ER of their own volition does not fall under these statutory guidelines. An individual who self-presents to an ER has the right to leave at any time unless the ER physician and mental health professional deem them a danger to themselves and/or others. Therefore, if your client came themselves to the ER and is in the waiting room and has yet to be seen by a doctor, they may decide that they don’t feel like waiting and just leave, and be permitted to do so.
Once the mental health professional conducts their evaluation, they will determine what level of care is necessary to maintain the individual’s safety. This could range from outpatient therapy, to a day hospital, to inpatient treatment, amongst other options. To be admitted into an inpatient psychiatric facility, voluntarily or involuntarily, an individual must be a danger to themselves and/or others due to a psychiatric disorder and be in need of treatment.
The client may be offered the opportunity to sign a voluntary commitment order, which means that they are accepting admission to a psychiatric hospital for treatment voluntarily. In Maryland, an individual over age 16 is able to sign a voluntary commitment as long as they are competent; for minor clients, under the age of 16, the parents would need to consent. Minors between the ages of 16 up to 18 can voluntarily admit themselves without parental consent, or a parent can sign for them regardless if the 16 to 18-year-old minor objects to the hospitalization.
Voluntary admission allows a client to sign a 72-hour notice requesting discharge once they are at the psychiatric facility. This allows the psychiatric facility to assess over those 72-hours if the individual can be safely released or would meet criteria for involuntary admission. I will cover what happens if they decide the individual meets criteria for involuntary admission in Part III of this blog series, next month.
In situations where the client is not competent to or refuses to sign the voluntary commitment order, but evaluating healthcare professionals believe that commitment is necessary to maintain safety, the healthcare professionals should decide if the individual meets criteria for involuntarily commitment. Two health care professionals to include physicians, psychiatrists, psychologists, or psychiatric nurse practitioners, are required to each fill out and sign a physician’s certification, certifying involuntary commitment. Additionally, one of the health care professionals must fill out and sign a report as to certification of commitment.
On these forms there must be an identified DSM 5 diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used by healthcare professionals as the authoritative guide on the diagnosis of mental disorders. Then, there must be a justification as to why the individual is in need of inpatient care, why the individual presents a danger to his/her own life or the life or safety of others, why the individual is unable or unwilling to sign a voluntarily commitment, and why there is no less restrictive alternative than inpatient psychiatric care available for the individual which is consistent with welfare and safety. All of these criteria must be met to involuntarily commit.
Frequently, individuals with mental illness lack insight into their symptoms when unstable. This makes involuntarily committing an individual often traumatic for them and their families. For the individual, as they lack awareness as to how they pose a danger to themselves or others, it can be extremely upsetting and anxiety provoking to suddenly find themselves confined to a psychiatric facility against their wishes. Family members may not always be willing to recognize the need for hospitalization, but even if they do, it is often extremely upsetting and stressful to watch a loved one go through this.
It is important to remember that not all individuals who come to the ER for a psychiatric emergency are kept. Even those who might meet criteria for voluntary admission might refuse to sign and if they do not meet criteria for involuntary admission they can be released. While some individuals might greatly benefit from inpatient admission, they may not pose an imminent danger to self or others and thus can be safely managed without involuntary commitment, via a less restrictive means of care such as a day program or outpatient therapy.
For practitioners what this means is that if you believe a client that you sent to the ER either by EP or on their own is dangerous and needs inpatient treatment, the EP needs to provide details reflecting this. Alternatively, and for best practice purposes, you should call the ER to provide such collateral information.
For those that are kept in the ER awaiting admission to a psychiatric unit whether voluntarily or involuntarily, now the real waiting game begins. Ideally, a bed on a psychiatric unit at the hospital where the individual is being held in the ER will be available and the individual will be transferred within hours. This is rarely the case, though. Remember, some hospitals don’t have inpatient psychiatric units at their hospital or don’t have a unit that is appropriate for your client’s treatment needs.
Regardless of whether there is a psychiatric unit at the hospital where the individual is waiting in the ER, it is important to realize that there are a limited number of beds on each inpatient unit that only become available when someone is discharged. Even if there is an inpatient unit at the hospital where the client is being held in the ER, it does not mean that they will be placed at that hospital. From my own personal experience with individual clients, I have had clients transferred to a psychiatric facility many miles away from the ER they were initially admitted to, even though there was a psychiatric unit at the hospital where the client was currently at!
Unfortunately for clients, there is no requirement that the psychiatric facility where the individual is placed be nearby or within local distance for the client’s family. If a voluntary client does not like where they are being sent, they can ask to be discharged from the ER and, as stated above, the individual will be evaluated to determine if they are safe to leave or meet criteria for involuntary commitment. If the individual is being sent involuntarily to a psychiatric facility, there is no choice. A client might present at an ER thinking they will go to a specific hospital’s inpatient psychiatric unit but that may or may not be the final outcome. It is important to warn clients of this as this is a frequent misconception. Again, from personal experience working with clients in this situation, this misconception often leads to increased stress and anxiety for the client. Regardless, what is most important is that your client is being kept safe in the ER; however, the time frame for finding a bed on an appropriate inpatient unit can vary significantly.
The reality is psychiatric beds are in short supply throughout Maryland and all over this country, especially for more specialized treatment needs such as neuropsychological disorders and dementia. Your client may end up in the ER waiting for a bed to open up for many hours, days, or even weeks. If they are there voluntarily and ask to be discharged the individual has a right to be evaluated to see if they are safe to leave or would meet involuntary commitment criteria. If they are waiting involuntarily, they should be evaluated daily during their stay to ensure that they continue to meet criteria for involuntary commitment. Once an open bed is found, the hospital will usually move quickly to transfer the client as emergency rooms want to minimize their length of stay. The ER’s don’t want individuals there any longer than necessary as it takes away a bed for someone who needs emergency care.
Once a bed is found, the hospital will require transport by ambulance to the psychiatric facility, as maintaining the safety of the individual and others is the main objective. This whole process can be very long and stressful, and the actual treatment at a psychiatric facility hasn’t even begun! While having an attorney at this point isn’t generally necessary, having an attorney to ensure that the hospital is following all laws can be helpful. In this capacity, an attorney can act as both the client’s counsel and their advocate to ensure the proper procedures are being followed; however, even if an attorney is not present, it is important the individual in crisis have an advocate of some sort, be it an attorney, mental health practitioner, family member, or friend. The advocate should be someone who knows how the system works and can also be a calming influence during this sometimes stressful process.
Next month, in Part III, the last installment of this series, I will cover what happens once the client arrives at the psychiatric facility, including the involuntary commitment hearing.
For more information, or for other legal considerations regarding clients or to set up a free consultation, contact Mayer Law, LLC today at (443) 595-M-Law!
This article is legal information and is not provided as a source for legal advice. It is made available by Mayer Law, LLC firm for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By reading this blog, you understand that there is no attorney-client relationship established between you and Mayer Law, LLC. This blog should not be used as a substitute for competent legal advice and you should consult with an attorney before you rely on this information.