Sunday, November 24, 2013

Virginia's Law On Civil Commitment: 4-6 Hours to find a bed or the dangerous go free

Virginia is a funny state.  They like their guns and they like their civil rights.  Well, not for sex offenders who get to serve life terms in "treatment" facilities after their prison terms are finished, but that's for another day.

If you've been paying attention to the news, you know that former Virginia state senator and gubernatorial  candidate Creigh Deeds was stabbed in the chest and face by his 24 year old son on Tuesday.  After the altercation, the son died of a gun shot wound, at this point his death was believed to be a suicide.  The son was a student at William and Mary College, one of Virginia's top institutions.  If that's not upsetting enough, it seems that the late Gus Deeds was brought to the Emergency Room  by police the day before for a psychiatric evaluation.  Virginia has a law that a bed must be located within  a few hours.  For some reason, possibly because no bed was available in that time frame, Gus Deeds was released.  It was a fatal mistake.  I'd also like to send you to Pete Earley blog post to read his take on the case: Deeds' Stabbing and Suicide Expose Bed Shortage But Will Anyone Care Tomorrow?

In What's Keeping People from Mental Health Help, Jennie Coughlin and Calvin Trice write in 

The process

Tucker said the VSCB looks to about 26 hospitals, as time allows, for patient placement when a psychiatric emergency occurs.
Once there is an emergency, a step-by-step process kicks in. Tucker said that a magistrate can issue an emergency custody order, or an ECO, if someone reports that a person is in crisis. The state of Virginia then requires that the person in crisis be able to talk to someone Tucker called a “pre-admission screener,” or pre-screener for short. The pre-screener comes from the local CSB.
He said that once an order is issued, the pre-screener has four hours to find an institution — with the possibility of a two-hour extension if needed.
“They’ve got to have a specific plan before the magistrate can act,” said David Deering, the executive director of the VCSB.
During that period, only the pre-screener has authority to stop the process.
If the pre-screener determines that the person meets the statutory requirements for commitment, then he or she must find a facility willing to take the person. The magistrate then can issue a temporary detaining order, or a TDO, allowing the person to be committed to the facility.
Once placed, patients may qualify for state payment of up to four days of treatment, if they have no third-party insurance.
The process is more difficult to execute than it used to be since there are fewer available beds, Deering said.
“The number of available site beds has been continuously going down across the commonwealth for year,” he said. “People are getting out of the business, because it’s a difficult and demanding business, and also the revenues to offset the costs are frequently not sufficient. That’s part of why you’re seeing a declining number of beds.”

So regardless of how dangerous someone is, there's a ticking clock to finding a bed somewhere in the state of Virginia.  What's amazing is that they do it most of the time (things have gotten faster since I last worked in an emergency room).  I believes this includes the transportation time from when the magistrate signs, the police find the patient, bring them to the ER, register them to the ER, get them seen, and locate a bed.  It's a lot to cram into 4-6 hours.

This policy is bad for several reasons: first off, many people brought by the police for psychiatric evaluations in our state are let go.  There may be one professional in the ER seeing patients, there may be many patients, there may be a situation that needs to be verified, consultation with other doctors to be had (in Maryland, two doctors must examine the patient to agree on commitment).  often spending a little time talking with the patient, bringing in family, setting up aftercare, letting drugs and alcohol wear off, clarifying if there was a real threat to begin with, getting medical clearance and labs back, a brain scan if needed, administering a medication --- these take a number of hours and sometimes (actually roughly half the time) enough bandaids are put on in the ER to make it safe to send someone home.  But if a time clock is running, there is no time for bandaids and the patient is more likely staying.  Which might not be bad, a 72 hour period to assess, clarify, treat, may be a good starting point and the inpatient unit can always opt to discharge sooner if that time isn't needed.  But more beds will get filled with a running time clock.

The other issue is that there aren't enough beds, so people who may well be dangerous are sometimes let go.  Tragically, this did not go well for the Deeds family.  

I had never heard of the 4-6 hour beat the clock to make a medical decision.  Do they have to do that with medical or surgical patients?   I know, I know, they are all there voluntarily, but actually, that may not be the case if they are refusing care and bleeding to death, or need care but wish to flee an accusation of a crime, came in while unconscious, or are objecting to life-saving care because of the money.  Even med/surg patients may end up being held for hours longer than they'd like.

And to Je Suis, note that Viriginia pays for 4 days of involuntary treatment.  

Okay, if you haven't please already, please do check out Pete Earley's article.