ED providers in Alameda County, CA, noticed they were seeing the same patients on involuntary holds repeatedly. To learn more about these patients, they analyzed 541,731 EMS encounters from 2011 to 2016.1

  • About 10% of patients brought by EMS to the ED were experiencing psychiatric emergencies.
  • Involuntary hold patients were more likely to be men, were substantially younger, and less likely to be insured.
  • A small subset of individuals who had been on five or more holds during the five-year study period made up about 40% of involuntary hold cases.
  • Most patients experienced only one involuntary hold during the study period. “People with severe mental health emergencies use ambulance services frequently,” says Tarak Trivedi, MD, the study’s lead author, an EP at Ronald Reagan UCLA Medical Center, and research fellow at UCLA Health.

Many times, though, those individuals do not specify a psychiatric complaint. For example, a patient with chronic untreated schizophrenia might call an ambulance repeatedly for chest pain. “If you were to randomly pull over any ambulance in Alameda County, there’s a one out of four chance there’s a patient on board who was at one point on a psychiatric hold in the previous four years,” Trivedi offers.

For some, there is no underlying psychiatric diagnosis, but they are going through a traumatic event. They call 911 because they do not know what else to do. “Who arrives? Police arrives, as well as EMTs,” Trivedi observes. “Race and socioeconomic status may play a major role in how police operate when they arrive on the scene.”

Some individuals believe they were placed on an involuntary hold unfairly, but still are not allowed to leave the ED. “We have a system that doesn’t do justice to psychiatric emergencies,” Trivedi says. Many patients with psychiatric complaints do not belong in the ED in the first place. “Often times, we end up seeing patients experiencing a psychiatric crisis who are in front of us because police have no other place to take them,” Trivedi notes.

EPs are trained to identify life-threatening conditions from a physiologic perspective as opposed to a psychiatric perspective. Trivedi and colleagues considered protocols that bypass the ED by allowing EMS to directly transport patients to a specialized regional center for evaluation of psychiatric emergencies. The protocols are somewhat controversial. “One reason this is not taking off around the country is there is some fear that acute medical emergencies could be missed,” Trivedi says.

The concern is police or EMS could mistake a medically life-threatening condition for a psychiatric crisis, or vice versa. “We wanted to look at that model and see how effective it was,” Trivedi explains.

Holding a patient indefinitely in an ED does not help his or her psychiatric condition. “Because they are on involuntary holds, they can’t leave. EPs can’t just release them because they would be negligent if something were to happen to them,” Trivedi says.

Yet EDs do not have the resources to provide that patient with immediate psychiatric help. “It’s bad for patients, bad for EDs, and bad for society,” Trivedi laments.

Trivedi and colleagues found paramedics could safely rule out the vast majority of medical crises. “They did a good job of sorting out who needs to go to the ER and who doesn’t,” Trivedi reports.

Of the patients who bypassed medical clearance in the ED, only 0.3% required re-transport to a medical ED in the 12 hours after they arrived at the psychiatric emergency services. “The lesson to be learned is we need to invest heavily in prehospital psychiatric infrastructure, with first responders trained in psychiatric emergencies, to take people places other than the ER,” Trivedi offers. The common belief is there is no way to distinguish medical crises from psychiatric crises in the field, so EMS needs to take everyone to the ED to sort it out. “We have proven that it is possible to do this safely without having to spend hours waiting in a regular ER,” Trivedi explains.

REFERENCE

  1. 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.