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.


Anonymous said...

I agree that 4-6 hours is too short, but I think some balance needs to be found. I know in NC, patients are sometimes held in the ER for up to a week prior to going to the involuntary treatment facility- during which time they have little to no treatment, privacy, or access to their family members. The answer is clearly more beds all around so that we can strike a better balance between freedom and safety.

Anonymous said...

We should considered the possibility that this young man, with no history of violence, became violent because he desperately, desperately did not want to be incarcerated, and possibly drugged, against his will. And that he killed himself because he saw no other way out. I'm a late middle age lawyer with no history of violence, but I would meet force with force if anybody ever tried to do such a thing to me.

Je Suis said...

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

Well, it's a step in the right direction, I suppose. At least it covers the initial assessment period, so that if the individual is found to not need extended inpatient treatment, no financial harm is done. Except, of course, if that person has their own health insurance, then the 4 days are not covered by the state. There's the ugly spectre of business again.

An interesting thing: some years back, I was involved in an accident with a drunk driver, who subsequently left the scene. Another driver had reported the accident, so I then called to report the person leaving (the EMT's had already arrived and ascertained that he seemed impaired, with a strong odor of alcohol, after which he left). When the police arrived, they were able to identify him based on my description (he was not driving his own vehicle, of course, so the license plate did little good) and the fact that this was the 4th time this year, according to them, that he had done this exact same thing. Long story short, he was arrested, and out on bail the next day. He served no more time that that, less than 24 hours all told. I, on the other hand, had to have surgery that put me out of work and stuck at home for 12 weeks. When I discovered that he was out again (I saw him driving on the same road) I went to the DA's office for answers. I was told that he had done nothing to keep him off the streets, despite his having no driver's license, no insurance, and a history of multiple events of this nature. I stated that he is going to kill someone; I was lucky, but the next time - and there will be one based on his history - someone might not be. The response was that there is nothing that can be done.

So, here's someone that is clearly dangerous, repeats the same dangerous behavior, and has seriously injured someone (as well as committed a felony by leaving the scene of an accident with injuries), but legally nothing can be done about it (believe me, I tried). So why, then, is someone like Gus Deeds deemed so in need of treatment, so dangerous that he must be locked up, while someone like the jackass that caused my injuries allowed to go free to do it again? Is it simply the stigma of a mental illness? After all, both of them exhibited behaviors that seemed dangerous, but only one of them made the news, while the other was free to go on his merry way, drinking and driving to his hearts content. No one wanted him to be locked up for 72 hours for observation, to lose his rights, to face a hearing on whether to be held for an extended period of time, much less medicated or given therapy. Dangerousness, it seems, is in the eye of the beholder, and a very subjective label at best.

Dinah said...

Anon1: I agree, balance, no one should wait in an ER for days.

Anon2:The young man had already been released and was not held against his will. Does the fear of incarceration (be it in a prison for years or being involuntarily treated for a number of days in a hospital) ever excuse trying to kill one's father, or anyone else? But that view, we should understand that everyone who kills a police officer desperately, desperately did not want to go to jail.

Je Suis: I hope the 4 days are covered by the health insurance.
And your story of the drunk driver is one more sickening example of how life is not fair. (I don't mean that in a dismissive way)

Anonymous said...

From what I read there were more than a couple of hospitals in the area which had beds, they just didn't call them. Sounds more like a cya situation here.


Anonymous said...

Also, I think 4-6 hours is plenty of time. It doesn't take a hospital 4-6 hours to treat a patient with an MI or a stroke. If they felt it was so urgent, why didn't they make the time? They would have found the time if it was an MI. Surely they could have called more than two hospitals?


Anonymous said...

See link:


Dinah said...

P-K: I've never worked in Virginia, and it's been years since I've worked in an ER here, but if the system is the same:

Family member goes to magistrate. Magistrate signs order. Start the clock.
Police are called, they go to patient's home, get patient, take him/her to ER.
Register/Triage at ER, vital signs, (I'll assume the patient brought in by police goes to the front of the line, but who knows). Find mental health professional to evaluate. Perhaps offer (? or if violent: Force) medications. Begin calling hospitals. Head nurse is in report. Wait for nurse to call back. Tell the story. Wait for nurse to talk with unit and see if they can manage patient. Oh, did I mention no one will take patient without labs and tox screen (send stat, but still takes time)? Unit calls back, they can't take patient, too high acuity on there unit. Call hospital #2. No beds. Call hospital #3...and the list goes on.

I don't think patients should be kept waiting for days, but with beat-the-clock going from magistrate to decision, the reality is that there will be people who are admitted because you can't give them them time to chill out and then assess them, you have to decide BEFORE you evaluate. It sounds like mistakes can be lethal.

Anonymous said...

Dinah, but why is it when it comes to an MI patient they seem to get a whole lot more done in that 4-6 hours? The MI patient also has to be assessed, they alo have to order multiple tests (labs, ekg, echo, etc), get multiple test results, etc, yet they manage to do it. This comes down to the fact that ERs don't prioritize psychiatric patients, even dangerous ones. They assessed the patient decided he was imminently dangerous and only managed to call two hospitals? I dare say if that is all that could managed in that time frame for an MI patient, people would have been fired.