WACEP President's Message, September 2018
Lisa Maurer, MD

You’re working a busy 12 hour shift, and a patient with chief complaint of “SI” pops up on the board.  Gulp.  The evaluation is uniquely straightforward: this 54 year old female has a history of depression and is having passive thoughts of suicide in a stressful time, very clearly presents with her husband for voluntary admission.  No ED hold needed.  You find no other medical concerns and even get her accepted at the nearest psych hospital promptly, which happens to be 50 miles away.  Bingo bango, you’re on a roll!  

Then comes the question of what “mode of transportation” are you going to fill out on the EMTALA form?  The patient just assumes that her husband can drive her there, but your hospital has a policy that all psych transfers must go by ambulance, sticking this family with a hefty bill.  Your gut is that she is extremely low risk for harm or non-adherence to the care plan during private transport.  Is there merit to insisting on ambulance transfer?

We had this exact question presented to our chapter by our members.  Certainly, there is a time and place when your spidey sense tells you to opt for ambulance transfer even for voluntary admissions.  However, for the seemingly low risk patients, we wanted to supply our members with data who wish to have discussions with their hospital administrators if you want to pursue more flexible standards for transportation in voluntary psych transfers.  See here for a seven-page legal summary concluding that the mode of transportation should be left to the judgement of the physician, done by our contracted attorney, Guy DeBeau from Axley Brynelson, LLP.  It includes an interesting summary of pertinent case law, and tips for how to safely document characteristics you may have considered when assessing your patient’s level of risk for harm during transfer. It is worth pointing out that the memo does not include any examples of civil suits for harm that occurred during a similar transfers in Wisconsin, because there aren’t any such lawsuits. 

For other points of discussion, WACEP has received some helpful tips from our partners in the WI Psychiatric Association.  They refer to the CMS booklet on Non-Emergent Medical Transport for the “standard of care” for transportation of psychiatric patients, which comments on the difference between clinical scenarios that necessitate emergent transport and those that are non-emergent.  For potential discussions of other transportation options, keep in mind non-ambulance secure transport choices as well, such as JBM, Able- Access, or Lock n Load.

Does your hospital have a policy to mandate that all patients being transferred for voluntary inpatient psychiatric care go by ambulance?  Do you feel that this is appropriate, or are you looking for a change?  We are interested in how we can further help with this issue in Wisconsin EDs.