EMTALA Violation? Examining Inequity in the Emergency Transfer of Psychiatric Patients

Background

Despite the enactment of Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 to help patients gain access to physicians regardless of their ability to pay, patients with psychiatric emergencies continue to receive disparate levels of care based on insurance. Between 2002 and 2018, nearly 20% of all EMTALA fines and 85% of the largest EMTALA settlements were related to mistreatment of psychiatric emergencies (CA Dept of Health, 2019). A recent multi-site study found that uninsured and public insured patients with mental health complaints were twice as likely as privately insured counterparts to remain in the ED for over 24 hours before being admitted to an inpatient psychiatric facility (Pearlmutter, 2017), with subsequent studies confirming this alarming trend (Smith, 2016).

Methods

An interdisciplinary team comprised of psychiatrists, emergency medicine staff, social workers, and transfer center specialists are conducting a retrospective data review for patients who received a psychiatric evaluation at Stanford Hospital Emergency Department (SHC ED) between January 2020 and February 2021. Primary outcome measures are length of stay and rates of acceptance for transfer, examining for statistically significant differences based on insurance status, race and housing.

Results
Between January 2020 to February 2021, a total of 1489 psychiatric consultations were completed. For those who met criteria for psychiatric admission and the SHC psychiatric unit was full, a transfer to an outside hospital psychiatric unit were attempted. Of the patients with private insurance, 48% were accepted to transfer to another facility, while only 7% of Medi-Cal patients were accepted for transfer during the same time period. Data analysis will be completed during May to August 2021 through a SHC designated quality improvement course.

Discussion/Conclusion
Consistent with previous literature, SHC ED patients with emergency psychiatric needs and Medi-Cal or public insurances are noted to have disproportionately long wait times in the SHC ED while waiting for transfer to inpatient psychiatric unit. These wait times result in significant delays in care. The transfer process is a complex one that requires coordination between multiple medical departments and hospital sites. Patients with public insurance and lower socioeconomic classes are more impacted by these delays when compared to patients with private insurance. We aim to address factors contributing to these inequities and identify interventions to improve access to care.

References:

California Department of Public Health. Care and Treatment of Psychiatric Emergency Medical Conditions. 2019.

Pearlmutter, M. D., et al. Analysis of emergency department length of stay for mental health patients at ten Massachusetts emergency departments. Ann Emerg Med 2017; 70(2), 193-202.

Smith, J. L., et al. Correlates of length of stay and boarding in Florida emergency departments for patients with psychiatric diagnoses. Psychiatric services 2016; 67(11), 1169-1174.