Dr. Downey is associate professor of Health Services/Public Administration at Roosevelt University in Chicago, Illinois. Dr. Zun is chairman and professor in the Department of Emergency Medicine at Finch University/Chicago Medical School and chairman in the Department of Emergency Medicine at Mount Sinai Hospital in Chicago. Ms. Burke is a clerk and clinical research coordinator in the Department of Emergency Medicine at the Rosalind Franklin University of Medicine and Science at Chicago Medical School.

Disclosures: Dr. Downey and Ms. Burke report no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Zun is a consultant to Alexza Pharma and on the speaker’s bureau of sanofi-aventis.

Please direct all correspondence to: La Vonne Downey, PhD, Roosevelt University, School of Policy Studies, 430 Michigan Ave, Chicago, IL 60605; Tel: 847-360-1003; E-mail: Ldowney@roosevelt.edu.


 

Abstract

Objective: The purpose of the study was to determine if there is a difference in the type of psychiatric patient transported via emergency medical service (EMS) as compared to police or walk in. The secondary purpose was to determine if staff was injured during EMS transport. The hypothesis was to determine if there is a significant difference between patients transported by EMS as compared to those who were transported by other means.

Methods: This study was a retrospective emergency department (ED) chart and EMS-run review performed in an urban community teaching hospital with 45,000 annual emergency department visits. Demographics, history and physical examination, patient and staff injuries, and interventions were reviewed. The participants were patients who entered the ED with a psychiatric diagnosis. Patients who were seen with other complaints were excluded. The data analysis included descriptive, frequencies, and analysis of variance.

Results: Three hundred patients were evaluated. Analysis of patients transported by EMS versus police, walk-ins, or those brought in by family or other means demonstrated significant difference in regular doctor, regular psychiatrist, drug and use, patients restrained, alcohol level, marital status, disposition, age ,and admitting diagnosis using a significance level of <.05. There was no significant difference between transport means and urine drug test, type of restraint, violent intent, gender, ethnicity, insurance, cost, or throughput.

Conclusion: This study found that the EMS system was more frequently used to transport intoxicated patients, who do not have a regular psychiatrist, have an admitting diagnosis of drug use, and are later discharged from the emergency department. The study did not find, due to lack of documentation, physical harm to police and EMS personal.


Focus Points

• There is a difference in the types of patients brought in by police, emergency medical service, or family members or those who walk in on their own accord.
• The knowledge of these differences can help assist the emergency department (ED) staff in their treatment plan for those patients.
• The knowledge of the difference in psychiatric patients who present to the ED can be used to train ED staff and based on further studies help to develop treatment protocols.

 

Introduction

Patients with psychiatric complaints frequently present to the emergency department (ED) via various means. Many of these psychiatric patients exhibit agitation and violent behavior.1 The number of psychiatric patients transported by emergency medical service (EMS) within the United States in not known. However, one study2 estimates 10% to 15% of EMS calls were for psychiatric patients. Grange and Corbett3 showed that EMS providers are exposed to violent behavior when performing their jobs at a rate of 8%, with 50% of the violent behavior directed against pre-hospital personal. Trinalli4 found that the potential for injury to prehospital providers from violent patients is widespread and at present there is no mechanism for identifying violent patients.

Fire or police personnel bring many psychiatric patients into the ED. These personnel may use means to control patients’ behavior during transportation, including handcuffs. Many EMS systems have standing orders to apply restraints to patients. The National Association of EMS physician prescribes the proper means to restrain patients.5 Cheney and colleagues6 demonstrated compliance with protocols for psychiatric transports has been poor even though EMS providers had a high level of concern for patient safety.

The range of injuries was studied by the National Association of EMS Physicians and National Association of State EMS directors in a 2002 report.7 Patients accounted for 89% of violent behavior, including verbal (20%), physical (48%), and both verbal and physical (30%) assaults.3,5 Factors that were found to predict violence were the presence of police and psychiatric disorders.3,8-10

The purpose of this study was to determine if there is any difference in the type of patients presenting to the ED with psychiatric complaints who are brought by police, fire department, family, walk-in, or other. The hypothesis was that patients transported by EMS were significantly different than those transported by other means. The secondary purpose was to determine whether the EMS patient or staff were injured during the transportation process.

 

Methods

This was a retrospective chart review of a random sample of psychiatric patients transported by fire, police, family, walk-in, or other during 1 year at a level-one adult and pediatric ED that serves 45,000 annually. Any patient with a psychiatric diagnosis in the ED diagnosed by the emergency physician was included in the study. Psychiatric complaints for inclusion are those noted in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.11 The diagnoses may include the following presenting complaints: psychiatric illness, altered mental status, depression, psychosis, bizarre or inappropriate behavior, violence, agitation, substance abuse, and suicidal or homicidal ideation. The psychiatric diagnosis must be the first or second provisional diagnosis on the ED chart. Those patients who present with other complaints or from inter-hospital transfers were excluded. Patient identifiers were removed from all charts. Patients were selected from a 1-year period. They were then randomizated by enrolling every fourth patient in the study with each month during the 1-year time period.

The ED charts and paramedic run sheet were used as a primary source of data. Basic demographic data was collected, including age, gender, race, time of day, time of week, and transport mechanism. Any treatment or intervention that the patient received, including oxygen, intravenous fluids, drug administration, or police intervention and/or restraints was documented. Hospital charges were noted. Injuries to self, staff, or family were also recorded, if documented.

An analysis using the Statistical Package for Social Sciences was used to determine if there were any significant relationships between the following: treatment; restraints; patient presentation; treatments during transportation; and injuries to patient, staff, or family as it relates to differences in transportation. This study was Institutional Review Board approved.

 

Results

Three hundred patients were enrolled in the study. The majority were evaluated: 102 walk-ins, 66 from EMS, 82 from police, 36 brought by family, and 14 by private ambulance. The breakdown of patients transported by EMS or police was as follows: male (51.6%), mean age of 41.7 years, single (77.3%), African American (71.2%), without a regular doctor (36.4%) or regular psychiatrist (13.6%), admitted with a diagnosis of drug use (42.4%), restrained (68.2%), with a positive alcohol level (42.4%), and discharged home (47.0%). The mean charges were $6,304, and the average time that patients spent in the ED was 506 minutes. See Tables 1–6 for more specific breakdowns.

Their payment sources varied with 54% having Medicaid and 26% being self-pay. Thirty percent of those that were self-pay walked in and the remaining seventy percent of self-pay were brought in by the fire or police departments. The majority of patients had some type of federal or state coverage such as Medicaid, Medicare, and/or the state Comprehensive Health Insurance Plan (specifically to the state of Illinois). Patients with insurance were more likely to walk in (38%), with 20% being brought by the fire department and 34% by the police.

Patients with differing diagnoses came by different means. Those patients with affective psychosis, which made up 38% of all patients, were brought in by themselves (44%), the police (26%), fire department (15%), or family (14%). Patients with schizophrenic disorders were brought in by police (50%), themselves (31%), or family members (9%). Two admitting diagnosis, alcohol dependency syndrome and nondependent abuse of drugs, were most likely brought by the fire department followed by the police; very few were walk-ins or brought by family members. The fire department also brought in 48% of those who tested positive for alcohol. The remaining patients who tested positive for alcohol either walked in or were brought by the police. Restrained patients were more likely to be brought in by the police (43%), followed by the fire department (22%) and themselves (22%).

Analysis of patients transported by EMS versus police or walk-ins demonstrated significant difference in the following: regular doctor, regular psychiatrist, drug use, patients restrained, alcohol level, marital status, disposition, age, and admitting diagnosis using a significance level of <.05. Due to the mixture of continuous and dichotomous variables, an analysis of variance was used to determine what, if any, significant differences occurred between those patients who arrived via EMS, police, family, or walk-in. There was a significant difference between how a patient was brought to the ED and principle diagnosis F=5.32 P=.000, having a regular doctor F=6.23 P=.000, having a regular psychiatrist F=4.49, P=.01, alcohol levels F= 4.89 P=.000, admitted illicit drug use F=2.69 P=.02, age F=2.95 P=.013, marital status F=3.18 P=.008, disposition from the ED F=7.47 P=.000, and behavioral restraints used F=4.55, P=.001. There was no significant difference between transport means and urine drug test, type of restraint, violent intent, gender, ethnicity, insurance, cost, or throughput. [See Tables 7–11, which can be found after the references.]11

 

Discussion

This study found that there is a difference in the type of psychiatric patient transported via EMS as compared to those brought in by police, family, or themselves. Patients transported by EMS were more likely to not have a regular doctor or psychiatrist, be single, be diagnosed as schizophrenics, have drug and alcohol dependency issues, need behavioral or chemical restraints, and be self pay. Grange and colleagues3 found that patients brought by EMS and police were not the majority of psychiatric patients that presented to the ED. They were different than the majority who walk in or are brought by family members. They found that these patients were more likely to have a comorbid substance use diagnosis which could impact the need for restraints.

This difference may help explain the studies that have demonstrated the high rate of injury of patients transported by EMS personnel. Tintanilli4 found that 67% of emergency medical technicians were injured transporting violent patients. Cheney and colleagues6 found an association between EMS injury and prior history of psychiatric illness. Unfortunately, due to lack of documentation, this study did not find physical harm to police and EMS personal.

This study, however did find that patients who needed restraint and drug or alcohol intoxication were more often transported by EMS. Since these findings are based on only 300 subjects, it would be inaccurate to extrapolate outward to say that all patients brought in by EMS or police present differently from other patients. These preliminary findings could lead to a refinement in the data collection and form the basis for more definitive studies. A larger patient base study would provide more robust information of different populations. A prospective study of psychiatric patients could be valuable to better understand which are using the EMS system and why this means of transportation is chosen. It would be interesting to examine different EMS systems to determine whether reasons for transport and use of restraint vary by location. The findings could have significant ramifications for EMS planning and training. National EMS physicians, in their position statement on patient restraint, describe the need for protocols that address the indications for restraints and the type of patient restraint.5 Cheney and colleagues10 found similar results where 71% of restrained patients were alcohol or drug intoxicated. These findings could also have implications for training and alerting ED staff that psychiatric patients brought in by EMS or police present differently than the majority of psychiatric patients that are walk-ins or are brought by family members.

 

Limitations

This study was limited in that the research was performed by one institution in an inner city emergency department. Since the study was retrospective, it was difficult to assess some of the details that would aid in understanding the reasons some patients come via EMS versus other means. It is uncertain why it was difficult to assess the number of injuries secondary to transporting patients in this study. The problem could be related to the low number of injuries, non-reporting of injuries, or retrospective nature of the study.

 

Conclusion

This study found that the EMS system is frequently used to transport intoxicated patients who do not have a regular psychiatrist, have an admitting diagnosis of drug use, and are later discharged from the ED. These findings could be used to alert ED staff that the psychiatric patient brought in by EMS or police present differently than the majority of psychiatric patients who walk in or are brought by family members. This information could be used further to develop a treatment protocol to assist the ED staff addressing the needs of these patients.  PP

 

References

1.    Kunen S, Niederhauser R, Smith PO, Morris JA, Marx BD. Race disparities in psychiatric rates in emergency departments. J Consult Clin Psychol. 2005;73(1):116-126.
2.    Pajonk FG, Schmitt P, Biedler A, et. al. Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings. Gen Hosp Psychiatry. 2008;30(4):360-366.
3.    Grange J, Corbett, S. Violence against emergency medical service personnel. Prehosp Emerg Care. 2002;6(2):186-90.
4.    Tintinalli J. Violent patients and the prehospital providers. Ann Emerg Med. 1993;22(8):1276-1279.
5.    The National Association of EMS physicians policy statement. Available at: www.naemsp.org/pdef/restraints.pdf. Accessed June 29 2010.
6.    Cheney P Haddock T, Sanchez L. Safety and compliance with an emergency medical service direct psychiatric center transport protocols. Am J Emerg Med. 2008; 26(7):750-756.
7.    The National Association of EMS Physicians and National Association of State EMS directors in their 2002 report. Available at: www.naemsp.org/pdef/restraints.pdf. Accessed June 29 2010.
8.    Flannery R. Precipitants to psychiatric patient assaults: review of findings 2004-2006 with implications for the EMS and other health care providers. Int J Emerg Ment Health. 2007;9(1):5-11.
9.    Sankaranaraynan J, Puumala S. Epidemiology and characteristics of emergency department visits by US adults with psychiatric disorders and antipsychotic mention from 2000-2004. Curr Med Res Opin. 2007;23(6):1375-1385.
10.   Cheney PR, Gossett L, Fullerton-Gleason L, Weiss SJ, Ernst AA, Sklar D. Relationship of restraint use, patient injury, and assauls on EMS personnel. Prehosp Emerg Care. 2006;10(2):207-212.
11.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.