Journal Watch: Medical Clearance of Psych Patients

Reviewed This Month

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. 

Authors: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA.  

Published in: Ann Emerg Med, 2018 Sep 28.   

Patients with an altered mental status can be challenging, particularly those experiencing a psychiatric emergency. Not only can they be a potential danger to you and your partner, they typically end up in an ED for a lot longer than necessary. Studies have demonstrated that these patients can tax EMS systems and add to ED overcrowding. 

One factor that contributes to the difficulty of caring for them is that field providers are typically required to transport patients to an ED even if they are sure an ED is not the appropriate destination for their patient. Further, patients who are experiencing psychiatric emergencies are often required to be medically cleared by an ED physician to ensure a life-threatening illness is not responsible for their behavior. Additionally, there is a sizable population of psychiatric emergency patients transported involuntarily to protect their safety or the safety of others. 

What if we were permitted to choose alternative destinations for our behavioral-emergency patients? Would this be better for them, the EMS system, and the hospitals? Would it be safe for our patients? UCLA emergency physician Tarak Trivedi, MD, and his coauthors recently published a manuscript that seeks to answer these questions. 

Just for background, there have been some smaller studies that reported that mistaking a psychiatric emergency for a nonpsychiatric life-threatening illness is rare. There are also reports of emergency medicine experts questioning the value of transporting these patients to EDs for medical clearance. 

Trivedi’s is a retrospective observational study—in other words, that data had already been collected, and there were no interventions introduced by the investigators. The data were collected over five years from EMS systems in Alameda County, Calif. The authors were evaluating a protocol that allows EMS providers to transport patients with isolated psychiatric complaints (i.e., no medical complaint or abnormal vital signs) directly to an appropriate psychiatric facility. 

The authors had two study objectives. First they sought to describe the characteristics of patients who received involuntary psychiatric holds and compare them to patients transported for other reasons. They defined involuntary-hold patients as those who had at least one involuntary hold during the study period. They also sought to evaluate the safety of the protocol allowing EMS providers to divert these patients to psychiatric emergency services. The authors used “failed diversion” as a proxy measure for safety. A failed diversion was defined as an event in which a patient was initially brought to a psychiatric emergency facility but required transport to an ED within 12 hours. 

During the study period there were 265,625 unique EMS patients who received care by Alameda County EMS. Almost 10% (26,283) had at least one involuntary hold. When comparing involuntary-hold patients to those who’d never been involuntarily held for a psychiatric emergency, involuntary-hold patients were more often men; they also accounted for substantially more EMS usage. Of the involuntary-hold patients, 48% had only one EMS transport during the study period, compared to 74% of “never-held” patients. Moreover, 4% (1,072) of involuntarily held patients had more than 20 encounters during the study period. There were only 0.4% (820) of never-held patients in this category.

Besides unique patients, the authors also looked at total EMS calls. During the study period there were 541,731 patient encounters, and 10% of these (53,887) were for patients receiving involuntary holds. Yes, 26,283 patients accounted for 53,887 EMS encounters involving involuntary holds. They also accounted for 74,116 encounters that did not involve involuntary holds. In total, involuntary-hold patients accounted for almost a quarter of all EMS encounters in this county (128,003; 24%). 

Of the 53,887 involuntary-hold encounters, 41% (22,074) resulted in direct transport to a psychiatric emergency facility. Only 0.3% (60) of these could be classified as failed diversions!

What is even more impressive is that the authors conducted a manual chart review and discovered that in 54 of the 60 failed diversions, the patient developed new symptoms after arrival at the psychiatric emergency facility, and there was nothing in the PCR that supported transporting these patients to the ED.

Of the six patients who should have been transported directly to an ED, none died or required CPR or an advanced airway during their second transport. Three patients required critical interventions; these included one glucagon administration, one naloxone administration, and placement of one nasopharyngeal airway. 

Limitations

The authors of this study did a nice job outlining their limitations. They included that this study was performed in one county, which the authors note has a notably higher rate of involuntary holds compared to the rest of California.

The protocol studied has been in place for years, and results may be different during an implementation phase. They also discussed limitations in the data and the matching algorithm they used to identify unique patients. 

This was a well-done study that significantly adds to the literature. It strongly suggests that a protocol that allows EMS providers to divert psychiatric patients to dedicated psychiatric facilities appears to be safe and beneficial.

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.