CCP in a 911 Setting

[NPO]

I have very little clinical interest in psychiatric care. Necessary, but not my cup of tea.

Agreed. But it's going to be something everyone at my agency goes through. Logistically and operationally it makes our job easier.

 

[RocketMedic]

Agreed. But it's going to be something everyone at my agency goes through. Logistically and operationally it makes our job easier.

Oh, I'm OK with the training and responsibility to do something like place holds on persons that need them. I am referring more to the long-term implications of psychiatric care and consultation- for example, I really don't want to be responsible for placing Jethro McOneTooth in a methamphetamine-free environment or getting Susie Anxious her next dose of Clonidine for free.

 

[Peak]

There are several problems with psych placement from the field.

Patients need to be medically cleared prior to psych evaluation, and unless the patient is a very good historian it would be pretty hard to do this simply on physical exam and without basic labs (CBC, CMP, TSH...) and toxicology (drug screen, BAL, APAP/ASA levels...). The patients who can provide a good history will likely benefit more from a crisis stabilization unit or intensive outpatient therapy than inpatient placement. Also many patients who are intoxicated or under the influence of drugs will appear psychotic, depressed, et cetera and after clearing their drugs don't need inpatient placement but instead outpatient resources.

Psych placement can also be difficult and it can be challenging, depending on the patient's needs and history it isn't uncommon to take 12-24 hours to find placement; we have had to hold patients 30 days in the ED before so that we could send them to the state hospital since they were not appropriate for the other inpatient facilities.

I would like the idea of preferentially taking patients to psychiatric EDs. There are a couple of hospitals in the area that have dedicated psych units/EDs attached to their main department, and since they can be medically cleared quickly they are then put in a much more appropriate, safe, and therapeutic unit while waiting for placement.

 

[chriscemt]

That would be a very easy way to keep people from becoming critical care paramedics.

As much as I wanted to say this response was unnecessarily snarky and/or ****ty (first two times I read through it), it's truly spot-on. [CCT = decision to psych evaluation] sounds just awful. It's certainly not using any kind of CCT skill that we'd otherwise value. And it's too bad, because using a higher level of education to some value to a given system should be the way we'd view additional education skills being valued, but, like yup.

...we have had to hold patients 30 days in the ED before...

Wuht.

 

[CCCSD]

NPO, which Bill was passed that allows Paramedics to put persons on a 72 hour hold?

 

[Tigger]

That would be a very easy way to keep people from becoming critical care paramedics. The critical care providers that I know have all gone that route because of the greater patient acuity, critical thinking, enhanced formulatory, and additional skills. Tasking them with the calls that a lot of them are trying to avoid will not lead to good things.

Those are all functions that could easily be added to a traditional medic scope as none of them require critical thinking.

If I went from being a 911 provider dealing with psychs, drunks, and other low acuity patient to a critical care provider and being tasked with dealing primarily with those patients, I would be out faster than a Democrat at the Trump hotel.

I disagree with the bolded part entirely. One of the hardest parts of my job is coming up with a plan that does not include an ED for psych patients as well as those folks that have poorly managed chronic conditions. Yea, it's not flashy, I don't do cool skills or push rad drugs, but do not think for a second that working with these patients does not take critical thinking. I agree completely that it has no overlap with critical care, but to say it could just easily be thrown in is simply not true. As one of the few agencies in the country that uses paramedics to place psych patients in inpatient facilities and other alternative destinations, we have struggled to make this a smooth process over the past three years and are still working hard to make it efficient.

There are several problems with psych placement from the field.

Patients need to be medically cleared prior to psych evaluation, and unless the patient is a very good historian it would be pretty hard to do this simply on physical exam and without basic labs (CBC, CMP, TSH...) and toxicology (drug screen, BAL, APAP/ASA levels...). The patients who can provide a good history will likely benefit more from a crisis stabilization unit or intensive outpatient therapy than inpatient placement. Also many patients who are intoxicated or under the influence of drugs will appear psychotic, depressed, et cetera and after clearing their drugs don't need inpatient placement but instead outpatient resources.

Psych placement can also be difficult and it can be challenging, depending on the patient's needs and history it isn't uncommon to take 12-24 hours to find placement; we have had to hold patients 30 days in the ED before so that we could send them to the state hospital since they were not appropriate for the other inpatient facilities.

I would like the idea of preferentially taking patients to psychiatric EDs. There are a couple of hospitals in the area that have dedicated psych units/EDs attached to their main department, and since they can be medically cleared quickly they are then put in a much more appropriate, safe, and therapeutic unit while waiting for placement.

We do a saliva drug screen, PBT, EKG, and Chem8 on all of our psych patients that have the potential to be "alternatively destinated." Patients with a suspicion of overdose on non-rec drugs are taken to the local critical access of further screening and then transferred by SUV later. Most of our patients go to a crisis unit. We will get a bed for patients at inpatient facilities if they have been there before or are minors (that's just what our contract wants). In rare cases that we cannot find a destination, we transport them to an SUV to a real ED with a psych hall.

 

[Peak]

@chriscemt Inpatient psych hospitals have to be willing to accept transfers, and often times patients have either burned bridges (non-compliant to non-emergency or non-court ordered meds, family that sneaks in drugs, willful property destruction and violence) or have behavior that isn't appropriate for their facility which can make finding placement quite difficult. Most facilities won't accept patients if they have had to be restrained (chemically or physically) in the ED in the past 12-24 hours. Some patients are just too medically acute for psychiatric facilities but also need high level psych care. For these patients we can apply to have them accepted at the state hospitals but unless they are a forensic patient the state often won't accept them unless they have had 30 days of psych treatment already.

 

[Peak]

We do a saliva drug screen, PBT, EKG, and Chem8 on all of our psych patients that have the potential to be "alternatively destinated." Patients with a suspicion of overdose on non-rec drugs are taken to the local critical access of further screening and then transferred by SUV later. Most of our patients go to a crisis unit. We will get a bed for patients at inpatient facilities if they have been there before or are minors (that's just what our contract wants). In rare cases that we cannot find a destination, we transport them to an SUV to a real ED with a psych hall.

I think that your system is quite a bit more progressive/whole picture than most systems are; and that your response area is very much a unique combination of distance but also proximity to a lot of services. I would guess that the patients you can easily place are also the ones who don't sit in the ED for more than 3-4 hours since they have a clean U-Tox, are cooperative to exam, and don't have any other medical complaints.

In fact I think that the county you are in is a great example of an area that would be very well served by critical care paramedics since the time frame for transport to a full service hospital is so great but also close enough that a lot of the benefit of HEMS is negated (although more rural services could also use CCPs while waiting for HEMS).

 

[chriscemt]

...Inpatient psych hospitals...

Still, though, 30 days? Wow. Not to get too far off the track here, but I can partly sympathize with the psychiatric patient experience (and their disinterest in seeking medical treatment) when it's a 54 hour stay in the ED (my personal record).

Uh, not my stay in the ED but rather the patient's stay, who we transferred.

 

[Tigger]

I think that your system is quite a bit more progressive/whole picture than most systems are; and that your response area is very much a unique combination of distance but also proximity to a lot of services. I would guess that the patients you can easily place are also the ones who don't sit in the ED for more than 3-4 hours since they have a clean U-Tox, are cooperative to exam, and don't have any other medical complaints.

In fact I think that the county you are in is a great example of an area that would be very well served by critical care paramedics since the time frame for transport to a full service hospital is so great but also close enough that a lot of the benefit of HEMS is negated (although more rural services could also use CCPs while waiting for HEMS).

We are working on getting CCPs on the shifts, the money is just not there right now to train and to pay (which is the bigger issue frankly). I think we'd actually see equal utility between transfers and scene calls, it's not like our local CAH is providing anything approaching critical care right now. Many emergent transfers are treated like 911 calls (you know, things like using your own drugs to RSI a hospital patient because they can't find theirs...)

As for the psych patients, no doubt that's who most of our clients are. The holdup is usually finding a bed if we choose to go the direct admittal route, which is possible if you want to really hit your head on the wall. Most of us our inclined to just take them to a crisis center, which will also take "cooperative-ish" patients who are under the influence of rec drugs. If they ODed on prescription meds, we can get them cleared at the hospital and then take them to the crisis center even if they are not clean yet so long as the ED doc is ok with that, which definitely speeds up stays. Occasionally we'll also place people on Emergency Committal substance holds and take them to detox in Colorado Springs, and then crisis will go get them once sober.

 

[vc85]

Yeah, my state also just passed a law allowing Paramedics to get special training that'll allow us to place psychiatric holds so we don't have to wait on/rely on law enforcement.

Wouldn't you still need to wait on LE for scene safety? So would that really save that much time or are your LE not willing to put psych holds when they are clearly needed

 

[NPO]

Wouldn't you still need to wait on LE for scene safety? So would that really save that much time or are your LE not willing to put psych holds when they are clearly needed

Not every psych patient is dangerous. There are plenty of times where they just need help or something along those lines.

Allowing the paramedic to determine the need for psychiatric hold for evaluation allows the paramedic to restrain the patient against their will with physical or chemical restraints.

 

[Tigger]

Not every psych patient is dangerous. There are plenty of times where they just need help or something along those lines.

Allowing the paramedic to determine the need for psychiatric hold for evaluation allows the paramedic to restrain the patient against their will with physical or chemical restraints.

Do we really need a hold to do this, especially if patient and provider safety is at risk?

 

[RocketMedic]

Seconded...isn’t this what we already do?

 

[NPO]

Ish... its a big legal grey area.

I'm not sure on the specifics of this new law we have, but it will make things much more black and white.
Currently this is how the law is interpreted:

"Patients may only be restrained by medical providers for medically-necessary care and
interventions. Patients may not be restrained solely for provider safety or preference; that may
only be performed by law enforcement."

(It also reclassified EMS as public safety officers which enabled us to get LODD benefits previously only available to PD and FD)

 

[CCCSD]

So a PM is going to determine a hold, then chemically restrain the patient, and deliver them to a psych facility? All by themselves? How are you going to deliver the meds? Control the scene?

 

[Tigger]

So a PM is going to determine a hold, then chemically restrain the patient, and deliver them to a psych facility? All by themselves? How are you going to deliver the meds? Control the scene?

Not sure I understand. Pretty easy to fill out the paperwork and give meds. Not sure what you mean by controlling the scene, peacocking around with behavioral crisis patients doesn't really seem to work in my experience.

 

[VFlutter]

Patients may not be restrained solely for provider safety or preference; that may
only be performed by law enforcement."

Flying in a helicopter is now considered a medical procedure...

 

[chriscemt]

"Patients may only be restrained by medical providers for medically-necessary care and
interventions. Patients may not be restrained solely for provider safety or preference; that may
only be performed by law enforcement."

Which state? Also, isn't an ambulance transport for the purpose of a psychiatric evaluation a "medically necessary intervention", especially when the patient has stated to you that they are going to kill themself?

 

[DrParasite]

I'm not sure on the specifics of this new law we have, but it will make things much more black and white.
Currently this is how the law is interpreted:

"Patients may only be restrained by medical providers for medically-necessary care and interventions. Patients may not be restrained solely for provider safety or preference; that may only be performed by law enforcement."

So this is accurate?