Advancing Emergency Medical Services' (EMS) Response Capability for Behavioral Health Emergencies: Los Angeles County's Performance Improvement Initiative.

INTRODUCTION: Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency's Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders. METHODS: A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE, health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement. RESULTS: The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities' capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport. CONCLUSION: This paper describes a comprehensive performance improvement initiative in LAC-EMSA's 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.

Short-Term Outcomes and Patient Perceptions after Paramedic Non-Transport during the COVID-19 Pandemic.

BACKGROUND: EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. METHODS: This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. RESULTS: Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. CONCLUSION: Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high.