A&E procedure for handling at risk patients

Harlequin

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Apologies. I know I've asked a couple questions in this vein before but it's a specific order of events that's giving me a headache.


American setting. Patient comes into A&E, suspected suicide attempt, then treated physically--and then what happensfrom there?


Specifically, what tests would the patient have to take or pass, how many people would they see, and when does insurance come into it? Are they carefully watched in the interim? And how quickly can all that happen?


Goal of the outcome: patient to demonstrate the event was accidental rather than intentional, and to get out of hospital asap.
 

cornflake

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Treated for what?

They're seeing psychiatrists or psychologists, probably two, to clear or hold them, if available. Yeah, they're watched, spoken to, assessed by the ER dr., etc., while waiting for the psych(s). Time depends on when and where -- likely several hours at a minimum. Convincing someone it was an accident will not likely be simple, but depends on what happened, history, etc.

Is someone with them?
 

Harlequin

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Treated for dry drowning. No long term damage in the end.

ER doctor--that's already a correction ;-) I'd put nurse down in outlines for that section. Many thanks.

No, brought in alone.
 
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cornflake

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Treated for dry drowning. No long term damage in the end.

ER doctor--that's already a correction ;-) I'd put nurse down in outlines for that section. Many thanks.

No, brought in alone.

I've never heard of dry drowning as looking like suicide (which obviously doesn't mean it doesn't happen or anything) -- I thought that was a delayed thing that people mostly don't recognize?

There are who check people in and triage them and then a dr. will assess -- in nost places. Again, all dependent on where, when, etc.
 

Harlequin

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Sorry, I probably don't mean that. Drowning where your troat closes uo, rather than from breathing in water.

Modern and middle america. I didn't pick a state, left it vague (like Springfield in Simpsons type location) but could do if needed.
 

cornflake

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Sorry, I probably don't mean that. Drowning where your troat closes uo, rather than from breathing in water. ?

Modern and middle america. I didn't pick a state, left it vague (like Springfield in Simpsons type location) but could do if needed.

...
 

DrDoc

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Is the patient a veteran? If so, the VA will be notified and they may have psyche evals from the past. Are family members contacted/ If so, they may have certain rights, like spousal committal, etc. If no family involved, it will be impossible for the hospital docs to hold him without extenuating circumstances.

FWIW
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mpack

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Apologies. I know I've asked a couple questions in this vein before but it's a specific order of events that's giving me a headache.


American setting. Patient comes into A&E, suspected suicide attempt, then treated physically--and then what happensfrom there?


Specifically, what tests would the patient have to take or pass, how many people would they see, and when does insurance come into it? Are they carefully watched in the interim? And how quickly can all that happen?


Goal of the outcome: patient to demonstrate the event was accidental rather than intentional, and to get out of hospital asap.

Part of it would depend on what led them to suspect suicide. Direct statements to that effect prior to the accident will lead to a more in-depth investigation. If there's no particular reason, such as a witness or suicide note, they may not do much investigation at all beyond basic questions. If you wanted an overnight hold for observation, that would be completely plausible. If you want a quick release, then have minimal reason to arouse suspicion.

Another aspect to consider is the socioeconomics of the locale. A poor, rural region may not have a psychiatrist on call, so the assessment would be handled by the ER doctor. You could use the circumstance in whichever way you wanted to push the plot. An ER doc with a background in general practice may not recognize an atypical suicide, for example. Such a doctor might release the patient as quickly as their physical signs were stabilized, with advice to follow-up with their family doctor. On the flip side, they may err on the side of caution and go with an extended hold, deferring the problem to senior staff at the time of reassessment. Either route is believable.
 

cornflake

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Is the patient a veteran? If so, the VA will be notified and they may have psyche evals from the past. Are family members contacted/ If so, they may have certain rights, like spousal committal, etc. If no family involved, it will be impossible for the hospital docs to hold him without extenuating circumstances.

FWIW
DrDoc

That's certainly not true here, or anyplace I've heard of really.

Anyone deemed by (usually two) psychs to be an imminent danger to themselves or others can be placed on a 72-hour involuntary hold. The hold can be extended as needed as long as conditions persist. A patient can get an atty to fight an extended involuntary hold, but that's up to a judge.

It has nothing to do with any family members, spouses, or anyone else. If you present as suicidal and a psych determines you're in danger, they can and will hold you, like it or not.
 

Anna Iguana

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That's certainly not true here, or anyplace I've heard of really.

Anyone deemed by (usually two) psychs to be an imminent danger to themselves or others can be placed on a 72-hour involuntary hold. The hold can be extended as needed as long as conditions persist. A patient can get an atty to fight an extended involuntary hold, but that's up to a judge.

It has nothing to do with any family members, spouses, or anyone else. If you present as suicidal and a psych determines you're in danger, they can and will hold you, like it or not.

In the US, laws for involuntary holds vary from state to state. In some jurisdictions it would not be likely that a hold would be easily extended past 72 hours. Another factor, to be blunt, is that some hospitals have adopted protocols to push patients out the door more quickly than they used to. If the patient didn't have family involved, and didn't have private insurance, hospital-employed staff would be under pressure to release the patient ASAP rather than filing paperwork with a judge to extend the hospital stay.
 

cornflake

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In the US, laws for involuntary holds vary from state to state. In some jurisdictions it would not be likely that a hold would be easily extended past 72 hours. Another factor, to be blunt, is that some hospitals have adopted protocols to push patients out the door more quickly than they used to. If the patient didn't have family involved, and didn't have private insurance, hospital-employed staff would be under pressure to release the patient ASAP rather than filing paperwork with a judge to extend the hospital stay.

This is important to note, no disagreement, treatment/handling of the mentally ill is kind of a disgrace in the U.S. -- I was just saying holding someone at all, especially on a 72-hour hold, is not in any way dependent on whether they have family or anything or anyone else involved.

Family can come and argue against or for a commitment but if a psych (or two depending on policy, here it's mostly two need to sign off, but it's a big city and that's not an issue -- though I think most hosps have a psych on call at all tines most places), says they're a danger and being held, they're being held (for an initial period). Similarly, if your wife or parents or whatever drag you in and say they want you committed but you're not determined to be a danger to yourself or others, you're not being held. Your family can't commit you against your will without a court order (much harder to get) or the same signoff that'd happen if you were brought in alone. A dr. will talk to and listen to them, if they explain you've been doing X, saying Y, but if you can then convince the psych you're fine, you're walking away.
 

MaeZe

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ED, not A&E, I see you got that. This is just adding to what Cornflake said.

If we have a patient in the ED with a suspected suicide attempt, once they are physically stable they will generally be sent to an inpatient psych facility where they can keep you 72 hours. Beyond that, if the docs there think you are suicidal they have to get a court order to keep you there. In this state we call the MHP (an officially designated mental health professional). You don't need a psychiatrist unless/until you are going to court for a longer hold.

By the end of the 72 hours you will have had counseling and an assessment.

If they believed the patient that it was accidental, they could just release them on the spot and not require the 72 hour hold.

Even if it was an actual attempt, if you say you are no longer considering suicide, it's almost impossible to keep a patient on a locked ward. For a serious attempt, you'd probably be held for 72 hours for a more thorough assessment even if you deny it was purposeful.

Patients are rarely held for long against their will like they might have been a century ago.
 

MaeZe

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In the US, laws for involuntary holds vary from state to state. In some jurisdictions it would not be likely that a hold would be easily extended past 72 hours. Another factor, to be blunt, is that some hospitals have adopted protocols to push patients out the door more quickly than they used to. If the patient didn't have family involved, and didn't have private insurance, hospital-employed staff would be under pressure to release the patient ASAP rather than filing paperwork with a judge to extend the hospital stay.
You don't push a suicide attempt out the door, you transfer them. :)

Also, acute care hospitals don't file court papers. Psych hospitals do but not the medical hospital.
 

MaeZe

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Part of it would depend on what led them to suspect suicide. Direct statements to that effect prior to the accident will lead to a more in-depth investigation. If there's no particular reason, such as a witness or suicide note, they may not do much investigation at all beyond basic questions. If you wanted an overnight hold for observation, that would be completely plausible. If you want a quick release, then have minimal reason to arouse suspicion.

Another aspect to consider is the socioeconomics of the locale. A poor, rural region may not have a psychiatrist on call, so the assessment would be handled by the ER doctor. You could use the circumstance in whichever way you wanted to push the plot. An ER doc with a background in general practice may not recognize an atypical suicide, for example. Such a doctor might release the patient as quickly as their physical signs were stabilized, with advice to follow-up with their family doctor. On the flip side, they may err on the side of caution and go with an extended hold, deferring the problem to senior staff at the time of reassessment. Either route is believable.
Yeah, rural areas might have unique circumstances.

There's a wealth of data on that in this paper.
 

Harlequin

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Wow, many thanks all (sends stars).

No, not a vet; no family involvement; there are some suspicious circumstances to the drowning but could be explained away (and are). Yes, semi rural setting.

Ideally done and dusted in a day.

It seems doable with some wrangling and, hopefully, not too much suspension of disbelief.
 

lizmonster

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At what point does insurance get involved? Do you speak to your insurance people when you go to somewhere like a hospital or do the doctors all handle it behind scenes?

If you go in alone: as soon as you're stable/coherent enough to answer questions. If someone is with you: they'll be taken aside while you're cared for and asked about it. (Although this may sound callous, IME they're polite and professional about it in general, but if you need them to be snotty for story purposes that can work.)

Also, you generally don't speak to your insurance people at all unless you're asking about coverage or arguing about a denied bill. You tell the hospital the name of your insurance company and your group number. Sometimes there's a copay - you pay something like $10-$50 up front, and then they bill the insurance company for the rest. If the rest isn't covered, you're billed later.

This is for commercial insurance. Not sure how it works for the ACA exchanges.

IME, of course; this may also vary by state. But as a general rule the ER likes to know who to bill, and they're unlikely to have your insurance info on record like your regular doctor's office would.

ETA If your character has been to this hospital before, the hospital might have the insurance information on record. In which case it could be a short conversation: "You still have XYZ insurance?" "Yes."
 
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MaeZe

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At what point does insurance get involved? Do you speak to your insurance people when you go to somewhere like a hospital or do the doctors all handle it behind scenes?

I would differ from Liz just a little bit here though not exactly.

If you are walking wounded there are administration questions you will be asked. But no one contacts one's insurance. You get treated and depending on the setting you might pay a copay but even if you owe one, not all EDs are in a partnership with the third party payers.

So for example, when I go to my HMO's ED, insurance and the medical care system are integrated. They'll ask for my copay. But if I go in an ED not connected to my HMO, they are not in the business of collecting payments for my insurer. I give my insurance info, the hospital bills the insurer, the insurer bills me the copay and other deductibles. Anything the insurance doesn't pay, the hospital will then bill me. Except sometimes the hospital is part of a "preferred provider" system in which case they agree to a certain fee schedule set up by the insurer. That amount still may or may not mean there is any uncovered amount the hospital then bills me.

If you are uninsured the hospital sends you a bill later.

EDs cannot by law turn anyone away, insurance or not. The same is true for the 3 day psych hold. Once you get to the psych facility their administration starts working on getting some kind of payment for you. Often that involves Medicaid and a whole bunch of other financial maneuvers because even with insurance there are always caveats on reimbursing for inpatient care.

You also have to keep in mind, health care providers are not directly involved in billing. No ED doctor sits around saying, get rid of this patient because he's uninsured. But sometimes they are involved in the financial aspects of the business. Different hospitals pressure the medical providers to different degrees to dump non-paying patients. Costs for patients who can't or don't pay their bills are absorbed by the hospital as bad debt. That essentially means, paying customers get billed a little bit to cover those patients who can't or don't pay.

And in some cases the doctor bills a patient and the hospital bills separately. It depends if the doctor has a private practice and uses the hospital setting, or if the doctor is an employee of the hospital. In some cases the docs are provided by a company that employs the doctors, or the doctors are a group practice of ED providers.

It can be very complicated. And yes, it is a bizarre and inefficient system. And if you think that's bad, you should see what the itemized bill looks like. :tongue

But readers don't need all that unless you want the medical bill to be part of the story.
 
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