transport service; psych transports

[emtmom]

I work for a transport service that frequently transports psych patients. I would like to know how other states and services handle this situation:

In our state, a psych hospital won't admit a pt unless they can evaluate them on the spot. They can't evaluate them if they are full of Haldol. But often, it is not safe for us to transport them unless they are Haldolled. Using physical restraints for a 2 hour transport seems inhumane. Besides, those have been known to break.

If they do not accept the patient, there is no one to transfer care to. The originating facility, usually an ER, argues that the patient has already been medically cleared. Psych facility argues that they can't hold someone unless they are presenting as a threat to themselves or others. (kidnapping/false improisonment).

There are really no protocols to deal with this. It's a catch 22 that we deal with regularly and it always resolves with some wacky, improvised scheme that someone makes up on the spot.

Any advice or experience out there? Thanks so much!

 

[KEVD18]

ive never had a facility refuse a pt because they had been given anti psychotic medication. in my state, the doctor at the receiving facility has to accept the patient before they even leave the sending facility.

when dealing with psych patients, if they need to be restrained, they get restrained. my safety is much more improtant than their comfort.

 

[medicdan]

to echo KEV's point, in MA, in order for an ambulance to transport a psych patient non-emergency, we need to be in possession of a Section 12 form (Pink Sheet). That sheet is signed by the sending ER (or facility)-- by either a Psychiatrist or a Police Officer. If we are transferring from ER to psych ward, they are "pre-admitted" on the referral of the sending shrink. If we feel it's nessecary, the section gives us permission to restrain the patient (or obtain meds from the sending facility).
My expierence has been that Section 12 paperwork is often accompanied by paperwork for a 72-hour involuntary hold, and that the psych eval is completed by the sending facility and if the recieving wants to conduct on of their own, they can wait for the drugs to wear off.


More info here:
http://www.mass.gov/legis/laws/mgl/123-12.htm

 

[JPINFV]

California's psych hold is a "5150" hold (named after its section of state law) is a 72 hour hold for initial evaluation and treatment of psychiatric conditions that cause a patient to be a danger to self, danger to others, or be gravely disabled (unable to care for one's self). The hold can be written by police officers, physicians, or designated health care workers (mobile evaluation teams). The only catch with a 5150 compared to other temporary holds (5250=14 days, temporary conservatorships, etc) is that the original must stay with the patient.

Following medical clearance, the patient is either transported directly to one of the psych wards (some hospitals had psych units for adults, kids, geriatrics, or a combination of the three, if they had a unit at all) OR to a temporary unit ran by the county (Evaluation and Treatment Services (ETS)) who would work to find placement. As such, I've never had a problem with a patient being chemically restrained by the transferring facility.

 

[MSDeltaFlt]

I believe in my state, the care is similar. Once a pt is accepted by a psychiatric unit, they are accepted and cannot refuse them. If they are sedated upon arrival, then they wait until the effects ware off for them to assess them... while the pt is in a room on their campus.

The only difference here is when the pt is a minor. They can only admit the pt with a legal guardian present. They will still accept the pt, but they cannot touch them yet until the legal guardian signs permission.

I've had to wait an hour and a half with a psych minor in the lobby of the psych hospital until the pt's mother showed up. Shoulda made her ride with. Won't make that mistake again.

 

[emtmom]

ninja-ems

Thanks so much for the info. I have heard of 72 hour holds and wish our state would adopt that law. I feel that our state has a lot to learn on this matter.

As for physical restraints, I will use them as needed, but I don't trust them much after seeing a patient bust through them. I am an EMT, not a ninja.

EMTMOM

 

[DBieniek]

Your safety always takes priority over the patient's comfort. Remember, just because they're a psych patient doesn't mean they're a psychotic murderer. Treat each case on an individual basis and apply appropriate restraints when needed. If they're that bad, put them on a backboard (using 30ft strap), and use all three seat belts on the cot. Follow your protocols. Contact medical control when in doubt.

 

[emtmom]

my safety

Thank you Dave, and others. This is all good, encouraging advise.

EMTMOM

 

[DBieniek]

Not a problem, just always make sure you are able to justify whatever restraint you decide to utilize.

 

[Dominion]

I've transported quite a few psych patients working for a private company, each time I've never had much of an issue, alot of times they are runaways/problem teens and such that are primarily rebelling against authority. I tend to let them be and not seem authorative, just the guy that's there to take them from a to b.

I've only had one bad psych patient who tried to jump out of the back of the ambulance while we were doing about 70 down the interstate. He got his hand on one of the handles before we got him back on the stretcher and tied down.

 

[MAC4NH]

I've transported a few over the years. In this state if the person is being transferred involuntarily, you need what is, essentially, a court order. We have commitment forms that must be signed by a judge and 2 psychiatrists as well as a screening document signed by another mental health professional. We do not transport unless the receiving facility agrees to receive the patient.

That being said, the receiving facility can try to refuse the patient if the above forms are not correct. On a few occasions I have had receiving facilities try to refuse patients (for usually dumb reasons like, "you were supposed to be here an hour ago") but the person refusing was always overruled by a superior.

As for physical restraints, we can use straps, cravats, etc on the 911 side for our own safety but if the person is that violent, we always try to get our PD to actually perform the restraint.

In my transport days, if the person needed to be restrained during transport, we used regular locking restraints but only after getting a written order from a psychiatrist which we would attach to our chart.

 

[DBieniek]

Yes, nine times out of ten it's going to be a voluntary and you have absolutely no right to restrain them in that situation.

 

[emtmom]

psych transports

Yes, the adolecent psychs have never been a problem. Had one last night that was a real sweet kid. It's the big fella's that are tearing mattresses in half in the ED that are overwhelming to me. I believe that these should be transported by LO...not ambulance. But our state treats these psychs as "medical" rather than criminal. Then I am really in over my head.

EMTMOM

 

[JPINFV]

^
Just wondering, why did you put medical in quotes but not criminal?

 

[emtmom]

"medical" in quotes

Oh, I just think that it should not be deligated to us medical folks to transport stuff like this. If it takes 3 security guards and 2 doses of haldol to keep a patient from hitting me, I think it should be a LE transport...or at least a LE assisted transport.

Patients can certainly be combative for medical reasons. But I am talking about patients who have been medically cleared and are being transported from an ED to a behavioral facility. I don't think EMS interfacility transportation is appropriate if they are still excessively combative.

Just my thoughts.
EMTMOM

 

[mikeylikesit]

give them a local anesthetic and let them wake up in a white coat. my dad ran a mental health facility for a long time...don't know how you guys do it...but thank you.

 

[mattulance]

Use of restraint

Little off subject , but what % of 5150 pts actually get physically restrained.

 

[JPINFV]

I did a lot of hospital to hospital psych transports and a few scene -> hospital transports. I can count on 1 hand the number of patient's that I've restrained. Sorry, but the 17 y/o goth chick with suicidial ideations doesn't need the leather bracelets.

(refresher note for people not from California. 5150 is a 72 hour hold for initial evaluation and treatment of psychatric disorders that renders a person a danger to self, danger to others, or gravely disabled (unable to care for self)).

 

[VentMedic]

In Florida it is called the Baker Act but is very similar to California's 5150.

We also have the Marchman Act for substance abusers.

Quote from Florida statutes:

A Marchman Act is a means of providing an individual in need of substance abuse services with emergency services and temporary detention for substance abuse evaluation and treatment when required, either on a voluntary or involuntary basis.

 

[Jon]

In my experience, it is a small amount of 302 (the PA code version of 5150) transports that are actually physically restrained. I know that a decent amount of the ones I've seen were chemically sedated, at least at one point in their experience - nothing like Vitamin H. Around here, if a 302 subject is committed outside the hospital, they are often transported by PD or EMS with PD assist (following behind, usually). This is sometimes with the local 911 service, and sometimes with a private that is contracted with Crisis. The 302 subject is then taken to the closest ED, where they are medically cleared and the county Crisis on-call worker comes in to see them. Afterwards, they are transferred by BLS ambulance to whatever inpatient facility is accepting them. At that point, the subject has often been given some form of sedative, either Haldol, Ativan, or something else, by the ED staff to calm them down. sometimes that is all it takes. When the patient is awake and somewhat agitated, the next step is ED staff or Security on a 1:1 with the patient for elopement prevention and patient safety. If the patient is REALLY agitated, or tries to run, they end up in leathers. Of course, they often got out of the leathers later when they calmed down. If restraints were still in use when transport arrived, they were transported restrained.

I spent a year and a half as a part time hospital security officer... we got to do the standbys... We also assisted the ED staff in takedowns/restraints, if medically necessary. Not all the officers were familiar with restraints... so some of us assisted more than others.

As for transporting restrained... Usually the immediate crisis is over, and the patients are calmed down before they get the transport... so often there isn't a need for restraint.



EMTMom... in answer to your question... I had one of those calls ONCE. Pt. was medically cleared and transferred to a facility 20 miles away... due to rush hour traffic, it was a 90-minute ride there. Once we got there, the facitly said that the pt.'s condition on arrival DID NOT match the report they'd gotten from the sending facilty (Pt. was altered and confused, and facility was a non-medical treatment center. I think the facility eventually accepted the patient... but we got to sit around there for an hour while they made up their mind. (To make it more entertaining, one of the other patients @ the facility was my partner's distant relative... so to avoid her seeing him, we hid in the back of the nurses station for the hour).
I had one other one where the sending facilty INSISTED on sealing all the medicla records in an envelope and we weren't allowed to open it... this was cool (as far as my company was concerned), until we got to the receiving facility and the paperwork wasn't correct.

Learning from my experience.... I only EVER trusted the "sealed envelope" routine from a select group of people that I dealt with all the time... and only after speaking with them each time and getting a verbal assurance that the paperwork was completed and enclosed. (This was as good as I could get, because my boss didn't want me opening the envelopes). Otherwise, in PA, the facility has already agreed to accept.. so they get them.