It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.
Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.
A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.
Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.
With thanks to Dr. Anita Everett for her consultation.
Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”