As resources become more scarce and as more patients lose insurance funding, psychiatry beds for mentally ill patients are becoming harder and harder to secure. In turn, psychiatry patients who need further care are putting an increasing stress on emergency departments. Subtle financial cherry-picking of patients makes it extremely difficult to obtain necessary care for patients. When called for a potential transfer, psychiatric institutions require an informational “face sheet” containing demographic … and insurance … information to be faxed to them prior to releasing a bed. Then the fun begins.
Patient #1
A young lady with pre-existing psychiatric problems used a Ginsu knife to cut her throat after her boyfriend broke up with her. She had been drinking … a little. Her alcohol was 210. We did some testing to make sure that she didn’t hit any of the vessels in her neck and then closed the laceration. Then we went about transferring her to see a psychiatrist. The psychiatric triage nurse requested that we fax them a “face sheet.” The patient happened to have no insurance.
We get a call back 15 minutes later.
“We won’t accept the patient until her alcohol level is less than 80.”
Fine. We’ll play the game. Alcohol levels generally decrease at a rate of about 20mg/dl/hour, so we’ll keep her locked in a room for another 6 hours.
Six hours later we draw another alcohol level. It is 82. Call the psychiatric nurse back and ask to speak to the psychiatrist.
“Nope. Alcohol has to be less than 80.”
OK, Nurse Ratchet. Whatever.
Wait another hour just to make sure that alcohol will definitely be lower than 80 and re-draw the alcohol level for the third time. Ahhh 57. Great.
Call psychiatric nurse and get put on hold. Finally speak to her and she agrees to page the psychiatric attending for us.
Forty five minutes later, psychiatric attending calls back.
“Have you reassessed her?”
“Of course.”
“Is she still suicidal?”
“Right now she’s pissed off that she had to wait so long, so she wants to leave.”
“But is she still suicidal?”
“I didn’t specifically ask her that.”
“Ask her.”
“She nearly decapitated herself with a butcher knife and you’re wondering whether she was sincere in her intent?”
“Ask her.”
[Walk into room, ask patient is she is still feeling like harming herself]
“F*^& you. I’m getting the f*^& out of here.”
“Are you suicidal?”
“No”
[Back to phone]
“She says she’s not suicidal now.”
“Then I’m refusing the patient.”
“You’re refusing to take a patient who tried to kill herself by slitting her throat with a knife?”
“She’s not suicidal any more. What do you need me for? Have her follow up in an outpatient center.”
[Click]
Patient #2
Another young lady came by ambulance after hearing voices that were telling her to kill herself. There were superficial cut marks on her wrist. She had intermittent psychiatric problems in the past and was noncompliant with her medications. She also had a history of hypothyroidism. She had Medicaid for insurance.
We get all the usual labs and everything is normal except she has a few bacteria and a few epithelial cells in her urine.
Calls to several hospitals with psychiatric services were unhelpful since they all allegedly had full beds. They still make sure that you tell the story and fax them a face sheet first, but then they call you back and say that they’re full.
Finally we get a place that has beds available.
“Did you check magnesium, RPR (for syphilis), and thyroid levels?”
“Actually, no.”
“Call us back when you get those results.”
“RPR probably won’t come back until tomorrow.”
“The labs need to be sent.”
“Fine.”
[Labs sent and actually come back, including RPR, in a couple of hours. Call psych triage nurse back.]
“Everything is normal except that her TSH level is elevated.”
“You need to repeat the TSH level.”
“Why?”
“We won’t accept the patient until her TSH level is normal.”
“Whaaaat? That could take days or even weeks.”
“The doctors here don’t treat medical problems such as that. Until the patient is medically stable, we cannot accept transfer.”
“I’m saying that the patient is medically stable. You just have to give her thyroid medication that has already been prescribed to her.”
“Sorry, we’re not accepting her until her labs are normal.”
And people wonder why psychiatric transfers take so long.
We get what we pay for.
Psychiatric services are traditionally reimbursed at a very low level.
Therefore fewer and fewer facilities are remaining open to offer the services. For examples, see here and here.
The remaining facilities get overwhelmed and either cannot or will not provide care for the patients in need of help.
Patients often end up in the emergency department where they must be kept until they can get the treatment they need. Sometimes that makes days that patients are stuck in a room in the emergency department instead of getting the treatment they need.
That same room is unavailable to other emergencies that need to be treated.
The backups in patient flow and resulting emergency department overcrowding cost lives.
The new health care bill addresses psychiatric care by creating a “productivity adjustment” for psychiatric hospitals (page 379):
‘‘(2) PRODUCTIVITY ADJUSTMENT. In implementing the system described in paragraph (1) for days occurring during the rate year ending in 2011 or any subsequent rate year for a psychiatric hospital or unit described in such paragraph, to the extent that an annual percentage increase factor applies to a base rate for such days for the hospital or unit, respectively, such factor shall be subject to the productivity adjustment described in subsection (b)(3)(B)(iii)(II).’’
Here’s how the adjustment will be calculated (page 377):
‘‘(II) The productivity adjustment described in this subclause, with respect to an increase or change for a fiscal year or year or cost reporting period, or other annual period, is a productivity offset in the form of a reduction in such increase or change equal to the percentage change in the 10-year moving average of annual economy-wide private nonfarm business multi-factor productivity (as recently published in final form before the promulgation or publication of such increase for the year or period involved). Except as otherwise provided, any reference to the increase described in this clause shall be a reference to the percentage increase described in subclause (I) minus the percentage change under this subclause.’’
… which is precisely why we’ll have fewer and fewer psychiatric services available to us and why more and more emergency department overcrowding will occur.
Since I got a little crazy with Matt over the Tamiflu thingy, I promise this is my only comment. Your stories of the bureacratic hoops you have to jump through is crazy. It amazes me that with all the advances in medicine, we might as well be applying leeches and laying on hands with our inadequate care and resources for the truly mentally ill. There’s got to be more to offer than soup kitchens and the ER.
I read a lot of ER blogs and there’s usually a post about a crazy patient. I get most of these posts are just about normal people who are choosing to act like a-holes but mixed in are some pretty sad stories.
Oh well, like Dr. Happy says, just take a run, eat your fruits and veggies and you’ll feel a whole lot better.
Crazy? You????
Compared to the demonstrated behavior of certain others in this forum, you’re a bastion of sanity in a sea of madness.
Well… now I know why our politicians don’t read the health care bills proposed… still NO excuse for passing something they don’t understand.
The slitting the throat denial is egregious. I wonder how the doctors really feel when they do something so absurd.
Why aren’t they accountable for denying patients? I guess because they know the ED by law has to hold said patient.
I have wondered how mental health professionals earn a good living since there is such disparity between physical vs psychological reimbursements.
We here so much talk about preventative medicine these days and that is true.. head it off so it doesn’t happen .. but, I also think that good mental health could also prevent some of the physical ailments. We all know what accumulated stress can do to our bodies ..not to mention addictive issues, depression, etc.
Frankly ..there making you jump threw those hoops like that and then still bringing you to a dead end seems insane on their part.
Self preservation I guess.
Something has to give somewhere.
When you got the 82 you should have lied. By the time they could have verified it would have been below 80 anyway.
We have to fax them the lab results.
You can fix part of your problem with placement easily.
Take the Insurance info off the face-sheet, and make it your transfer policy for all transfers (out and in).
When they gripe about it, tell them you’re looking out for them: now they won’t make an EMTALA violation using data they legally cannot use to make a placement decision anyway.
We tried that.
Hospitals balked saying that they needed to know insurance coverage so that they could tell if their hospital was “in network” for the patient’s insurance plan.
Ended up being a problem with admin and we had to leave things the way they were.
No i think Grunt has a point…What if you were to print it
post a label over it. obstructing its view. Beat them at there own game
Nothing like having a little “wallet biopsy” to get in the way of patient care. We get cases like this so often on the floors as the patients need to be “Medically Stable” before Psych will take them so they hang out on the floor, in a private room, usually with a MHT on 1:1 supervision and they hang out for days, sometimes weeks for simple things that could be treated simply (like UTIs). We even had a transfer from Psych to the floor for just that – a freaking UTI! And being on the floor, they do not get the group sessions, counseling or other treatments that they would get on a dedicated Psych unit. Sure they get a little from the MHT, but it not the same intensive treatment they would normally get. All we do is sling some meds their way and pray they don’t decompensate further. It is bad all the way around and loses sight of the real reason we are here: to care for the patient.
This isn’t a healthcare bill at all. It’s a hostile takeover. Our country’s in the best of hands.
That is simply gobbletygook.
I just found out the easiest way to get involuntary psych beds. Get the patient arrested! The involuntary state hospitals always keep a few beds open for people under arrest and the police hate waiting around the ER. Our last patient like this got a bed in 4 hours!
I used to have ETOH patients with nice things like .22 wounds to the chest arrested so I could haul them in.
Saved a return trip.
“… which is precisely why we’ll have fewer and fewer psychiatric services available to us and why more and more emergency department overcrowding will occur.”
So what are you doing about it? Or if nothing, what do you propose we do about it?
Here’s how to solve the problem:
1. If we’re going to continue to use EMTALA as a means to provide emergency care to everyone, enforce the law. Specialty center won’t take a patient when they have beds available? Report them. Problem is that the referring hospitals don’t want to get into a pissing match with the larger institutions. So violations go unreported unless there is a bad outcome. Enforce fines or other sanctions under the law against hospitals that don’t report violations. Heck, I’d even let the feds come in and do random audits to see if hospitals aren’t reporting.
2. Create a statewide or national database of hospitals/capabilities/specialty beds available. Anyone wanting to transfer any patient to a referral center can go look up on the database what hospitals have beds available in what specialties. No more multiple phone calls to find an available hospital. If you’re listed as available on the database, you have to take the patient in transfer. Either that or create a centralized dispatch similar to 911 services that will find the closest open bed.
3. Create financial incentives for the hospitals that have most percentage of beds open for the most amount of time during a year and/or disincentives for receiving hospitals that accept the fewest transfers.
4. Create standardized screening requirements for all transfers so that hospitals can’t play this “stabilize the TSH” game. Any testing above the basic requirements can be done at the discretion of the transferring hospital (in order to stabilize the patient), but may not be requested/demanded by the receiving hospital as a precondition to accepting transfer.
How’s that for a start?
Can I find these suggestions, which sound great, in a bill anywhere?
of course not. the political hacks who think they are “solving” this crisis are not listening to those in the trenches.
Physicians are a pretty wealthy group as far as interest groups go. Where are your lobbyists?
create a centralized dispatch similar to 911 services that will find the closest open bed.
The closest open bed. (laughing hard)
Hysterical.
As if there was something close to resembling a “supply”.
I like number three. A lot. In my experience, this might be the best shot: pocketbooks.
I get so mad when I see or here that happen. I want to become nurse but when i see that day in and day out i just cringe.
Once, then when it happens to me i became enraged and it was a surreal moment, almost psychotic episode. I was just calm one moment and screaming that no-one knows what they are doing anymore and the system is broken. In which it is. We being people who are patients, nurses, MAs, Doctors janitors secretaries, ect. Need to rule out the doctors, Administrators, CEOs that want to increase their books. And help patients get the help that they need and truly deserve.
WC
In the local Paper in Raleigh, They cited this as well. 3700 patients were put on a waiting list fir services due to lack of beds.
Here is a link to the article;
http://www.newsobserver.com/news/local_state/story/181026.html