As you may recall, back in November 2018, the Virginia Department of Behavioral Health and Developmental Services put into place new Medical Assessment and Screening Guidelines across the Commonwealth. These guidelines improve the process for evaluating the medical and/or psychiatric needs of individuals presenting in the ED, as well as facilitating disposition.
The Guidelines were developed through a Medical Assessment Workgroup made up of representatives from the Virginia College of Emergency Physicians (VACEP), the Department of Behavioral Health and Developmental Services (DBHDS), and the Virginia Hospital & Healthcare Association (VHHA). In addition, feedback was sought from multiple behavioral health stakeholders throughout Virginia.
This workgroup, known as Protocol Review and Monitoring Committee (PRMC), has created answers to frequently asked questions we’ve been getting on the Guidelines. After reviewing the FAQ, if you still have questions or are encountering obstacles in your implementation of them, reach out to VACEP members and PRMC members Joran Sequeira or Bruce Lo.
Who was involved in creating the guidelines?
Representatives from the Virginia Hospital and Healthcare Administration (VHHA), Department of Behavioral Health and Developmental Services (DBHDS), Virginia College of Emergency Physicians (VACEP) met over 2 years to create the guidelines. The Virginia Association of Community Services Boards (VACSB) was consulted throughout the process.
Why was there a need for the guidelines?
The goal was to standardize the Medical Assessment and Screening process for psychiatric admissions from emergency departments. A complete history and physical exam and only clinically indicated diagnostic studies need to be completed by an ED provider. There has been an abundance of medical literature showing that blanket ordering of labs, urinalysis, EKG is unnecessary and even harmful to the patient. Blanket testing has not proven to change patient outcomes or admission decisions by emergency physicians or psychiatrists, and is a waste of healthcare dollars, time and resources to test patients who are otherwise healthy. In addition, there was a need to clearly delineate exclusion criteria for state hospitals, emphasize doctor-to-doctor conversation in the event of disagreement, create an escalation process and clarify what happens in the event a patient with capacity refuses testing.
What EDs and hospitals does this apply to?
These guidelines apply to all EDs where psychiatric patients are taken for medical clearance and all private hospitals, state hospitals and crisis stabilization units to which patients are admitted.
When did it go into effect?
November 5, 2018
What testing is required?
Required testing differs based on age. Minimal testing is required for patients with no active comorbidities. Please see chart below. If there are any signs/symptoms that suggest organic causes or medical stabilization prior to psychiatric admission (ingestion, trauma, acute change in mental status, eating disorder, active co-morbidities etc.), consider further testing which may include but not limited to CBC, BMP, Toxicology labs, EKG and/or imaging.
What about patients with alcohol intoxication?
For adult patients to be admitted, BAL needs to be less than 0.25 AND they have to be clinically sober. In addition, adult patients need to have a CIWA of 8 or lower. Pediatric patients need a BAL of 0.00.
What happens if there is disagreement between the emergency department and the admitting psychiatric hospital/unit on testing and medical stability of the patient?
There should first be a conversation between the ED Physician and the Psychiatrist. Usually discussion leads to an amicable agreement on both ends. Remember it is Virginia law that if an ED doctor requests to speak with a psychiatrist, the conversation must happen.
What happens if the ED physician and the psychiatrist still do not agree on testing?
There is an escalation pathway delineated in the guidelines. If the two physicians cannot resolve the disagreement, then the case is taken to the Medical Directors. If still unresolved, the CEO of the institution(s) will get involved. All escalation cases should be sent to the PRMC (see below).
If a psychiatric facility has the resources to admit a patient, are they able to refuse a patient because certain testing was not performed?
No, this is an EMTALA violation. If a psychiatric unit is able to take a patient based on available resources and has a bed, they should admit the patient. If there is disagreement on testing, a doctor-to-doctor conversation must occur first. This is written in the Virginia Code (point #20): See above on escalation for persistent disagreements.
In ingestion cases, who decides when a patient is medically stable for psychiatric admission?
If there is disagreement as to when a patient is medically cleared after a toxic ingestion, the Toxicologist at Poison Control is the consultant who decides when a patient is safely cleared. This is written in Virginia Code (point #20).
What happens if a patient is unwilling to give blood or urine?
If a patient has capacity to make decisions and refuses to give blood or urine sample, they will not be forced to do so, physically or chemically. This also holds true for those under an ECO. Attempting to obtain blood/urine on a patient, who has capacity to refuse, is considered assault.
What if a patient who was medically assessed now has inpatient medical needs or becomes unstable at the psychiatric facility?
EMTALA law means that every ED has to do a medical screening evaluation. If an improper evaluation was done or something was missed, please provide feedback to the ED team for the future. Feedback ensures improvement. If a facility or provider continues to send unstable patients please reach out to the PRMC (see below).
What cases meet exclusion criteria for State Hospitals and CSUs?
There are a number of cases that meet exclusion criteria that can be found within the guidelines. Such cases include acute delirium, dementia with no psychiatric symptoms, acute TBI, acute respiratory distress, hospice, high risk for complicated withdrawal such as delirium tremens, IV antibiotics, etc.
Are cases and the guidelines being actively reviewed?
Yes, the Protocol Review and Monitoring Committee (PRMC) meets regularly to discuss any feedback to the group and cases that were escalated.
Where can I see the guidelines online?
Who can I contact with further questions or feedback regarding the guidelines?
Please contact your CSB, VHHA, VACEP or DBHDS representative. Please put only HIPPA-compliant information in your email. If there are any issues with certain staff members, hospitals, etc., please email the names so we can speak to all those involved in the case.
