EMS World

JAN 2019

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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JOURNAL WATCH: EXAMINING THE LATEST IN EMS EVIDENCE 18 JANUARY 2019 | EMSWORLD.com P atients with an altered mental status can be challenging, par- ticularly those experiencing a psychiatric emergency. Not only can they be a potential danger to you and your partner, they typically end up in an ED for a lot longer than necessary. Studies have demonstrated that these patients can tax EMS systems and add to ED overcrowding. One factor that contributes to the diffi- culty of caring for them is that field providers are typically required to transport patients to an ED even if they are sure an ED is not the appropriate destination for their patient. Further, patients who are experiencing psy- chiatric emergencies are often required to be medically cleared by an ED physician to ensure a life-threatening illness is not responsible for their behavior. Additionally, there is a sizable population of psychiatric emergency patients transported involuntarily to protect their safety or the safety of others. What if we were permitted to choose alternative destinations for our behavioral- emergency patients? Would this be better for them, the EMS system, and the hospi- tals? Would it be safe for our patients? UCLA emergency physician Tarak Trivedi, MD, and his coauthors recently published a manu- script that seeks to answer these questions. Just for background, there have been some smaller studies that reported that mistaking a psychiatric emergency for a nonpsychiatric life-threatening illness is rare. There are also reports of emergency medicine experts questioning the value of transporting these patients to EDs for medi- cal clearance. Trivedi's is a retrospective observational study—in other words, that data had already been collected, and there were no interven- tions introduced by the investigators. The data were collected over five years from EMS systems in Alameda County, Calif. The authors were evaluating a protocol that allows EMS providers to transport patients with isolated psychiatric complaints (i.e., no medical complaint or abnormal vital signs) directly to an appropriate psychiatric facility. The authors had two study objectives. First they sought to describe the characteris- tics of patients who received involuntary psy- chiatric holds and compare them to patients transported for other reasons. They defined involuntary-hold patients as those who had at least one involuntary hold during the study period. They also sought to evaluate the safety of the protocol allowing EMS pro- viders to divert these patients to psychiatric emergency services. The authors used "failed diversion" as a proxy measure for safety. A failed diversion was defined as an event in which a patient was initially brought to a psychiatric emergency facility but required transport to an ED within 12 hours. During the study period there were 265,625 unique EMS patients who received care by Alameda County EMS. Almost 10% (26,283) had at least one involuntary hold. When comparing involuntary-hold patients to those who'd never been invol- untarily held for a psychiatric emergency, involuntary-hold patients were more often A California protocol safely allows diversion to psychiatric facilities By Antonio R. Fernandez, PhD, NRP, FAHA What if we were permitted to choose alternative destinations for our behavioral emergency patients? Look for research podcasts based on the topics featured in this column at www.emsworld.com/pcrf-podcasts REVIEWED THIS MONTH Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Authors: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Published in: Ann Emerg Med, 2018 Sep 28. MEDICAL CLEARANCE OF PSYCH PATIENTS Not taking psychiatric patients to the emergency room may be safer and more beneficial for patients.

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