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November President's Message - Impossible Situations
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11/22/2017 at 7:51:12 PM GMT
Posts: 7
November President's Message - Impossible Situations

Impossible Situations

By Aimee Moulin, MD, FACEP

The struggle to find an inpatient bed at a designated psychiatric facility is something we all share. Decades of cuts to inpatient and outpatient services have taken their toll on our mental healthcare system. California has lost 25% of inpatient psychiatric beds since 1995. As of 2016, California had 1 bed for every 5,886 people.1 Nationally there has been a steady increase in emergency department (ED) visits by patients with mental health diagnosis; 10% of all ED visits are for psychiatric illness and almost 2% of all visits result in a transfer to an inpatient psychiatric hospital. 2, 3 The mismatch of the need for mental healthcare services and available resources places us, and our patients, in an impossible situation every day, every shift.

Our Chapter has worked to improve systems of care for patients with psychiatric illness. California ACEP has advocated for your ability to make clinical decisions about patients with psychiatric illness so that you can do what’s right for your patients. The Chapter has worked to update the outdated LPS Act. We’re pushing to break down the barriers to transferring mental health patients: supporting the creation of an online psychiatric bed registry to help match patients to resources and working to open up psychiatric facilities to patients will all types of insurance.

So it was with much trepidation that we have followed the AnMed Health case that fined a South Carolina hospital under the Emergency Medical Treatment and Active Labor Act, otherwise known as EMTALA. EMTALA requires hospitals that accept Medicare to provide appropriate medical screening and treatment to stabilize the patient’s condition.
The mere whisper of an EMTALA violation strikes fear in every emergency physician and administrator. On top of that, add the frustration and legal mine–field of our antiquated laws governing involuntary treatment and this particular case has been especially fraught.

The South Carolina based AnMed health system settled with the Office of Inspector General for $1.295 million for failing to appropriately screen and stabilize psychiatric patients presenting to their ED. The case involves 36 patients with serious mental illness, including suicide and homicidal ideations. These 36 patients, in the opinion of the treating emergency physician, needed inpatient psychiatric treatment at a facility equipped to treat patients on an in-voluntary basis. However, the state-run inpatient psychiatric facility designated to accept patients on an involuntary basis did not have enough beds to meet the demands of the community. Patients meeting criteria for involuntary hospitalization waited in the AnMed Health ED for an open bed. Sound familiar…? 

A survey of California ED directors found patients were waiting in ED’s over 24 hours.4 Length of stay for psychiatric patients are significantly longer than for non-psychiatric patients with similar dispositions.5 Not surprisingly, closures of inpatient psychiatric beds have a measurable impact on nearby ED’s.6 It leads to an impossible situation that regularly plays out in EDs. 

What is less familiar is that the AnMed Health System did have inpatient psychiatric services and an on-call psychiatrist. Yet the hospital didn’t make these resources available to help take care of their ED patients, even though patients in this case waited between six to thirty-eight days to be transferred. The EMTALA violation was for failing to use available hospital resources (i.e. psychiatry consultation) in the stabilization of psychiatric patients. AnMed Health did not admit liability under the settlement deal. 

This case has raised a lot of questions. By citing the hospital for not obtaining psychiatric consults, some have argued this calls into question an emergency physician’s ability to medically screen and stabilize psychiatric patients. However, this case seems more to do with what obligations a hospital has to making its consultants available to emergency physicians who request them, rather than to suggest that an emergency physician is not qualified to medically screen and stabilized psychiatric patients. It also raises the question of what obligations a hospital has to provide consultation when they have telepsychiatry available.

Our broken mental healthcare system has placed emergency physicians in impossible situations. Clearly the status quo is not acceptable. We need solutions and resources to provide care for our patients will mental illness.
What do you think about the AnMed Health case? What solutions have you found to do your best to provide mental health care in the midst of a system that we all know if failing our patients and us? Post your thoughts in the comments below. 



  1. Lowe S. California's Acute Psychiatric Bed Loss. California Hosptial Association. 2017.
  2. Capp R, Hardy R, Lindrooth R, Wiler J. National Trends in Emergency Department Visits by Adults With Mental Health Disorders. The Journal of emergency medicine. 2016;51(2):131- 135.e131.
  3. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables, tables1,4,15,25,26. In: National Center for Heatlh Statistics DoHaHS, ed. Atlanta GA: Centers for Disease Control and Prvention; 2017.
  4. Stone A, Rogers D, Kruckenberg S, Lieser A. Impact of the mental healthcare delivery system on california emergency departments. The western journal of emergency medicine. 2012;13(1):51-56.
  5. Zhu JM, Singhal A, Hsia RY. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11. Health affairs (Project Hope). 2016;35(9):1698-1706.
  6. Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of Decreasing County Mental Health Services on the Emergency Department. Annals of emergency medicine. 2016;67(4):525-530.

Last edited Wednesday, November 22, 2017
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