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

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

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 1799.111 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

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.