If the emergency physician is able to determine whether an EMC exists, an on-call physician is not needed to help make that determination. It is only when the emergency physician needs the assistance and expertise of an on-call physician to determine if an EMC exists that the hospital is required to utilize the services of the on-call physician in screening the patient, and this is true regardless of whether the medical condition is a medical problem, surgical problem, pediatric problem, neurosurgical problem, or psychiatric or behavioral health problem.
Explore This IssueACEP Now: Vol 36 – No 10 – October 2017
In the 36 cases cited by CMS in its statement of deficiencies against AnMed Health, it was not at all difficult for the emergency physician to ascertain whether the patient suffered from an EMC. Many were well-known chronic psychiatric patients with obvious emergency conditions such as acute psychosis, suicidal intent, or behavior that threatened others. Many, just hours before, had encountered the state mental health system and had been sent to the emergency department by a psychiatrist via law enforcement, already on involuntary commitment papers for the emergency department to hold them until a bed became available in the state hospital. Others, through an appropriate history and physical examination, were readily determined to have an EMC without requiring the expertise of an on-call psychiatrist to make that determination. It’s not difficult for an emergency physician to determine that a 50-year-old man who tried to blow his head off with a 45-caliber revolver is actively suicidal.
The logic and the law are the same with respect to stabilizing patients with emergency conditions. If the services of an on-call physician/psychiatrist are not necessary or required to stabilize the individual, then the hospital has no duty under the law to mandate its on-call physicians/psychiatrists to present to the emergency department to provide stabilizing services.
So when is a psychiatric patient stabilized? CMS has specifically defined psychiatric patients to be stable “when they are protected and prevented from injuring or harming themselves or others.”6
Thus, once the hospital emergency department utilizes its usual interventions to “protect and prevent psychiatric patients from injuring or harming themselves or others” (medical clearance, searched, secured, removal of means and opportunity to harm self or others), the patients with psychiatric emergencies have been “stabilized,” as that term is defined by EMTALA, and the on-call physicians need not be involved to stabilize the patient.
Moreover, once stability is achieved, the law ends, and once the patient is stable, any further treatment, such as the care provided while the patient is boarded in the emergency department, psychiatric consultations, or any discharge or transfer, is not governed by EMTALA. As stated by CMS: