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Transporting the high-risk psychiatric patient: Clinical and legal challenges
“I’ve given up, doctor. We gave it our best, but I am at the point where I want to end my life.” You receive this call at 2 a.m., and you’re flooded with a series of emotions and are bewildered – until your training kicks in.
Countless hours of working with patients in emergency department settings while on call as a resident inform your ability to triage the situation. Years of supervision guide your supportive statements as you work collaboratively with your patient to address the emotional and existential distress. As the call proceeds and you realize that your patient will require hospitalization, you are struck by a sobering question: “How am I going to arrange for my patient to go to the nearest hospital in the middle of the night?”
The options for transporting patients with serious mental illness (SMI) typically vary from bad to worse and usually filter down to three possibilities:
1. Get a friend or family member to transport them to the nearest ED.
2. Call emergency medical services (EMS) for transport to the nearest ED.
3. Call the police and request transport to the nearest ED.
Several factors would determine which of those options you would use alone or in combination. Current training paradigms for mental health professionals offer a limited body of literature on evidenced-based strategies for patients with SMI. At best – if not handled properly – these experiences can aggravate patients’ mental health conditions. At worst, they can lead to the loss of our patients. Together, we have more than 40 years’ experience working in complex mental health care systems that run the gamut, from providing direct clinical care to directing mental health care divisions.
Sobering statistics prevail
In 2017, suicide was the 10th leading cause of death in the United States, accounting for more than 47,000 deaths. Suicide was the second-leading cause of death among individuals aged 10-34 and the fourth leading cause of death for individuals aged 35- 54.1 In 2017, more than 70,200 Americans died from a drug overdose, including illicit drugs and prescription opioids.2 Drug overdose deaths nearly quadrupled between 1999 and 2017, from 16,849 deaths to 70,237, respectively.2
The life expectancy of an American with SMI is 14-32 years less than that of the average population.3 Those numbers are on par with many sub-Saharan countries, including Sudan and Ethiopia, and surpass the health disparities for most racial and ethnic groups.
The decrease in life expectancy for people with SMI is rarely the result of suicide but rather the effect of medical comorbidities, including heart disease, stroke, pulmonary disease, diabetes, and cancer.3 Individuals with SMI are much more likely to suffer from chronic illnesses that are associated with co-occurring addictions, side effects of psychotropic medications, and social determinants of mental health, such as poverty.
Major depressive disorder among people with SMI presents acute and chronic medical risks. For example, people with major depressive disorder are at a higher risk for stroke and cardiovascular disease.4 There is a threefold increase in cardiac-related deaths for individuals who experience depression after a heart attack.5 In addition, depression increases the risk of cardiac-related death after a heart attack more than any other risk factor, except for congestive heart failure.6
The transportation challenge
When the complexity of psychiatric conditions is conceptualized to include decreased life expectancy because of medical comorbidities, medical complications that can result from psychotropic medications, and the high incidence of co-occurring substance use disorders (SUDs), it is clear why we are concerned about the type of transport used for patients experiencing a psychiatric emergency.
A common practice for patients presenting for medical treatment for a mental health condition is for them to be transported by law enforcement in handcuffs, or by private vehicle, because of a lack of medical transport options.
One tragic example occurred on Sept. 18, 2018, when two Horry County, S.C., deputies were providing a hospital-to-hospital transport for two mental health patients. The patients, who had no legal charges and were not under arrest, were locked in a transport cage in the back of a law enforcement vehicle for transport during Hurricane Florence. While the driver tried to move through floodwaters, the car stalled and became submerged. The patients were unable to open the locked cage door, and the deputies responsible for the transport did not have a key to unlock the cage.
The two women died as a result of the incident. Both deputies are facing two counts of involuntary manslaughter – with a potential prison sentence of 5 years each.7
The system that promotes the use of law enforcement to transport medical patients who are not in legal custody perpetuates a high risk to patients. Also at risk are law enforcement professionals who often are not adequately trained to evaluate, intervene, and manage patients in need of medical treatment (for acute medical, SUDs, or mental illness).
Recommendations for transporting high-risk patients
The legal and regulatory standards required by the Centers for Medicare & Medicaid Services guidelines8 for behavioral health patients are consistent in saying that law enforcement restraints cannot be used in hospital settings – unless the patient is under law enforcement custody. If the patient is admitted to an inpatient psychiatric unit, law enforcement restraints are never allowed to be used. Despite those guidelines for handling these situations within hospital settings, a similar standard does not exist for interhospital transport of high-risk behavioral health patients.
Patients often are transported between facilities by law enforcement, and at times, with the use of law enforcement restraints. However, use of law enforcement for interhospital transport of patients not in the custody of law enforcement is both detrimental to and clinically dangerous for the patient. Not only does the scenario put the patient at risk, but it also places law enforcement professionals at risk with the potential for legal liability if the patient medically decompensates during the transport.
Also, using law enforcement to intervene and provide transportation for behavioral health patients in crisis might cause further harm to the patient’s psychological condition and deter the patient from presenting for treatment.
The appropriate level of interfacility transport for a behavioral health patient requiring an inpatient level of care is secure transport with trained medical professionals. If necessary, restraint guidelines should follow the same standard as they do in hospital settings. In situations with high risk for violence or agitation, law enforcement should be requested to accompany EMS during the transport. Handling the situation in this way allows for a collaborative approach to provide adequate medical support, and provide for the physical safety and security of the patient – and of EMS personnel.
Across police and sheriffs’ departments nationwide, law enforcement officers are required to transport mental health patients from one location or hospital to another. Hospitals and outpatient locations, often with no alternative, rely on local law enforcement agencies to provide safe transport between acute and mental health facilities. Departmental policies and the widespread belief that mental health patients automatically pose a substantial danger to themselves or others have led to these patients being handcuffed and put in the back of police cruisers. Essentially, they are treated like criminals who are under arrest.
The CMS has strict criteria for ordering, applying, evaluating, reevaluating, and reporting restraint-associated deaths. Likewise, The Joint Commission, during its accreditation survey, rightly scrutinizes a facility’s use of restraints. Both the CMS and The Joint Commission define restraint by the function of the device and not the type of the device.
According to the CMS, a restraint is any manual method, physical or mechanic device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Within a police cruiser, handcuffs on a mental health patient who is not under arrest would fall squarely within this definition of restraint.
A patient’s current behavior or clinical needs – not history or diagnosis – should determine whether a restraint is warranted. A patient experiencing a psychiatric crisis who is not under arrest might very well escalate and become destructive and combative when being placed in handcuffs in the back of a police vehicle. What should police do at that point? Should they arrest the individual? We offer the following five recommendations.
Key recommendations
- Patients who require interhospital transport for an acute behavioral health crisis should be transported by medical professionals with the training and expertise to manage mental health and medical conditions.
- Interhospital transport restraint guidelines should be in line with CMS guidelines for hospital restraints. No patient that is not under law enforcement custody should be transported in law enforcement restraints.
- Patients at high risk for violence/agitation (an underlying condition causing violence/agitation may include dementia, traumatic brain injuries, delirium, SUDs, or psychiatric conditions) should be managed in accordance with medically indicated intervention such as medical restraints or medications.
- If required, a request should be made for law enforcement officers to accompany EMS to provide support and to ensure the safety of the patient and EMS professionals during the transport.
- EMS professionals should receive specific training to manage acute psychiatric and SUD conditions, and should be aware of the life-threatening medical complications that can result from SUDs and psychiatric conditions/medications.
We recognize that patients with SMI require clinicians to work collaboratively, perhaps with law enforcement, to safely transport them from one point to another. Only when the rules we have outlined are followed will our patients get transported in such ways that allow them to get the care they need.
Dr. Norris is editor-in-chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Ms. Palmieri is a managing partner of Healthcare Legal Education & Consulting Network (HLECN), and the chief clinical officer and cofounder of XFERALL. HLECN focuses on clinical education and training, and XFERALL is a company that provides a technology platform aimed at improving access to care for behavioral health and medical patients. Ms. Slater is a managing partner of legal education for HLECN, and a trial attorney at Colley Shroyer & Abraham in Columbus, Ohio. Mr. Whaley is director of the safety and security department at GWU Hospital.
References
1. National Institute of Mental Health: Suicide.
2. National Institute on Drug Abuse. Overdose death rates. Revised January 2019.
3. Post by former NIMH Director Thomas Insel: No health without mental health. Sept. 6, 2011.
4. Dhar AK and Barton DA. Depression and the link with cardiovascular disease. Front Psychiatry. 2016 Mar 21;7:33.
5. Lichtman JH et al. Depression and coronary heart disease. Circulation. 2008;118:1768-75.
6. Hare DL et al. Depression and cardiovascular disease: A clinical review. European Heart J. 2014 Jun;35(21):1365-72.
7. “ ‘How many people have to die?’ SC mental health patients endure nightmare transport.” The News & Observer. 2019 May 29.
8. 42 C.F.R. Part 482. Part IV. Department of Health and Human Services. Medicare & Medicaid programs; Hospital conditions of participation; Patients’ rights; Final rule. 2006 Dec 8.
“I’ve given up, doctor. We gave it our best, but I am at the point where I want to end my life.” You receive this call at 2 a.m., and you’re flooded with a series of emotions and are bewildered – until your training kicks in.
Countless hours of working with patients in emergency department settings while on call as a resident inform your ability to triage the situation. Years of supervision guide your supportive statements as you work collaboratively with your patient to address the emotional and existential distress. As the call proceeds and you realize that your patient will require hospitalization, you are struck by a sobering question: “How am I going to arrange for my patient to go to the nearest hospital in the middle of the night?”
The options for transporting patients with serious mental illness (SMI) typically vary from bad to worse and usually filter down to three possibilities:
1. Get a friend or family member to transport them to the nearest ED.
2. Call emergency medical services (EMS) for transport to the nearest ED.
3. Call the police and request transport to the nearest ED.
Several factors would determine which of those options you would use alone or in combination. Current training paradigms for mental health professionals offer a limited body of literature on evidenced-based strategies for patients with SMI. At best – if not handled properly – these experiences can aggravate patients’ mental health conditions. At worst, they can lead to the loss of our patients. Together, we have more than 40 years’ experience working in complex mental health care systems that run the gamut, from providing direct clinical care to directing mental health care divisions.
Sobering statistics prevail
In 2017, suicide was the 10th leading cause of death in the United States, accounting for more than 47,000 deaths. Suicide was the second-leading cause of death among individuals aged 10-34 and the fourth leading cause of death for individuals aged 35- 54.1 In 2017, more than 70,200 Americans died from a drug overdose, including illicit drugs and prescription opioids.2 Drug overdose deaths nearly quadrupled between 1999 and 2017, from 16,849 deaths to 70,237, respectively.2
The life expectancy of an American with SMI is 14-32 years less than that of the average population.3 Those numbers are on par with many sub-Saharan countries, including Sudan and Ethiopia, and surpass the health disparities for most racial and ethnic groups.
The decrease in life expectancy for people with SMI is rarely the result of suicide but rather the effect of medical comorbidities, including heart disease, stroke, pulmonary disease, diabetes, and cancer.3 Individuals with SMI are much more likely to suffer from chronic illnesses that are associated with co-occurring addictions, side effects of psychotropic medications, and social determinants of mental health, such as poverty.
Major depressive disorder among people with SMI presents acute and chronic medical risks. For example, people with major depressive disorder are at a higher risk for stroke and cardiovascular disease.4 There is a threefold increase in cardiac-related deaths for individuals who experience depression after a heart attack.5 In addition, depression increases the risk of cardiac-related death after a heart attack more than any other risk factor, except for congestive heart failure.6
The transportation challenge
When the complexity of psychiatric conditions is conceptualized to include decreased life expectancy because of medical comorbidities, medical complications that can result from psychotropic medications, and the high incidence of co-occurring substance use disorders (SUDs), it is clear why we are concerned about the type of transport used for patients experiencing a psychiatric emergency.
A common practice for patients presenting for medical treatment for a mental health condition is for them to be transported by law enforcement in handcuffs, or by private vehicle, because of a lack of medical transport options.
One tragic example occurred on Sept. 18, 2018, when two Horry County, S.C., deputies were providing a hospital-to-hospital transport for two mental health patients. The patients, who had no legal charges and were not under arrest, were locked in a transport cage in the back of a law enforcement vehicle for transport during Hurricane Florence. While the driver tried to move through floodwaters, the car stalled and became submerged. The patients were unable to open the locked cage door, and the deputies responsible for the transport did not have a key to unlock the cage.
The two women died as a result of the incident. Both deputies are facing two counts of involuntary manslaughter – with a potential prison sentence of 5 years each.7
The system that promotes the use of law enforcement to transport medical patients who are not in legal custody perpetuates a high risk to patients. Also at risk are law enforcement professionals who often are not adequately trained to evaluate, intervene, and manage patients in need of medical treatment (for acute medical, SUDs, or mental illness).
Recommendations for transporting high-risk patients
The legal and regulatory standards required by the Centers for Medicare & Medicaid Services guidelines8 for behavioral health patients are consistent in saying that law enforcement restraints cannot be used in hospital settings – unless the patient is under law enforcement custody. If the patient is admitted to an inpatient psychiatric unit, law enforcement restraints are never allowed to be used. Despite those guidelines for handling these situations within hospital settings, a similar standard does not exist for interhospital transport of high-risk behavioral health patients.
Patients often are transported between facilities by law enforcement, and at times, with the use of law enforcement restraints. However, use of law enforcement for interhospital transport of patients not in the custody of law enforcement is both detrimental to and clinically dangerous for the patient. Not only does the scenario put the patient at risk, but it also places law enforcement professionals at risk with the potential for legal liability if the patient medically decompensates during the transport.
Also, using law enforcement to intervene and provide transportation for behavioral health patients in crisis might cause further harm to the patient’s psychological condition and deter the patient from presenting for treatment.
The appropriate level of interfacility transport for a behavioral health patient requiring an inpatient level of care is secure transport with trained medical professionals. If necessary, restraint guidelines should follow the same standard as they do in hospital settings. In situations with high risk for violence or agitation, law enforcement should be requested to accompany EMS during the transport. Handling the situation in this way allows for a collaborative approach to provide adequate medical support, and provide for the physical safety and security of the patient – and of EMS personnel.
Across police and sheriffs’ departments nationwide, law enforcement officers are required to transport mental health patients from one location or hospital to another. Hospitals and outpatient locations, often with no alternative, rely on local law enforcement agencies to provide safe transport between acute and mental health facilities. Departmental policies and the widespread belief that mental health patients automatically pose a substantial danger to themselves or others have led to these patients being handcuffed and put in the back of police cruisers. Essentially, they are treated like criminals who are under arrest.
The CMS has strict criteria for ordering, applying, evaluating, reevaluating, and reporting restraint-associated deaths. Likewise, The Joint Commission, during its accreditation survey, rightly scrutinizes a facility’s use of restraints. Both the CMS and The Joint Commission define restraint by the function of the device and not the type of the device.
According to the CMS, a restraint is any manual method, physical or mechanic device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Within a police cruiser, handcuffs on a mental health patient who is not under arrest would fall squarely within this definition of restraint.
A patient’s current behavior or clinical needs – not history or diagnosis – should determine whether a restraint is warranted. A patient experiencing a psychiatric crisis who is not under arrest might very well escalate and become destructive and combative when being placed in handcuffs in the back of a police vehicle. What should police do at that point? Should they arrest the individual? We offer the following five recommendations.
Key recommendations
- Patients who require interhospital transport for an acute behavioral health crisis should be transported by medical professionals with the training and expertise to manage mental health and medical conditions.
- Interhospital transport restraint guidelines should be in line with CMS guidelines for hospital restraints. No patient that is not under law enforcement custody should be transported in law enforcement restraints.
- Patients at high risk for violence/agitation (an underlying condition causing violence/agitation may include dementia, traumatic brain injuries, delirium, SUDs, or psychiatric conditions) should be managed in accordance with medically indicated intervention such as medical restraints or medications.
- If required, a request should be made for law enforcement officers to accompany EMS to provide support and to ensure the safety of the patient and EMS professionals during the transport.
- EMS professionals should receive specific training to manage acute psychiatric and SUD conditions, and should be aware of the life-threatening medical complications that can result from SUDs and psychiatric conditions/medications.
We recognize that patients with SMI require clinicians to work collaboratively, perhaps with law enforcement, to safely transport them from one point to another. Only when the rules we have outlined are followed will our patients get transported in such ways that allow them to get the care they need.
Dr. Norris is editor-in-chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Ms. Palmieri is a managing partner of Healthcare Legal Education & Consulting Network (HLECN), and the chief clinical officer and cofounder of XFERALL. HLECN focuses on clinical education and training, and XFERALL is a company that provides a technology platform aimed at improving access to care for behavioral health and medical patients. Ms. Slater is a managing partner of legal education for HLECN, and a trial attorney at Colley Shroyer & Abraham in Columbus, Ohio. Mr. Whaley is director of the safety and security department at GWU Hospital.
References
1. National Institute of Mental Health: Suicide.
2. National Institute on Drug Abuse. Overdose death rates. Revised January 2019.
3. Post by former NIMH Director Thomas Insel: No health without mental health. Sept. 6, 2011.
4. Dhar AK and Barton DA. Depression and the link with cardiovascular disease. Front Psychiatry. 2016 Mar 21;7:33.
5. Lichtman JH et al. Depression and coronary heart disease. Circulation. 2008;118:1768-75.
6. Hare DL et al. Depression and cardiovascular disease: A clinical review. European Heart J. 2014 Jun;35(21):1365-72.
7. “ ‘How many people have to die?’ SC mental health patients endure nightmare transport.” The News & Observer. 2019 May 29.
8. 42 C.F.R. Part 482. Part IV. Department of Health and Human Services. Medicare & Medicaid programs; Hospital conditions of participation; Patients’ rights; Final rule. 2006 Dec 8.
“I’ve given up, doctor. We gave it our best, but I am at the point where I want to end my life.” You receive this call at 2 a.m., and you’re flooded with a series of emotions and are bewildered – until your training kicks in.
Countless hours of working with patients in emergency department settings while on call as a resident inform your ability to triage the situation. Years of supervision guide your supportive statements as you work collaboratively with your patient to address the emotional and existential distress. As the call proceeds and you realize that your patient will require hospitalization, you are struck by a sobering question: “How am I going to arrange for my patient to go to the nearest hospital in the middle of the night?”
The options for transporting patients with serious mental illness (SMI) typically vary from bad to worse and usually filter down to three possibilities:
1. Get a friend or family member to transport them to the nearest ED.
2. Call emergency medical services (EMS) for transport to the nearest ED.
3. Call the police and request transport to the nearest ED.
Several factors would determine which of those options you would use alone or in combination. Current training paradigms for mental health professionals offer a limited body of literature on evidenced-based strategies for patients with SMI. At best – if not handled properly – these experiences can aggravate patients’ mental health conditions. At worst, they can lead to the loss of our patients. Together, we have more than 40 years’ experience working in complex mental health care systems that run the gamut, from providing direct clinical care to directing mental health care divisions.
Sobering statistics prevail
In 2017, suicide was the 10th leading cause of death in the United States, accounting for more than 47,000 deaths. Suicide was the second-leading cause of death among individuals aged 10-34 and the fourth leading cause of death for individuals aged 35- 54.1 In 2017, more than 70,200 Americans died from a drug overdose, including illicit drugs and prescription opioids.2 Drug overdose deaths nearly quadrupled between 1999 and 2017, from 16,849 deaths to 70,237, respectively.2
The life expectancy of an American with SMI is 14-32 years less than that of the average population.3 Those numbers are on par with many sub-Saharan countries, including Sudan and Ethiopia, and surpass the health disparities for most racial and ethnic groups.
The decrease in life expectancy for people with SMI is rarely the result of suicide but rather the effect of medical comorbidities, including heart disease, stroke, pulmonary disease, diabetes, and cancer.3 Individuals with SMI are much more likely to suffer from chronic illnesses that are associated with co-occurring addictions, side effects of psychotropic medications, and social determinants of mental health, such as poverty.
Major depressive disorder among people with SMI presents acute and chronic medical risks. For example, people with major depressive disorder are at a higher risk for stroke and cardiovascular disease.4 There is a threefold increase in cardiac-related deaths for individuals who experience depression after a heart attack.5 In addition, depression increases the risk of cardiac-related death after a heart attack more than any other risk factor, except for congestive heart failure.6
The transportation challenge
When the complexity of psychiatric conditions is conceptualized to include decreased life expectancy because of medical comorbidities, medical complications that can result from psychotropic medications, and the high incidence of co-occurring substance use disorders (SUDs), it is clear why we are concerned about the type of transport used for patients experiencing a psychiatric emergency.
A common practice for patients presenting for medical treatment for a mental health condition is for them to be transported by law enforcement in handcuffs, or by private vehicle, because of a lack of medical transport options.
One tragic example occurred on Sept. 18, 2018, when two Horry County, S.C., deputies were providing a hospital-to-hospital transport for two mental health patients. The patients, who had no legal charges and were not under arrest, were locked in a transport cage in the back of a law enforcement vehicle for transport during Hurricane Florence. While the driver tried to move through floodwaters, the car stalled and became submerged. The patients were unable to open the locked cage door, and the deputies responsible for the transport did not have a key to unlock the cage.
The two women died as a result of the incident. Both deputies are facing two counts of involuntary manslaughter – with a potential prison sentence of 5 years each.7
The system that promotes the use of law enforcement to transport medical patients who are not in legal custody perpetuates a high risk to patients. Also at risk are law enforcement professionals who often are not adequately trained to evaluate, intervene, and manage patients in need of medical treatment (for acute medical, SUDs, or mental illness).
Recommendations for transporting high-risk patients
The legal and regulatory standards required by the Centers for Medicare & Medicaid Services guidelines8 for behavioral health patients are consistent in saying that law enforcement restraints cannot be used in hospital settings – unless the patient is under law enforcement custody. If the patient is admitted to an inpatient psychiatric unit, law enforcement restraints are never allowed to be used. Despite those guidelines for handling these situations within hospital settings, a similar standard does not exist for interhospital transport of high-risk behavioral health patients.
Patients often are transported between facilities by law enforcement, and at times, with the use of law enforcement restraints. However, use of law enforcement for interhospital transport of patients not in the custody of law enforcement is both detrimental to and clinically dangerous for the patient. Not only does the scenario put the patient at risk, but it also places law enforcement professionals at risk with the potential for legal liability if the patient medically decompensates during the transport.
Also, using law enforcement to intervene and provide transportation for behavioral health patients in crisis might cause further harm to the patient’s psychological condition and deter the patient from presenting for treatment.
The appropriate level of interfacility transport for a behavioral health patient requiring an inpatient level of care is secure transport with trained medical professionals. If necessary, restraint guidelines should follow the same standard as they do in hospital settings. In situations with high risk for violence or agitation, law enforcement should be requested to accompany EMS during the transport. Handling the situation in this way allows for a collaborative approach to provide adequate medical support, and provide for the physical safety and security of the patient – and of EMS personnel.
Across police and sheriffs’ departments nationwide, law enforcement officers are required to transport mental health patients from one location or hospital to another. Hospitals and outpatient locations, often with no alternative, rely on local law enforcement agencies to provide safe transport between acute and mental health facilities. Departmental policies and the widespread belief that mental health patients automatically pose a substantial danger to themselves or others have led to these patients being handcuffed and put in the back of police cruisers. Essentially, they are treated like criminals who are under arrest.
The CMS has strict criteria for ordering, applying, evaluating, reevaluating, and reporting restraint-associated deaths. Likewise, The Joint Commission, during its accreditation survey, rightly scrutinizes a facility’s use of restraints. Both the CMS and The Joint Commission define restraint by the function of the device and not the type of the device.
According to the CMS, a restraint is any manual method, physical or mechanic device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Within a police cruiser, handcuffs on a mental health patient who is not under arrest would fall squarely within this definition of restraint.
A patient’s current behavior or clinical needs – not history or diagnosis – should determine whether a restraint is warranted. A patient experiencing a psychiatric crisis who is not under arrest might very well escalate and become destructive and combative when being placed in handcuffs in the back of a police vehicle. What should police do at that point? Should they arrest the individual? We offer the following five recommendations.
Key recommendations
- Patients who require interhospital transport for an acute behavioral health crisis should be transported by medical professionals with the training and expertise to manage mental health and medical conditions.
- Interhospital transport restraint guidelines should be in line with CMS guidelines for hospital restraints. No patient that is not under law enforcement custody should be transported in law enforcement restraints.
- Patients at high risk for violence/agitation (an underlying condition causing violence/agitation may include dementia, traumatic brain injuries, delirium, SUDs, or psychiatric conditions) should be managed in accordance with medically indicated intervention such as medical restraints or medications.
- If required, a request should be made for law enforcement officers to accompany EMS to provide support and to ensure the safety of the patient and EMS professionals during the transport.
- EMS professionals should receive specific training to manage acute psychiatric and SUD conditions, and should be aware of the life-threatening medical complications that can result from SUDs and psychiatric conditions/medications.
We recognize that patients with SMI require clinicians to work collaboratively, perhaps with law enforcement, to safely transport them from one point to another. Only when the rules we have outlined are followed will our patients get transported in such ways that allow them to get the care they need.
Dr. Norris is editor-in-chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Ms. Palmieri is a managing partner of Healthcare Legal Education & Consulting Network (HLECN), and the chief clinical officer and cofounder of XFERALL. HLECN focuses on clinical education and training, and XFERALL is a company that provides a technology platform aimed at improving access to care for behavioral health and medical patients. Ms. Slater is a managing partner of legal education for HLECN, and a trial attorney at Colley Shroyer & Abraham in Columbus, Ohio. Mr. Whaley is director of the safety and security department at GWU Hospital.
References
1. National Institute of Mental Health: Suicide.
2. National Institute on Drug Abuse. Overdose death rates. Revised January 2019.
3. Post by former NIMH Director Thomas Insel: No health without mental health. Sept. 6, 2011.
4. Dhar AK and Barton DA. Depression and the link with cardiovascular disease. Front Psychiatry. 2016 Mar 21;7:33.
5. Lichtman JH et al. Depression and coronary heart disease. Circulation. 2008;118:1768-75.
6. Hare DL et al. Depression and cardiovascular disease: A clinical review. European Heart J. 2014 Jun;35(21):1365-72.
7. “ ‘How many people have to die?’ SC mental health patients endure nightmare transport.” The News & Observer. 2019 May 29.
8. 42 C.F.R. Part 482. Part IV. Department of Health and Human Services. Medicare & Medicaid programs; Hospital conditions of participation; Patients’ rights; Final rule. 2006 Dec 8.