1. Behavioral Health Patients in the ED Dignity – Humanity – Respect - Safety
Rev. 12/5/17
Pre-discussion with EMS and Law Enforcement
Pt to right place, first time
Medical evaluation required?
Transport to Hospital with ED & BHU
Is there a hospital nearby with a BHU and ED?
YES
YES NO NO
Engage in discussions with county EMS (law enforcement, fire department and paramedics) and develop protocols to determine when it is safe to transport the patient directly to an LPS facility where patient has received treatment in the past, or is currently receiving outpatient treatment.
Ask where usually goes for treatment
Transport to Emergency Dept.
Transport
YES
Pt require EMS transport for safety?
Release to family for transport NO

2. Behavioral Health Patients in the ED Dignity – Humanity – Respect - Safety
Arrives at ED via: ambulance, squad car, private auto, or dropped off
Triage for safety & conduct safety huddle. Include law enforcement if in ED
Go to page 3
Is patient volatile? (threat to self or others)
Pt willing to stay for treatment/ admit?
Does patient have decision-making capacity?
YES NO
Begin de-escalation according to hospital policy NO
YES
Begin treatment for psychiatric issue
Consult with patient’s psychiatrist if known
AB1119
Triage and treat according to ESI
Admit or arrange for transfer for voluntary in-patient psychiatric hospitalization
Always presume the patient has capacity until determined otherwise. Patients may have suicidal ideation or be under the influence of a substance and still have capacity.
Engage family in discussion of patient’s discharge plan with patient’s consent.
*Remember that patients with psychiatric issues may qualify as having an Emergency Medical Condition under EMTALA
NO*
Stabilized?
Discharge home
Engage family*
F/U at outpatient psych
YES

3. Behavioral Health Patients in the ED Dignity – Humanity – Respect - Safety
Most behavioral health patients presenting to the ED will NOT require an involuntary 72-hour hold. Consider other options.
From page 2
Does patient have capacity?
Engage assistance from family or significant others
Arrange for sitter
Consider placement on hold for observation
Consider placement on 5150 hold and arrange transfer to an LPS facility
Tarasoff warning indicated? NO
Continue de-escalation attempts
YES
Concern for safety
What are you afraid will happen if patient leaves?
Ask patient why she wants to leave. Attempt to meet need.
Discharge home with family
F/U prn at outpatient clinic
Review other outpatient options (AA, Chemical Dependency)
No concerns
Patient still wants to leave
YES
Admit or arrange for transfer for voluntary in-patient psychiatric hospitalization NO
Begin treatment
Consult with patient’s psychiatrist if known NO
Stabilized?
Discharge home
F/U at outpatient psych clinic
Review other outpatient options
YES

4. Behavioral Health Patients in the ED Dignity – Humanity – Respect - Safety
Detain v. Allow Elopement
Patient lacks capacity and is threat to self or others
Is a trained, competent team available to safely detain the patient?
Is patient an immediate threat to self or others?
Do the benefits of detaining the patient outweigh the risks?
YES
YES
YES NO NO
Notify law enforcement:
Provide description of patient and direction last headed NO
Call a “Code Gray” to detain patient
Safety of the patient and staff is key. When determination of need for detainment is made during the initial assessment, discuss the plan for detainment in the safety huddle. Consider the need of restraints or an initial dose of medication to treat the agitation.
When in doubt, do what is necessary to keep the patient safe. Hospitals are sued for wrongful death, not wrongful life in elopement cases.
Every elopement attempt, regardless of success, should be investigated for process issues and missed opportunities to address the patient’s escalation earlier in the cycle to prevent the patient reaching the point of attempted elopement.