Annals of Medicine: Systems Engineering: The Alerts


By Robert C. Reiser, MD

Heart attack!

Brain attack!



Cardiac arrest!

Respiratory failure!

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.


  1. As a part-time emergency mental health clinician, ED physicians typically tend to hand over mental health cases because of the time involvement, subject matter, and quite frankly – a distaste for the mental health population. The belief that mental illness is a pseudoscience is still quite common among MD’s & PA’s and they are quick to, rightly, point out that we don’t have reliable tests that show a direct cause/effect relationship to emotional, behavioral, and affective patterns. We haven’t reduced mental health to a simple test, a scan, or a pill/procedure to fix it and so most time-pressed MD’s tend to dedicate their efforts to where they feel most effective, treating medical patients.

    One answer- bringing psychiatrists into the ED- is so far fetched that it is nearly laughable. Psychiatrists are aging out of practice at a rate faster than any other specialty and because of the stigmatization of mental illness that is pervasive in medical schools and the fact that the pay is relatively lousy (compared to a cardio-thoracic surgeon, or an anesthesiologist, or any other specialty) that med schools aren’t producing enough of them to keep up with the demand. This also crunches the “available and appropriate bed” quandary because some units rely on swing shift and contract psychiatrists to care for their patients. Meanwhile, the mental health professionals on staff or from the CSB’s have no interest in becoming psychiatrists because of a century old division in the mental health profession stemming from parts of psychiatry seeming countertherapeutic to treating professionals.

    My understanding was that CSB’s became the only entities to evaluate ECO’s and obtain TDO’s was to reduce hospital systems lining their own pockets- TDO’ing patients to their own units for increased billing. An impartial, 3rd party assessor from the CSB can determine appropriateness for hospitalization without an economic benefit or loss- without a bottom line to worry about, without being compromised in making decisions that could effect their already shoestring budgets. In cases where the CSB has to travel (like the case in Bath County with Creigh & Gus Deeds), if a CSB person is not available, why not allow hospitals the leeway to bring in a mental health provider in the area to do a third party evaluation? Or, if that’s not an option, why not allow the hospital’s emergency mental health staff to obtain the TDO with the understanding that they cannot TDO a patient to their own unit?

    There’s no question that:
    a) every hospital should have an emergency mental health staff, 24/7, 365, and they should pay them better. This is a soapbox issue, but when a doctor is treating an issue of life or death, his or hear earning potential for a year of work is (sometimes) well into the six figure range. A licensed mental health professional who has 4 years of undergrad, 60 credit hours of Master’s degree work (2-3 years in most cases) 4,000 hours of supervised residency (2-3 more years) and who passes a national exam won’t see six figures if they added up 2-3 years of combined earnings. The fact is, emergency mental health clinicians are the specialists that get called in to consult on cases where medical teams want a recommendation for what to do with a patient.
    b) An ECO clock should not start until the patient has been delivered to a mental health professional. Not dropped off at the ED door, not in the ED bay, but the 4 hours starts when the mental health consult starts
    c) ECO’s should be easier to obtain. If I have a patient in a bay who says they intend to kill themselves and “there’s nothing you can do about it” my recourse is to go back to my office, call a magistrate, tell that person who is not a mental health professional the patient’s mental health history, their diagnosis, the current symptoms of their diagnosis(/es) that the patient is currently exhibiting, and then tell them why I believe they are a risk to themselves or others. If that magistrate is busy when I call, I wait. Once the magistrate gives a verbal, I still have to wait for a fax from them that comes to our ED and the security team serves the papers. The turnaround time for obtaining an ECO can be as long as an hour on busy nights and until the security staff has that piece of paper in their hands…that patient can walk right out of the emergency department and do whatever they please. We have no legal right to hold them.
    d) ECO’s and TDO’s should be able to be extended
    e) Mental health professionals should have more discretion as to where they TDO a person. Right now, you can’t obtain a TDO without an admitting facility because the detention order mandates that the patient stays at a certain place for a certain amount of time until a hearing can take place. Why not, in cases of “no appropriate or admitting beds” allow CSB prescreeners to TDO patients to a hospital floor, an ICU unit with a sitter, or even to remain in the bay of the ED UNTIL such a time that an appropriate or admitting bed clears up. In less than perfect circumstances, I have asked ED physicians to allow voluntary admission patients to stay in the ED overnight until a psychiatric unit was able to discharge a patient in the morning (making room for my patient). Yes, ED’s are busy and crowded…but in the “lesser of two evils” comparison, taking up a bed and keeping people safe will always win. I might add that on the night that I talked my ED doc into allowing a patient to stay overnight, I had literally called every admitting facility in Virginia that has a unit for children and adolescents and EVERYONE was full or claimed to be full.
    f) Admitting units need to fess up when they have an open bed or the ability to have an open bed. There are times when units will say they are full to mental health professionals out of the area because they want to save that last bed or two for their hospital, their unit, or a patient that might come in. One of the ideas that is getting kicked around currently is the idea of a statewide registry of psychiatric inpatient units and their respective censuses. Wouldn’t it be great if we could log on to a secured website and see who has beds?

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