Screening Tool Optimizes EMS Mental Health Transports

ESO Staff

There are more than 7.4 million mental health–related emergency department (ED) visits in the U.S. every year, and of these, approximately 30 percent arrive by ambulance. Unfortunately, due to a deficit in dedicated inpatient psychiatric beds, patients experiencing a psychiatric crisis often remain in the ED for hours or even days. This is particularly painful for someone suffering with mental health issues, not to mention adds significant workload and difficulties for ED staff and decreased operational efficiencies. Today, however, some agencies are experimenting with utilizing an in-field screening tool that instead directs psychiatric patients that meet specific protocol to a standalone psychiatric care facility, bypassing the ED.

The Current State: Hard on Everyone

In most counties and municipalities, all EMS calls involving “involuntary psychiatric holds” are required to be transported to a receiving medical facility in order to ensure that the symptoms are not being caused by an underlying medical issue. When an ED is particularly busy or short on beds dedicated to inpatient psychiatric cases, a patient can be left sitting for hours and hours with little or no relief. When they are finally able to be evaluated, it may be decided that they should again be transported, this time to a facility that can provide the appropriate mental health care. The hours they have spent in the ED have done them little good, and have added additional workload to an already busy and stressed staff.

Experimenting with a New Process

Recently, a team of researchers undertook a study on one EMS agency utilizing a screening tool for psychiatric symptoms, tracking its effectiveness on reducing the number of non-medical cases sent to languish in the ED. In Alameda County, CA – population 1.6 million people – the Alameda County EMS Agency developed and approved an EMS protocol that allows the crew to identify patients with isolated psychiatric complaints who meet specific criteria and transport them directly to the county’s psychiatric emergency service. Patients who do not meet the protocol criteria, or are otherwise judged unstable by the ambulance crew, are transported to an ED.

Examining five years of retroactive data, researchers developed a picture of what the county’s calls typically looked like, and how effective the new protocol has been in more effectively directing patients to the best and most appropriate care facilities. Alameda County historically faced a significant number of involuntary psychiatric holds, with most patients demographically being younger, uninsured males. Many had many previous EMS encounters, including previous involuntary holds, and many of these calls also involved the local police force.

An Example Protocol

The Alameda County EMS protocol primarily applies to patients between the ages of 12-64 (patients older or younger are automatically transferred to ED or the local children’s hospital). Additionally, adolescents with specific criteria – such as being away from adult supervision for an extended period of time or chronic medical conditions – were also transported directly to a receiving medical facility. Additionally, if a patient was combative and required sedation, exhibited specific abnormal vital signs, or showed signs of medication overdose or drug toxicity, he or she was transported to the ED.

If, however, a patient in the appropriate age bracket was cleared of all medical criteria, EMS team then looked at psychiatric protocol, such as:

  • Patients with history of drug use who do not show signs of significant toxicity
  • Patients with abnormalities in vital signs but without other significant physical findings or history suggesting an acute medical problem
  • Patients with minor abrasions or contusions not needing laceration repair or other complex care or evaluation
  • Patients who otherwise appear healthy but have communication barriers or are unwilling to answer questions


Checking for Success

While the protocol definitely made for a more streamlined process for the EMS team and the receiving facilities, the agency and the researchers knew it was very important to review the metrics for any “redirects,” meaning that a patient was actually transported back to the ED within 12 hours of original transport. This, of course, would suggest that an underlying medical condition was missed and that the patient had, in fact, needed medial attention.

Researchers found that of the 541,731 total EMS encounters in Alameda County during the study period, 10% of patients were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation rather than an ED. Only 0.3% were considered “failed diversion” requiring re-transport to the ED within 12 hours, showing that the protocol was indeed effective in correctly identifying patients who could benefit more readily from care at a psychiatric facility rather than the ED.

Researchers did note that there were some limitations that should be considered when looking at the Alameda County metrics. For example, Alameda County’s frequency of involuntary holds may be abnormally high, with 195.7 holds per 10,000 people. Additionally, the study could not account for situational circumstances, such as who initiated the 911 calls and patient homelessness, elements researchers felt may impact the results in some ways.

Promising Results

The results of the study and successes at Alameda County seem to suggest that there is great potential for EMS agencies to use their expertise along with a well-developed protocol to more efficiently transport patients – specifically those in psychiatric crises – to the most appropriate facility. Efforts like these can not only lighten the load for ED staff and make operations more efficient, but get patients the care they need more quickly from the appropriate providers.

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