# When does a 5150 hold exactly begin?



## Brydandon (Oct 18, 2019)

So I picked up a patient from a non-psych medical only hospital here in Southern California.

The patient was in the hospital for a week due to an OD, and I noticed that the 5150 hold date was written that week.

So I ask the head nurse/case manager if there was a 5250 hold in place. Because it was way passed 72hrs from when the hold was first written.

The nurse/case manager said that it doesn't matter when the 5150 hold was written and that the 5150 hold is still valid because they are a medical only hospital not a psych hospital.

The nurse said we took care of the medical condition of the OD but the patient has to go to another facility to honor the 5150. That the 5150 begins not the date of when it's written but begins the date of when the patient is being transported to a designated facility for psych evaluation.

Is what this Nurse/Case Manager said true or false?

I was taught that the 5150 begins the date and time it was written regardless of where the patient is at.

Or was the Head Nurse/Case Manager right..is the 5150's 72hr hold effect only activated when enroute to a designated facility for assessment, evaluation and crisis intervention?

Thank you fellow EMS comrades!


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## akflightmedic (Oct 18, 2019)

https://www.calhospital.org/sites/main/files/file-attachments/bhfaq.pdf
		


A 5150 is the legal document or instrument that authorizes holding a person against their will and is valid only at an LPS designated facility or Emergency Department. The purpose of the initial period of detention under a 5150 hold is for evaluation and if applicable, further observation and treatment of a person that is gravely disabled or is a danger to self or others.* They are not valid in non-designated facilities such as the general acute care hospital.*


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## Brydandon (Oct 18, 2019)

This is my first time hearing about such a delayed effect with a 5150 hold. Perhaps it's because when I normally interact with holds its straight to an LPS facility.

The 5150 holds itself doesn't break that concept down as you have broke it down to me, even in all the fine print the 5150 has on it's super vague. Thank you for that.

So just to clarify..

The patient was taken to a non-LPS facility first, at the same time the 5150 hold was written (which was a week ago), the 5150 hold written ultimately has to be honored at the end of the treatment at the non-LPS facilities regardless of the time and date the 5150 hold was written, then post non-LPS treatment the hospital must make arrangements to honor the 5150 hold written a week ago, when transport arrives the 5150 holds 72 hr effect becomes activated now that the patient is being transported from a NON-LPS facility to an LPS designated facility?


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## akflightmedic (Oct 18, 2019)

This is what you say happened....I am not in CA, have never worked CA and intend to never do so. Having said that, I did read a bunch of other websites and case studies simply out of boredom. It seems what transpired is a recurring situation and a sticky one...but not for the legality reason. It is messy for the $$$ reasons...who gets paid and how, when a 5150 goes to a hospital. Or when a LPS sends a 5150 to the hospital for other treatment they cannot perform, who is responsible for that bill?

In these various scenarios over the dollar, the recurring theme was never about the patient or the patient rights.The case reviews did state several times that a 5150 was re-prescribed multiple times when the client was in a non-LPS facility to ensure it remained valid. It also had other reasons for payment (again). LOL!


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## akflightmedic (Oct 18, 2019)

And do not forget, the 5150 is not a diagnosis. It is a tool to be used by police officers, case workers, etc. to protect someone's life.


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## Brydandon (Oct 18, 2019)

Ahhhh... I see. 

Thank you for taking that time to dive deeper into cross referencing the situation.

Much appreciated.


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## Peak (Oct 18, 2019)

There is federal statutes about how legal holds are placed, although most of it varies from state to state. That being said if someone is placing a legal hold it is effective when they place it and not at a later time. Whether or not a facility can actually honor the hold will vary, but it doesn't wait to kick in later. The 72 hours starts when the hold is written. 

Emergency holds (such as a 5150) are not intended to serve for an extended period of time. Some states allow emergency holds to be renewed if the patient is not in a psychiatric facility and others still hold the burden of either allowing the patient to leave or persuing certification in the courts. One emergency hold is certainly not valid for a week.


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## hometownmedic5 (Oct 19, 2019)

Logic would say that the duration of the documents effects would be from the minute that the document is used to restrict the named patients freedom and extend to the statutory period thereafter. California is anything but logical, so clearly that’s out the window.


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## GMCmedic (Oct 19, 2019)

I guess my question is, if the hold is not valid till time of transfer, how can they keep a patient against their will in the time the medical issie is being resolved?


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## Peak (Oct 19, 2019)

GMCmedic said:


> I guess my question is, if the hold is not valid till time of transfer, how can they keep a patient against their will in the time the medical issie is being resolved?



There is some variance from state to state, but in addition to certifications and emergency psychiatric holds there are also medical holds. If a patient is not medically cleared and does not seem to have appropriate decision making they may not be free to leave.

Some potential examples include patients who are altered on substance, hepatic encephalopathy, meningitis, neurotoxic effects of methotrexate, and so on.

In these cases many states have said that a psychiatric hold is not appropriate unless the patient is medically cleared during psychiatric evaluation. Some others still allow for their emergency holds to be used during these events. Certainly if you are in a state that has this practice then the hold is effective immediately, not later when medically cleared or during transfer.

You must also consider that a psychiatric hold may still be appropriate in the medical patient. For example a patient who is gravely disabled as a results of not being medication complaint and who has schizophrenia and presents with infectious tenosynovitis needs medical treatment and cannot make their own decisions, however their lack of competency may simply be from their baseline mental health issues and not from their medical condition.

Holding patients against their will is very complex whether it be a psychiatric, medical, or legal reason. Determining competency is a very difficult process. That being said in this case the nurse/case manager is incorrect. The time on the orrigonal emergency hold is not suspended. Either they are being held on a medical hold, they must renew the emergency hold, seek certification in the courts, or arrange for transport to a state designated facility that can honor holds.

Unfortunately this is very poorly understood outside in most medical areas, but especially outside of the areas with the most exposure to it like emergency services, intensive care, and psychiatric facilities. There is also often not a perfect answer, legislation doesn't account for  every possible patient presentation. Even in my state which has a pretty clear and robust system for holding patients against their will we are often placed in situations where the presentation doesn't quite fit. It is key for facilites to keep good legal counsel, psychiatrists, a strong ethics team, and so on for the odd cases and one should not just assume or state what they think is correct if they don't know.

To prove how complex these situations can get I'll present a case which is drawn from several similar experiences we've been challenged with.

EMS presents to you a patient who is gravely disabled as a result of profound mental retardation. This patient ran away from his group home, and is brought into the emergency department as the group home does not feel like they can safely care for the patient and does not have the reasonable ability to keep residents inside of their facility. The patient has been certified by the state as not being capable of making their own decisions. The patient does not have any new psychiatric or medical illness. Since they do not have a medical illness they cannot be admitted to the hospital. Since they do not have a new psychiatric illness and do not require medication stabilization it is not appropriate to admit them to an acute psychiatric ward. During the state certification it was determined that this patient must have a proxy for their medical and psychiatric decision making, but does have the right to live in the community and not in a long term mental health facility. As part of the certification the courts determined that family is not an appropriate proxy, but rather combination of the current residential facility and the county adult protective services department while allowing as much decision making by the patient that is reasonable and prudent.

Can this patient be placed on a new psychiatric emergency hold?
Can this patient be placed on a medical hold?
Can you appeal to the courts to change the certification?
Can EMS transport this patient against their will to the emergency department from the field?
Can you hold this patient against their will in the emergency department on their current certification?

It is determined that there is not appropriate facility for the patient in state and eventually an appropriate facility is found in another state. The facility accepts the patient pending approval from the current decision making proxy and the promise that the current residential state will pay for the patient's long term care.

Can this patient be transported against their will to another state against their will?
Is their certification still valid during transport?
Is their certification still valid when their arrive to their new facility which is in a new state and hence not the one that originally certified the patient?


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## Ewok Jerky (Oct 19, 2019)

I'm not a lawyer but in my experience with delayed transfers the doc will renew the 5150 paperwork every 48 hours. 

If that was my patient, and they refused transport I wouldn't go without a new signed order.


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## RedBlanketRunner (Oct 20, 2019)

akflightmedic said:


> This is what you say happened....I am not in CA, have never worked CA and intend to never do so. Having said that, I did read a bunch of other websites and case studies simply out of boredom. It seems what transpired is a recurring situation and a sticky one...but not for the legality reason. It is messy for the $$$ reasons...who gets paid and how, when a 5150 goes to a hospital. Or when a LPS sends a 5150 to the hospital for other treatment they cannot perform, who is responsible for that bill?
> 
> In these various scenarios over the dollar, the recurring theme was never about the patient or the patient rights.The case reviews did state several times that a 5150 was re-prescribed multiple times when the client was in a non-LPS facility to ensure it remained valid. It also had other reasons for payment (again). LOL!


Just three monkey wrenches gumming up the works. Fed will/may/can defer to state. Some states allow the courts to have a say in holds, and the ever popular financial aspect and socialized medicine.
I know of one fantastical mess that is ongoing where a hold was utilized with other evidence to place a man in a conservatorship. Then other family members intervened and this has been dragging through the civil court system for at least three years. A law enforcement agency and a hospital along with several individuals are being sued.


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## CCCSD (Oct 20, 2019)

Which case is this?


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## RedBlanketRunner (Oct 21, 2019)

CCCSD said:


> Which case is this?


Asking me?


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## CCCSD (Oct 21, 2019)

Yep. You posted a case. Which case is it?


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## Akulahawk (Oct 23, 2019)

Brydandon said:


> So I picked up a patient from a non-psych medical only hospital here in Southern California.
> 
> The patient was in the hospital for a week due to an OD, and I noticed that the 5150 hold date was written that week.
> 
> ...


The 5150 hold begins at the time that the hold is written. It is good for up to 72 hours. The time and date that the hold is applied must be written on the paperwork and the hold must be filled out correctly in order for the application to be valid. If the hold expires, then it is no longer valid. The hold only continues to be valid if the cause of the hold isn't a medical problem (psychiatric problem only), thus patients on a hold are brought to an Emergency Department for "medical clearance." These patients must be re-evaluated frequently (before a hold expires) to determine if they still meet criteria to remain on a hold, thus if an original 5150 is due to expire, a new hold can be written if the patient still meets criteria (and that must be documented). A patient on a 5150 hold that is admitted to the hospital breaks that hold, but the patient may also not be allowed to leave and upon discharge from the medical services, a new hold may be written if the patient still meets criteria for a hold to be placed. If the patient no longer meets criteria for a hold when a hold expires, the patient then may leave and should suffer no legal consequence because the patient wasn't admitted after exam at a designated mental health facility, it expired before that point. A patient _from_ a mental health facility that's on a hold who comes to the ED and is admitted to the hospital does not break the mental health hold from that facility. 

Remember that the purpose of the 5150 hold that we're familiar with is actually only an _application_ to have a patient examined at a mental health facility. If the patient is examined and does not need to be admitted to the facility for treatment, the hold is broken and the patient can leave. Having a psychiatrist examine a patient in the ED is not usually the same as having the patient examined at the MHF, even if it's the same psychiatrist as the ED is NOT usually a designated mental health facility. A local hospital created a mental health holding area where medically cleared 5150 patients are sent, but that just gets those patients out of the ED. The rest of the stuff still applies as those patients are NOT yet at a designated mental health facility.

A patient cannot be placed on a 5250 by an Emergency Department. Only designated psychiatric facilities can do this and this requires a formal hearing. 

In short, if you transported a patient against his/her will to a mental heath facility, the patient was otherwise alert/oriented, and the 5150 was expired and no new one had been written, it is quite possible that you have committed kidnapping and false imprisonment.


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