Improving Care in Psychiatric Emergencies: Prehospital Management

Tarak Trivedi MD. MS, National Clinician Scholars Program, UCLA

Melody Glenn, MD, Alameda County EMSGene Hern, MD MS, Alameda County Medical Center

David Schriger, MD MPH, UCLAKarl Sporer, MD , Alameda County EMS

Background• Prehospital

– Management of psychiatric emergencies begins with dialing 911– Police officers decide whether the person is “a danger to themselves or others”

and place an involuntary hold– Only feasible destination for police is usually the Emergency Department (ED)

• Emergency Department– 7.4 million annual mental-health* ED visits – 30% of ED mental health patients arrive by ambulance– Due to lack of 24/7 psych consults and psychiatric inpatient beds, many patients

get “stuck” in the ED for hours to days

*Unknown how may are for involuntary holds

Alternative Care Models: PES & EM-PATH Units• A possible solution to offload traditional EDs are to create specialized psychiatric EDs

– Psychiatric Emergency Service (PES) – Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) units

• Regionally-based, EMTALA-compliant dedicated emergency services for appropriatepatients with isolated psychiatric crises

• 24/7 ambulance receiving center with psychiatrist in triage

• Screen + Evaluate + Treat without need for psychiatric consults in a general ED

• Decisions to admit made after re-evaluation and preliminary attempt to stabilize failed at 24 hours

PES & EmPATH Units: Physical Space• Calming environment separate from main ED

– Large, open space where patients can be together in the same room– High ceilings and ambient light. – Self-access to food, drinks, linens, phones, books, games, TV– Room for walking about or pacing.– “Per chair” model, outfitted with recliners. – Space recommendation: 80 sq. ft. per patient; 36 sq. ft. patient area

around the recliners– Open Nursing Station, No Bulletproof Plexiglass for main area

Physical Space Design

EmPATH units• Treated as outpatient service, avoiding many regulatory

demands of inpatient psychiatric care

• No need for actual “number of beds” which would limit capacity– Many use recliner chairs or other furniture for rest/sleep

• Focus is on relieving the acute crisis, not comprehensive psychiatric evaluation– “Treat the Chief Complaint”

Can pre-hospital providers identify patients at very low risk for physiological emergencies?

• Is it safe for EMS to use a protocol to medically clear certain patients and transport them to a PES or EM-Path unit?

• What is the scale of prehospital management of psychiatric emergencies in a large urban county?

Alameda County: Pre-hospital Protocol

• Alameda County: 1.6 million people, 13 EDs, 1 PES

• Police summon EMS to assess all patients on involuntary holds – Avoids “criminalization”– Isolated psychiatric complaints can be

transported directly to PES

• Appropriate patients are taken directly to a stand-alone PES (John George Hospital)

Screening Protocol

• Transport to ED if…– Age > 65– Medical Complaint– Depressed Level of

Consciousness– Heart Rate > 120– Glucose < 60 or > 250– BP > 190/110

John George Hospital

• Average of 1500-1800 emergency psychiatric patients/month

• 85% on a involuntary detention hold (California Section 5150)

• 0.2% of patients placed in seclusion/restraint

• Top 10% of patient satisfaction scores in USA though competing with voluntary, luxury facilities

Methods: Design

• Retrospective descriptive analysis of Alameda County Emergency Medical Services (EMS) database

• All adult EMS encounters from November 2011 – 2016

• Data includes demographic, clinical, and geographic variables as well as a detailed paramedic narrative describing the ambulance encounter

Methods: Identifying Unique Patients

• No unique identifier

• Names and Date of Births often with errors

• Probability Match Algorithm– Tarak Trivedi ----- Tarik Trevedi ----- Taruck Treevaydi– Tarak Trivedi ; 6/2/1987 vs 5/2/1987

Annual Meeting 2018 Los Angeles, CA

Methods: Identifying Involuntary Holds

• Narrative Analysis– “5150”

• MPDS Code

• Impression– Behavioral

Crisis

Methods: Identification of Involuntary Holds• The first field, known as the MPDS code,

directly indicated that an encounter was for an IVH. There were two codes that Alameda County EMS uses to designate this: “25A” or “5150”. This field was not always complete

• The Primary or Secondary Impression was coded as a “Behavioral/Psychiatric Crisis” or “Psych Crisis - 5150” category & the Medic Narrative field included the term (or variation of the term) “on a 5150”

• If the term (or variation of the term) “not on a 5150” was ever present in the Medic Narrative, the encounter was not considered an IVH, regardless of other coding.

Methods: Identification of Failed Diversions

• Identified patients taken to PES instead of medical ED, who then had a repeat transport within 12 hours

• Manual review of clinical circumstances and paramedic narratives

• Link to Alameda County Vital Statistics Data to ensure no deaths*

* Unpublished, data became available after publication

Failed Diversion Within 12 Hours

Medical ED

Patient Psychiatric Emergency Services

Diverted

Re-transported

Patient

Results• 257,625 Unique Patients

– “Involuntary Patients”: Defined as having had at least 1 involuntary hold (N=26,283, 10%)

• 541,731 Encounters– 10% (N=53, 887) were for

transport of a patient on an involuntary hold

• 24% of all EMS encounters were for “Involuntary Patients”

“Involuntary Patients”

Patients withwho never

had aninvoluntary

holdEncounters for

InvoluntaryHolds

53,887 *0 by definition

Encounters for Other Reasons

74,116 413,728

Total Encounters(N=541,731)

128,003(24% of All

Encounters)

413,728 (76% of All

Encounters)

10% were“Involuntary Patients”

At least 1 or more involuntary holds during

the 5 years

72% of “Involuntary Patients”

had only 1 hold over the 5 years

1 Involuntary Hold

2 – 4 Involuntary Holds

5 + Involuntary Holds

Legend

1 Involuntary Hold

2 – 4 Involuntary Holds

5 + Involuntary Holds

Legend 21% had 2-4 holds placed over 5 years

1 Involuntary Hold

2 – 4 Involuntary Holds

5 + Involuntary Holds

LegendThere was a small

group of 1907 patients (7%) that were on 5 or

more involuntary holds over 5 years

1 Involuntary Hold

2 – 4 Involuntary Holds

5 + Involuntary Holds

Legend 39% of all encounters for

involuntary holds were for

this high-utilizer group

(5 or more Holds)

Results: Prehospital Diversion

22,074 Involuntary Hold encounters (41%) diverted to PES

60 (0.3%) were transported again to a medical ED within 12 Hours

60 Failed Diversion Within 12 Hours

Medical ED

22,074 encountersPsychiatric Emergency

Services

Diverted

Re-transported

60 Encounters

Data on 60 Failed Diversions

• 54 developed new symptoms at PES

• 6 were “true” protocol failures– Altered Mental Status x 2– Hypoglycemia x 2– Advanced Pregnancy– Age older than allowed

N=54

Developed new symptom 13 (24%)

Effect of AdministeredMedication

10 (19%)

Seizure with history of seizure disorder

8 (15%)

Asymptomatic, staff request for ED evaluation

7 (13%)

Mental status change 6 (11%)

New traumatic injury at PES 5 (9%)

Patient called EMS afterdischarge from PES

5 (9%)

Alameda County Public Health Death Data

• 19,032 (7%) patients died within 30 days

• 90 / 53,887 (0.1%) 5150 transports died– None were taken to PES

• Only 2 patients taken to PES died within 7 days

Limitations• Descriptive study from a single county

– Threshold for placing involuntary holds may be much lower in Alameda County.– Many county protocols may not require ambulance transportation for all

involuntary holds

• Diversion protocol in place for years– May not be applicable to early implementation phases of a county EMS protocol

• No data on other outcomes after admission or discharge from PES

Conclusions

• Patients who had at least one involuntary hold disproportionally used EMS – 24% of all EMS encounters were for this group of patients (10% for holds, 14% for

other reasons)

• Strategies to reduce crises for high utilizers has high potential to unburden the system– 39% of all involuntary holds were placed on 1907 patients who had 5 + holds

• EMS transport of select patients in psychiatric crisis to a specialized psychiatric emergency services is safe– Routine transport to the ED for patients on involuntary holds may be

unnecessary

On Creating the Protocol

• Initial Diversion Protocol co-written with EMS Medical Director and Emergency Psychiatry Chief (Zeller)

• Approved and refined by medical directors of all eleven county EDs, and adopted as official county EMS policy

• Relies on Psychiatrists to treat basic medical conditions– Oral detox, manage hyperglycemia, asthma, regular meds without

sending to medical ED

2014 Study on ED Boarding Times

• Compared medical ED psychiatric patient boarding times and hospitalization rates in PES system vs usual care

• Psych patient boarding times in area EDs were 1 hr 48 min– CA avg: 10 Hrs, 3 min (not counting time at PES)

• 76% eventually discharged within 24 hours from PES, avoiding unnecessary hospitalization and sparing inpatient beds

Zeller et al 2014

Acknowledgements

• UCLA National Clinical Scholars Program• Department of Veteran’s Affairs• Alameda County EMS • John George Psychiatric Emergency Services• Melody Glenn, MD. Gene Hern, MD. Karl Sporer, MD.• David Schriger, MD, MPH.• NCSP Co-fellows and Program Mentors