Things that might make the ER situation better

One of the things that I get asked most often is “how do you decrease the wait time in the ER and increase the likelihood that a person you bring in will receive some kind of care or be admitted?” I have no unique answers to this problem but have kept track over the past couple of years of all the things that people say have helped—here they are:

1. Identify the problem at a management level. It’s no good if each individual officer keeps talking to each individual nurse/MD. It’s a systems problem not an individual problem. You need a systems approach. Make sure that ER management staff are aware that this is an issue for your organization.

2. Identify one particular police officer and one member of the hospital staff to head up the discussions. It’s no good for “the shift commander” to deal with “the charge nurse” when trying to set policy. Best results are obtained when specific individuals are identified—and senior management personnel are most effective.

3. Make sure you have all the players around the table. If the ER is having a problem with the psychiatry floor, working only with the ER will not solve the problem.

4. Have data. Saying “it’s too slow” won’t get you anywhere. You need, “In March 2003, the average wait was 4.3 hours for a total time expenditure amounting to….”

5. Have data. Look at the outcomes of cases. If only a minority of the people who you take to the ER are getting treated or admitted, you are barking up the wrong tree. You need a different strategy. It means that you and the hospital people have a very different idea of what the mental health act. Work through the differences, but in the end, remember that the hospital has the upper hand.

6. Talk their language. The best ways to do this are:

7. Get someone from the health care world on your side. Let’s face it—police prefer to talk to and believe police people and medical people prefer to talk to/believe medical people. If you are considering taking a patient to the ER, see if there is some way to get them pre-screened by a crisis team worker, someone from a mental health clinic, their case worker—whoever. A physician is more likely to believe someone is acutely suicidal if a mental health worker says it than if a police officer says it. (Before you get all huffy about this, think: if you wanted advice about Criminal law, would you believe an MD or a police officer?)

8. Locate or agitate for the development of a place/agency where you can take people who are clearly in need of mental health care but not certifiable under your law. The best solution to the ER problem is stay out of the ER as much as possible and that means teaming up with someone else. Look at the available models for police/mental health liaison.

9. Make sure police officers REALLY understand mental health law. In most places, the MHA is very restrictive and medical personnel can do nothing without consent. Believe it or not, they don’t turn people away because they don’t care or just to annoy you.

10. If you are going to have training about the MHA, have a local psychiatrist do it. You’ll get their viewpoint—and an opportunity to get the parties in the same room at the same time.

11. Accept that sometimes the docs actually know what they are doing. Case in point: the worst thing you can do for a chronic self-abuser/parasuicidal person is admit them to hospital. It makes them more, not less, likely to do it again. Sound counter-intuitive? Indeed. But it is true. The docs are doing the right thing. It would be wrong for them to admit someone to hospital because they are taking up your time. What’s the answer? I don’t know. But think about it….

12. Aim for consistency among officers in how they deal with the ER. If you are not consistent, they will not be consistent.

13. If you develop written agreements (and everything should be in writing), have police carry a copy with them because you can be pretty sure no one in the hospital will know anything about it when the moment of conflict arises. Or find out where they keep it in the ER. (For one type of dealings I had with the police, they could never find the appropriate files for after hours incidents, so I learned where they kept them and was able to say “it’s in the third file drawer outside Debbie’s office on the second floor, filed under….”

14. Try to develop an understanding about transmittal of information. There is not likely to be agreement about this because the law is against you. But have your (legal) people meet with their (legal) people and see if you can make any headway. Again, putting it in writing is a good idea. If a police officer arrives in the ER looking for information and can produce a document signed by the hospital lawyer that says it OK under Mental Health law and professional regulation to provide the following bits of information, it just might help. (Keep in mind again that health care people do not generally withhold information for the sole purpose of making your life miserable. They are bound by restrictive laws and are subjects to complaints. For most professions, breach of confidentiality is a HUGE source of complaints and disciplinary action. You do not have the right to expect health care providers to break the law. If the laws stink—and they do—it is not the fault of the individual practitioner and he/she cannot change it.)

15. Consider alternatives: if there is no way that wait times can be improved. Talk about using hospital security people, or billing them for your time (that will get their attention)

16. Heads up—many ER’s and psychiatry wards appreciate a phone call ahead of time from dispatch letting them know that are you are going to arrive with someone for them to assess.

The moral of the story…

This is a systems problem that is bigger than any individual police service and any individual ER. Going head to head with the hospital is a no-win proposition. You have to define the problem as a common problem, not as a problem for you. Saying “you guys in the ER are driving us nuts,” no matter how nicely, is not likely to be as effective as trying to make the hospital realize that, like them, the police are responsible for the health and safety of a specific community. And like the hospital system police often find themselves overwhelmed with demands for service. So a 'what can we do to help you' approach often works well.

There are no cures. You just try to make it better. (Actual data is helpful here too. It can be hard to notice that the wait time has gone from 4.3 to 2.5 hours because you want it to go to 15 minutes. But…..)

A final thought from Cst. Scott Maywood of the Toronto Police, who has been in this business as long as anyone and who has wrestled with his share of ER’s:

“When there's a delay, look around you. If the waiting room is full and all the Doctors are covered in blood, then there's a good chance that the physically healthy emotionally disturbed person in the custody of trained and fully equipped Officers is not going to be seen in a hurry. But remember, we work in a profession where it could very well be you that's being brought in.”

Back to the top