Patient Dumping and EMTALA Enforcement Involving Psychiatric Emergencies

Project Summary Psychiatric emergencies comprise a large and increasing proportion of emergency department (ED) visits, with many psychiatric patients receiving suboptimal care while boarding in EDs. The Emergency Medical Treatment and Labor Act (EMTALA) established a duty for hospitals to screen and stabilize patients presenting to EDs

regardless of ability to pay. EMTALA requires that any patient with a medical or psychiatric complaint presenting to a dedicated ED have a timely screening exam, stabilization of emergent conditions, and transfer to another facility for a higher level of care if services required for stabilization are unavailable at the original

facility. Hospitals violating EMTALA are at risk for termination of Medicare provider agreements, which typically results in hospital closure or downgrading of emergency services. Despite potentially grave consequences, hospitals continue to violate EMTALA. Overall, 17% of EMTALA citations are labeled by the enforcing agency

as involving psychiatric conditions. However, a review of recently available data suggests that these labels underestimate citations involving psychiatric conditions. Specific conditions and circumstances (e.g., suicidal ideation, threats to staff) resulting in care denial or outcomes of involved patients (e.g., hospitalization, death,

incarceration) have not been explored. A more rigorous exploration and categorization of individual citations associated with the care of patients with psychiatric emergencies is warranted to inform care, encourage compliance, and maintain uninterrupted provision of emergency services. Higher odds of EMTALA citations are

found among hospitals that are large, urban, for-profit, and disproportionately serve Medicaid patients. However, hospital-level factors associated with EMTALA citations involving psychiatric emergencies have not been explored. Hospitals with less capacity to care for patients with psychiatric conditions on-site are more

likely to discharge patients compared with hospitals that have greater capacity. Whether the capacity of a hospital (or lack thereof) to stabilize patients with psychiatric emergencies is associated with risk of EMTALA citation remains uninvestigated. A multidisciplinary team, including an AHRQ-supported sponsor, co-sponsor,

and key advisors, will provide support and guidance as the applicant develops and completes projects to 1) identify and characterize EMTALA citation events involving psychiatric emergencies, 2) explore novel measures of hospital capacity to care for patients with psychiatric emergencies, and 3) evaluate the

association between hospital capacity to care for patients with psychiatric emergencies and receipt of EMTALA citations. Through didactics and completion of these projects, the applicant will gain experience with 1) health policy/analysis, 2) qualitative methods, 3) quantitative methods, 4) impactful dissemination of findings, and 5)

writing compelling funding proposals, as he trains to become an independent health services researcher.