Emergency Department Care of Intoxicated Patients and Those with Mental Health Conditions at the Louis Stokes Cleveland VA Medical Center, Ohio

The VA Office of Inspector General (OIG) conducted a rapid response inspection to evaluate allegations that some patients, presenting with mental health-related issues to the Louis Stokes Cleveland VA Medical Center Emergency Department, were not adequately assessed prior to transfer to the facility’s Psychiatric Observation and Assessment Center (PAOC), thus placing patients with medical conditions at risk. The OIG substantiated the allegation; however, the conditions described in the allegation generally occurred prior to August 2018 and facility policy then did not require patients with primarily mental health concerns to be screened in the Medical Emergency Department first. Following visits from The Joint Commission and the Office of Medical Inspector in July 2018, the facility changed its policy to require that all patients presenting with intoxication or an acute mental health condition are medically screened in the Emergency Department before transfer to the PAOC. To determine if the facility was following the new policy, the OIG reviewed 205 encounters for patients seen in the Emergency Department and subsequently transferred to the PAOC between January 1 and March 31, 2019. The OIG did not substantiate that patients were transferred to the PAOC without medical screening examination notes, were transferred in acute alcohol withdrawal, or were transferred with critical laboratory values. The OIG found no evidence of adverse clinical outcomes related to the management of patients receiving care in the PAOC. In March 2019, the facility issued a policy that defined the procedures for evaluation and treatment of patients presenting with suspected substance intoxication and provided mandatory Clinical Institute Withdrawal Assessment training for all Emergency Department and PAOC staff. The OIG made one recommendation related to the clinical elements to be included in a medical screening examination to deem a patient medically stable prior to transfer to the PAOC.