EMS Providers Placing 72 Hour Holds

[Akulahawk]

These are not in an ambulance but a specially dispatched, designed and equipped vehicle.

It's a rather interesting system design that allows them to to avoid the hold and provide and refer to other services.

This appears, by this small description, to essentially be the mental health equivalent of a "Community Paramedic" in that you have a Paramedic that's specially educated to provide services beyond that of traditional EMS, to include referrals outside the normal Psych Emergency Services system.

Sounds like there's some good promise there!

 

[SandpitMedic]

I'm all for it. It is a medical thing. Why should the police be doing it in the first place? Jailing someone for a crime and placing someone on a medical detainment to evaluate their mental state after making threats against the selves/others is like comparing apples to oranges.

And behavioral emergencies are in fact in our scope of practice.

 

[Wolfe]

I'm all for it. It is a medical thing. Why should the police be doing it in the first place? Jailing someone for a crime and placing someone on a medical detainment to evaluate their mental state after making threats against the selves/others is like comparing apples to oranges.

And behavioral emergencies are in fact in our scope of practice.

I agree whole-heartedly with this, with as many "mental evals" as we are sent to I would like to believe that the majority of EMS providers can/should be better equipped to assess these types of patients moreso than the run of the mill LEO (no offense intended). I feel that this is much more a medical than law enforcement decision.

From a "financial" standpoint, once you've been taken into custody you shouldn't be liable for the costs as you're now effectively a ward of the state. Paramedics placing holds should have their holds/runs reviewed so that they're making good mental health decisions and not "financial" decisions for their company...

Precisely my thoughts, I wouldn't want a perceived conflict of interest clouding a higher-level-of-care's opinion of what I thought (at the time) was the best course of action for the patient. My concern would be that the holds could be seen as a method of forcing what would have otherwise been an NPC signature into transport/high billing level leading to a dismissal by the next level up. I would hope that there would be a way of handling the "billing" side differently in these cases, perhaps treating the patient "financially" as if this encounter *were* an NPC.



I think this would be a very reasonable addition to our list of options in an (albeit very specific) set of circumstances.

 

[ZombieEMT]

Stupid Question

I have a question, maybe sounds stupid, but where are you going to hold them? You say you are going to place a patient on a hold for 48-72 hours? Where are you holding that patient?

I know we take a patient who is deemed a danger to himself or others, based off of simple assessments and questions. We then take the patient to the emergency room or crisis unit. That is where a MD/DO will make the decision of a hold.

In regards to this thread, I just do not see what you mean by a hold.

 

[SandpitMedic]

I have a question, maybe sounds stupid, but where are you going to hold them? You say you are going to place a patient on a hold for 48-72 hours? Where are you holding that patient?

I know we take a patient who is deemed a danger to himself or others, based off of simple assessments and questions. We then take the patient to the emergency room or crisis unit. That is where a MD/DO will make the decision of a hold.

In regards to this thread, I just do not see what you mean by a hold.

In the hospital or a designated alternative destination for behavioral/psychological emergencies.

Common place here is that the police place people on a "legal hold," and then we take them to the ER involuntarily to be further evaluated. Legal hold meaning you take them because they are unstable to make their own rational decisions. At times that requires restraints and or chemical sedation; in most cases people don't put up much resistance. The police often use this status to "off-load" drunks, transients, trouble makers-without a crime just to free their hands of them and pass them off to us.

Currently that practice has caused much headache and backlog in the ERs due to over crowding. A facility designed for that would be much more ideal. When I worked in CA we had a county mental treatment facility which received these patients.

 

[OnceAnEMT]

In the hospital or a designated alternative destination for behavioral/psychological emergencies.

...

Currently that practice has caused much headache and backlog in the ERs due to over crowding.

Exactly the problem that I see. Be it a public or privately owned hospital, no crew or even police officer can just claim a room for 72 hours. This is where taking them first for an eval by an MD comes in handy.

 

[STXmedic]

I have a question, maybe sounds stupid, but where are you going to hold them? You say you are going to place a patient on a hold for 48-72 hours? Where are you holding that patient?

I know we take a patient who is deemed a danger to himself or others, based off of simple assessments and questions. We then take the patient to the emergency room or crisis unit. That is where a MD/DO will make the decision of a hold.

In regards to this thread, I just do not see what you mean by a hold.

A hold means the patient can not check himself out or leave AMA. The doctor can clear him and transfer or release him as soon as he evaluates him. I rarely see the patient in the ED for the duration of the hold. Along with the ED, the patient can also be taken to any number of specialty psych facilities, which is generally the preferred route- especially for pediatrics.

I have never seen a problem with an ER crying because they're full (and they are never shy of voicing their frustrations). We try to work with the facilities to not cause overpopulation if at all possible, and our local physicians are typically very receptive. Again, a 48 or 72 hour hold does not mean they are in the ER bed for that amount of time. It means they can not choose to leave until that time has expired. The physician can, and almost always does, transfer or release them much sooner than that.

 

[SandpitMedic]

Well I'm not sure where you are at, but here the ERs are constantly full with psych patients. There are 12 hospitals here, most are more than 50% full with legal holds. And the ER staff are not shy about crying about it.

 

[STXmedic]

Do y'all just transport to the ER for your psych holds? ERs only account for about half of our available options of receiving facilities. We try to share the wealth between them if possible.

 

[SandpitMedic]

For EMS locally in Vegas. The ER is the only option. The police do not transport. We do, so everyone must be "medically cleared" in the ER.

Following that, they can be transferred if there is a bed available in one of the few private psychiatric treatment centers and they have insurance. The common denominator is that most do not have insurance AND they are not truly acutely in psych crisis, but rather gaming the system for three hots and a cot. I have seen folks in the ER hallways and DOUs (difiniteve observation unit) for 7 days when no psych facility beds are available or open to uninsured patients.

Those that are having true crisis are typically seen within 3 days at the ER by a social worker or psychiatric practitioner, and are then released, referred, or transferred. The system here is broken. The psych observations along with the overwhelming number of ETOH folks that require observation account for a lot of ER resources here. It will take a major event for things to change around here, so that this current systems deficiancies can be widely noticed by those making decisions and assigning funding. (Literally just got a call for a psych pt right now while writing this.)

On the topic. The bottom line is that I have the experience and working knowledge to say that this person requires voluntary or (if neccessary) involuntary further evaluation by a psychiatric SPECIALIST. Which is exactly what the Emergency Medicine physicians in the ER do. Minimal additional training would be required legally to transition from PD placing legal holds and Paramedics placing legal holds. The MDs simply have a short chat and say, hold this guy in the ER until a social worker or psych specialist talks to them... And do you know why almost everyone stays on the hold??? Because the doctor and facility do not want to get sued by the family of the one in 500 guy who gets released and then jumps off of the parking garage out front.

 

[Akulahawk]

There have been times that I've transported people directly to Psych Emergency Services and bypassed the ED. Usually we transport to the ED first and then they'll medically clear (leaving psych as the only remaining cause of symptoms) and off to PES they go...

The folks that typically go directly to PES are those that have already been seen by a physician... so it's not us transport-level folks that make the decision to bypass the ED. Well, at least the ones I've been involved with.

Sometimes LE does their own transporting. Those I never hear about in the field.

 

[SandpitMedic]

There have been times that I've transported people directly to Psych Emergency Services and bypassed the ED. Usually we transport to the ED first and then they'll medically clear (leaving psych as the only remaining cause of symptoms) and off to PES they go...

The folks that typically go directly to PES are those that have already been seen by a physician... so it's not us transport-level folks that make the decision to bypass the ED. Well, at least the ones I've been involved with.

Sometimes LE does their own transporting. Those I never hear about in the field.

Well when SCMHTC (shmick) was open, years ago, Sac PD and SD used to just take people there. We did too. They closed in ?2010? I wanna say, due to funding.

 

[Carlos Danger]

Huh? What exactly do you think they're doing with these psych holds? You say absolutely not, but then say its okay for a psych eval. That's the entire purpose of the psych hold... They are forced to the ED to be held for 48-72hrs, or until cleared by a physician. They are not being "physically imprisoned" for any unclear crime...

I suppose I didn't word that well.

What I meant was, an EMS provider or cop forcing a patient to the ED to be evaluated by a physician because the patient appears to be an imminent threat to themselves seems reasonable, and I think legal provisions for that should exist. However, that is different than a paramedic or cop "placing a 72 hour involuntary hold".

The difference may be subtle, but I think it is important.

 

[SandpitMedic]

Nooooo

They mean the same thing...

I take folks to the ER involuntarily every day under implied consent. Ie. ETOH people. Can't walk: ER.. Can't respond appropriately: ER... Can't care for yourself: ER... Crazy bones: ER... Smoked too much meth: ER. And when they sober up and are able to make rational statements and display the ability to care for themselves they are released.

Placing them on an involuntary hold for 72 hours directly corresponds to them being deemed unfit to make their own rational decisions via expressing severely manic, psychotic, unorganized, suicidal, or homicidal thoughts.... You don't just do it on a whim.