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Better Models for Troubled Patients

Patients whose problems aren’t physical take up a lot of EMS providers’ time. A block of presentations on the final day of the Gathering of Eagles conference in March looked at ways to handle them better.

In Chicago police have worked with the National Alliance on Mental Illness on CIT (crisis intervention team) training that has now reached 30% of officers. In 2017 they responded to 40,663 total CIT events, city EMS medical directors Joe Weber, MD, and Katie Tataris, MD, reported—calls like suicide attempts and threats, disturbances, and mental health transports. Meanwhile, Chicago Fire faced more than 24,000 mental health calls for things like suicide attempts, psychiatric emergencies, and altered mental statuses.

These challenges were historically faced separately. Then in 2016 the mayor’s office created a Mental Health Steering Committee with a coordinated crisis response group that brought EMS, fire, police, and dispatchers together for collaborative training with NAMI. The resulting eight-hour CIM (crisis incident management) class delivers a basic review of mental health topics and education about and for each stakeholder with a focus on total response and scene management. Through case scenarios using trained actors, participants practice communication skills and de-escalation—learning, for instance, that communication is just 7% verbal and has far more to do with body language and volume/tone.

Mental health training for all emergency response personnel, Tataris and Weber concluded, is a critical step to ensuring an effective response.

In California’s Alameda County, behavioral emergencies comprise 10% of total EMS calls, medical director Karl Sporer, MD, reported. With too few hospital psych beds, these patients can languish in EDs. A new field-screening protocol lets EMS take them directly to standalone psychiatric emergency care.

From 2011 to 2016 county providers recorded 53,887 involuntary hold encounters, of which 41% (22,074) were screened to the psych facility. Fewer than 2% of those needed to return to an ED within 12 hours, and of 60 (0.3%) who required emergency transport, 54 had developed new symptoms while at the psych care.

These patients, Sporer said, were younger, more likely to be male, and less likely to be insured than the general EMS population. What’s more, they had an average of two other EMS transports each and aggregately accounted for a total of 24% of all EMS encounters.

San Antonio docs David Miramontes, MD, and C.J. Winckler, MD, described an alternative approach involving law enforcement navigation of behavioral health patients. Officers there now have a protocol to work through a local resource called MEDCOM to take stable patients without acute medical problems directly to psych facilities.

For emergent needs like delirium/agitation/violence, mental status changes, trauma, or overdose, officers still summon EMS and fire. For urgent needs like medical assessment, complaints of illness, and requests for evaluation, they call EMS. Otherwise they contact MEDCOM to coordinate transport to an appropriate psych destination. Patients can’t go with police if they have wounds or trauma; any history of overdose or drug ingestion; significant intoxication or behavioral disturbance; or various implanted tubes, ports, and lines.

From January through October 2018, around 55% of emergency detention cases were navigated directly from law enforcement to behavioral care, while around 30% were held in emergency departments until cleared. Performance improvement efforts are focused on watching for secondary transfers.

Lacking a psychiatric hospital, South Carolina’s Charleston County EMS utilizes a 24/7 mobile crisis team to serve its psychiatric patients. Because of the jurisdiction’s large size, however, it can take 45–50 minutes to arrive, medical director David French, MD, explained. That’s a long time when someone’s in crisis. To get help to people quicker, his system has turned to telehealth.

The capability allows EMS crews to connect to mobile crisis resources using video software on laptops and phones and can cut the initiation of care to minutes.

These calls draw an ALS ambulance and a quick-response vehicle. Only adults without medical or trauma complaints and with stable vitals are eligible. After an initial ALS assessment, cooperative patients are offered the telepsych option, and if they accept, the ambulance returns to service.

The mobile crisis team determines the patient’s disposition through consultation and with input from EMS and law enforcement. Possible outcomes include voluntary or involuntary hospital admission, immediate navigation to a mental health center, or a follow-up appointment. Those detained are transported by law enforcement.

From May 2017 through the first days of 2019, French reported, about 1,200 mental health calls were considered for telepsych disposition, resulting in 678 ED diversions and 572 patients averting hospitalization. Based on average transport and hospitalization costs, that produced an estimated system savings of $1.8 million or more.

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