Annals of Medicine: Systems Engineering: The Alerts
By Robert C. Reiser, MD
ER doctors are used to quickly treating extremely time-sensitive diseases. We are good at it. And by using systems engineering we are getting better at it, saving more lives every year with one glaring exception: mental health emergencies like the one that took the life of Virginia State Senator Creigh Deed’s son Gus Deeds’ this past month.
When a patient having a heart attack rolls into the ER, no matter what time of day, a preprogrammed alert page simultaneously goes out to dozens of people. The cardiac catheterization lab personnel are alerted to prepare the cath lab, the CCU staff is alerted to prepare a bed, the attending cardiologist and the fellow and resident cardiology physicians are summoned to the ER to rapidly evaluate and treat the patient. In the ER, our staff are page alerted and they all know their roles, from the IV tech to the pharmacist, the nurses and ER residents, social work and chaplaincy, patient transporters, radiology techs and myriad others. We can reliably get the patient definitive treatment in minutes. Every step of every case is subsequently reviewed to see if opportunities for improvement exist.
In the ER we have stroke alert teams, sepsis alert teams, trauma alert teams, precipitous delivery alert teams and for inpatients, cardiac arrest alert teams, medical emergency alert teams, and behavioral emergency alert teams, and they all operate similarly to the myocardial infarct alert system. Paradoxically, the most time-sensitive disease, cardiac arrest, has no ER alert team. This is because the required personnel and equipment are always in the ER ready and waiting.
Is this intensive marshalling of resources 24 hours a day expensive? Of course it is. Would anyone having a heart attack want access to this system constrained by cost or law? Not likely.
Most mental health emergencies are the opposite of time-sensitive diseases. They take time and patience to evaluate and to treat. Many times family or authorities will need to be contacted to provide independent information on the patient’s mental state and previous treatments and events. But the Commonwealth of Virginia has by statute and frugality turned the evaluation and disposition of behavioral emergencies into a frantic struggle against the clock, sometimes with tragic outcomes. Here how the system works, and doesn’t.
Emergency Custody Orders (ECO’s) and Temporary Detention Orders (TDO’s)
By statute, any citizen of the Commonwealth can petition a local magistrate to order another person to be taken into emergency custody for evaluation of suspected incapacitating mental illness. Magistrates replaced Justices of the Peace in Virginia in 1974 and they function in a very similar way and with similar levels of training. Here is how the statute defines incapacitating mental illness:
“There exists a substantial likelihood that, as a result of mental illness, the person will, in the near future,
(a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm, or
(b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs,
(ii) is in need of hospitalization or treatment, and
(iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.”
If the magistrate issues an ECO, the statute then stipulates:
“Any person for whom an emergency custody order is issued shall be taken into custody and transported to a convenient location to be evaluated to determine whether the person meets the criteria for temporary detention.”
There are many variations on how and where this can happen, but most commonly the police are called to arrest the patient and transport him or her to the nearest ER.
Interestingly, although these evaluations are almost all done in hospital ERs, there is little to no role for M.D.s in this process. The statute calls for evaluations by community services board (CSB) staff only, and only a community services board member can release a patient from an ECO before it expires. In the words of the statute:
“The evaluation shall be made by a person designated by the community services board who is skilled in the diagnosis and treatment of mental illness and who has completed a certification program approved by the Department.”
Once the ECO is issued by the magistrate the clock starts ticking even if the patient isn’t yet in custody or even found. The ECO expires after four hours, although a one-time, two-hour extension can be sought. The police can always initiate an ECO on their own without consultation with a magistrate, but the same four- to six-hour expiration applies.
Within that four-hour window one of three things can happen. The patient can be evaluated by the CSB and released if found to be mentally stable and safe. Alternatively, the CSB worker can recommend to the magistrate that the patient be held for up to 48 hours against their will for treatment and stabilization. In that case the magistrate can issue a temporary detention order (TDO). The third alternative is that the ECO can expire while the evaluation is still ongoing and then the patient cannot be legally held, no matter their mental state.
In order to issue a TDO the magistrate has to designate the hospital facility that the patient is going to be confined to. And therein lies the rub. If no available and suitable psychiatric hospital bed within the state of Virginia can be found by the CSB worker within the four-hour window, then a TDO cannot be issued and the patient must be released, regardless of their mental condition. This appears to be what happened to Gus Deeds.
Over the past five years Virginia has reduced funding for mental health by 9 percent or 39 million dollars, resulting in a loss of over 380 psychiatric hospital beds. Demand for the remaining five thousand beds is high and the CSB workers working under the ticking clock must call all over the state to try and find an accepting facility for the TDO, before the ECO expires. About once a day on average in Virginia someone is released from an ECO/TDO for lack of finding a bed before the ECO expires. The results are predictable.
CSB workers do this difficult, thankless work 24 hours a day, in the face of ever-diminishing funding and the regulatory noose of the arbitrary four-hour resolution requirement. Meanwhile the Seung Hui Chos and the Gus Deeds fall through the holes in the statute and system.
After the Virginia Tech mass shooting in 2007 a special review panel convened by the Governor made explicit recommendations about ways to amend the Virginia ECO/TDO statutes in order to better serve the patients and the population. The first was to extend the ECO period, effectively doubling it. The second was to allow Emergency Medicine Physicians to do the ECO/TDO screening when CSB workers were not easily available. The third was to expand the number of mental health beds available for TDO patients. To date none of these simple fixes has been done.
We have enough time-sensitive diseases and alert systems in the ER already. We need to slow down the process of evaluating mentally ill patients and give them the thoughtful consideration that they deserve and the resources they need to heal. The Governor’s review panel got it right. Now the legislature has to follow through.