Why do we use ambulances to transport medically-stable psychiatric patients from a community hospital to an inpatient psychiatric care or mental health facility?
This questionable practice has troubled me for many years and is again at the front of my mind after an incident where an ambulance in Utah is reported to have rolled after a “psych patient” grabbed the wheel as the vehicle was moving down the highway.
In some states the transfer of psychiatric patients by ambulance is common and it presents real issues for field personnel and EMS managers. About 10 years ago I was the executive director for a hospital-operated ambulance service in a small upper-Midwest city. Our peak ambulance staffing was five units and the state mental health facility (MHF) was three hours away. When either of the local hospitals wanted a psychiatric patient moved to the MHF and the local interfacility service declined to provide care we were called. To complete the transfer our unit was out of service for at least six hours.
Does a psych patient need an ambulance?
The timeout of service was not the concern. Instead, my greatest concerns were the safety of the crew and the appropriateness of using an ambulance.
The patient needed a ride. They did not require oxygen, resuscitation, medications that paramedics carry, bandaging, splinting, or any type of prehospital care. They needed a ride.
Moreover, EMS had no legal authority from the state to detain anyone against their will. (Yes, in a few states EMS has that authority, such as under Florida’s Baker Act.) If the patient changed their mind about going to the MHF and wanted to exit the vehicle on the side of the interstate the right of EMS to do anything except let them out was legally unclear. Patients were not restrained (nor was it appropriate to do so), they were not sedated, and if they were medicated it was with oral medications that they had taken for a long period of time. Again, these were medically-stable patients who needed a ride.
Several times there were difficulties on these transports. As you know the back of an ambulance is a dangerous place, filled with sharp corners, cabinets, objects that can be used as weapons, and minimal opportunity for escape. Medics who attempted to restrain patients who decided to leave the ambulance would get into combat, for which they were not trained. The crew size was insufficient to restrain the patient. Most hospital guidelines call for a minimum of five caregivers to restrain a violent patient. Even a radio call for help might not see five or more responders arrive for 30-60 minutes, if ever.
What are alternatives to ambulance transport?
From the outside, it appeared clear that the local 911 service was the only entity that the hospitals could “bully” into performing unnecessary and probably uncompensated service. I wondered, how did these transfers meet “medical necessity” for payment by Medicare, Medicaid, or other payors?
A retrospective review of the transfers to the MHF showed that some were paid for, most were not. We had some discussions about the hospital assuming responsibility for payment for these transfers.
This led to a series of discussions about the appropriateness of this practice and it was ultimately agreed by the involved hospitals that this was not the best way to handle “psych transfers.” The practice used in other states - transport by law enforcement - was adapted for the hospitals. A sedan with a security barrier to protect the driver, as well as secure seat belts, was procured, and hospital personnel handled the transfers.
A good bit of money was saved. Ambulances remained in service in the community that needed them. Ambulances were used only for psych patients that had medical needs that could be cared for in an ambulance and two or three extra attendants were provided.
Is the scene safe during transport?
Remember that “scene safety” includes the interior of the ambulance as it moves down the road. It is time for the practice of transporting an unrestrained psychiatric patient in standard ambulances with a crew of two to come to an end. The patient should NEVER be allowed to ride in the cab of the ambulance. Another shortcut practice, allowing a psych patient to sit on the bench seat, is dangerous for the patient and the provider and illustrates that there is no medical necessity for the ambulance.
It is time for EMS chiefs and executives to look closely at the clinical, safety, and economic rationale for unnecessary psych patient transports by ambulance and work to devise a better way.
