While there is no simple solution to ED crowding caused by a backup of patients with behavioral health concerns, a new study offers intriguing results on what could be part of the answer for at least some hospitals.
Investigators have found that a relatively straightforward screening protocol developed by the Alameda County EMS Agency in California has proven to be a safe and effective way to medically clear close to half the patients receiving involuntary psychiatric holds in the field. These patients can be transported directly to a psychiatric emergency facility rather than stopping at a general hospital ED for medical clearance first.
Looking at data compiled over a five-year period ending in November 2016, researchers found that out of 541,731 EMS encounters in Alameda County, 53,887 involved involuntary psychiatric holds. In these cases, EMS relied on the protocol to transfer 41% of the patients with involuntary holds directly to a specialized psychiatric facility, enabling 22,000 patients to be treated there without first making a trip to the ED.1
Tarak Trivedi, MD, the study’s author, is a practicing emergency physician and a research fellow in the UCLA National Clinician Scholars Program. He explains that the protocol used by EMS to determine which involuntary hold patients can bypass the ED is quite conservative. “If the patient asks to go to an ED — in every one of those cases, the patient is taken to the ED,” he says. Further, he notes that any patient 65 years of age or older or younger than 12 years of age automatically goes to an ED.
“It is generally quite clear that if [EMS personnel] have any doubt, then they err on the more conservative option, which is to transport the patient to the ED.”
Trivedi adds that in the field, patients often understand that they are experiencing an emergency that is psychological in nature and ask specifically for a psychological evaluation.
“A lot of times, the patient may be experiencing suicidal ideation or [a patient with schizophrenia] will be complaining of increased auditory hallucinations,” he says. “This is not unique to Alameda County. I am confident that this is how psychiatric emergencies go down in most other parts of the country.”
In the study, only 60 patients taken directly to a psychiatric facility had to be transported to the ED within 12 hours, with six of these cases representing what investigators termed a protocol failure. These were cases that involved patients who had medical issues or characteristics that should have been picked up by adherence to the protocol but that EMS missed.
For example, if someone was out of the appropriate age range for direct transport to the psychiatric facility, that was a protocol failure. Similarly, Trivedi notes that there was one patient who was pregnant who should have been transported to the ED. Instead, that patient was taken directly to the psychiatric facility. “We didn’t have any reports of any on-site deaths as a result of EMS transporting the wrong type of patient [directly to the psychiatric facility],” Trivedi notes.
For the other 54 patients who were taken to the ED within 12 hours of arriving at the psychiatric facility, new symptoms surfaced. For instance, some patients had seizure disorders that were not apparent to EMS personnel. Others developed new medical complaints that they did not report initially. Additionally, there were instances in which patients who had received sedation at the psychiatric facility later experienced a fall within 12 hours of arrival.
Other Elements Needed
From the data, investigators concluded that paramedics can safely administer the screening protocol to determine medical clearance in cases involving involuntary psychiatric holds. Researchers also noted this type of approach could be used in other settings.
However, this is just part of an overall solution that requires other elements to succeed. For instance, if paramedics are to bypass the ED, they must pick a designated psychiatric facility where they can transport these patients for needed psychiatric evaluation and care.
Some years ago, Alameda County established a designated psychiatric emergency services facility to care for such patients. Investigators demonstrated at the time that the approach can significantly affect boarding times by patients awaiting psychiatric care in general hospital EDs.2
The approach, which became widely known as the “Alameda Model,” has been adopted in other communities across California and in some other states. But there are other models that could leverage EMS teams to handle the medical clearance task for certain categories of psychiatric patients, thereby relieving busy EDs.
“That facility fee and that provider fee ... are not a good use of funds for insurance companies, Medicaid, or whoever is paying the tab for these patients,” Trivedi observes. “I would much rather have [payers] focus that money toward whoever is helping the patients from a psychiatric perspective.”
- Trivedi TK, Glenn M, Hern G, et al. Emergency medical services use among patients receiving involuntary psychiatric holds and the safety of an out-of-hospital screening protocol to “medically clear” psychiatric emergencies in the field, 2011 to 2016. Ann Emerg Med 2019;73:42-51.
- Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 2014;15:1-6.