Improving hand offs between police and emergency departments
Police have been described as “street corner psychiatrists.” They are often the community resource that responds at all hours when emergency calls come in for someone in mental health crisis. Police also serve a gatekeeper function in determining what services are required for an individual in crisis.
They are tasked with the important and difficult decision of whether the person experiencing a mental health crisis is directed to the mental health system, or whether they ought to enter the criminal justice system.
Once the decision has been made that the person requires a medical assessment, police services escort and accompany the individual to the emergency department until the transfer to the appropriate health care provider is complete.
Waiting for the person to be assessed can involve lengthy wait times for police, which means that they aren’t able to respond to other calls in the community.
Jodi Younger, clinical director of Psychiatry and Addiction Services at St. Joseph’s Healthcare Hamilton also highlights that having an officer accompany a patient in the emergency department can reinforce stigma and criminalization of the mentally ill. She notes that “the vast majority of people brought in by police in mental health crisis are low risk [of violence] and no different than a patient brought in by a family member or friend.”
Over the past decade, there have been increased efforts nationally to improve the transfer between police and the health care system. However, these efforts are often fragmented. Given this fragmentation, and the different organizations and sectors involved, there are challenges in measuring the extent of police time spent dealing with mental health crises, and the success of these collaborations.
Police apprehensions for mental health
The police decision to apprehend someone experiencing a mental health crisis and order them to undergo a medical assessment involves different legislation in each Canadian province and territory. This is different from the police bringing in someone who has committed a crime for medical clearance, before the person is charged through the criminal justice system.
For example, section 17 of the Ontario Mental Health Act allows police officers to apprehend individuals who are acting in a way that the officer believes may be of harm to themselves or others, or show an inability to care for themselves.
Once an apprehension is made under the Mental Health Act, police are under a legal obligation to transport that person to be examined by a physician. After examination, there are a number of options – including releasing the person back into the community or admitting them to the hospital on a voluntary or involuntary basis for further assessment and care.
Improving the transfer between police & emergency departments
Hospital emergency departments are required to treat all patients according to their level of need.
Many Canadian emergency departments are busy and have long wait times. Patients with less urgent needs often wait for considerable periods of time before being seen by a physician.
The Canadian Triage Acuity Scale (CTAS), developed in 1998 through the Canadian Association of Emergency Physicians, and endorsed by the National Emergency Nurses Affiliation, classifies patients entering the emergency department into five levels of need.
CTAS 1 is the highest level of need for those patients who are severely injured or acutely ill and should be seen immediately. These patients include those who have suffered a cardiac arrest or major trauma. CTAS 5, the lowest level of need, includes patients who have non-urgent medical complaints, but nevertheless require medical care such as stitches or care for a sore throat.
A 2012 study of individuals presenting to Ontario emergency departments with mental illness complaints found that most were scored at a CTAS 3 . While these individuals wait to be seen in the emergency department, so too do the police.
Collaborations between emergency departments & police
The Ontario Provincial Human Services and Justice Coordinating Committee released a report in April 2013 that detailed some of the initiatives taking place in the province to try to reduce emergency department wait times for police officers accompanying people experiencing mental health crises.
An example of one such collaboration is between the Ottawa Police Services and The Ottawa Hospital, which since 2009 has a protocol in place to reduce police wait times.
Donna MacNeil-Charbot, Liaison officer for the Ottawa Police Services with Ottawa-area hospitals said the collaboration was motivated by concerns that “if we’re waiting with a patient at the hospital, we’re not able to serve the community as police officers”.
The collaboration was established after a review of relevant legislation and safety requirements for both the hospital and police. A process was put in place whereby individuals in mental health crisis accompanied by police were flagged as a priority to be seen by emergency department staff. Dr. Guy Hebert, Chief of the Emergency Department at the Civic campus of The Ottawa Hospital, says that they are “prioritized within reason” within the group of patients at their triage level.
Following medical assessment, a decision is made about whether it is safe for the patient, as well as hospital staff, for the police officer to leave the emergency department Then, hospital security takes over monitoring the patient in the emergency department.
Ottawa Police Services are unable to provide data to Healthy Debate on the wait times prior to, and following the collaboration being put in place. However, MacNeil-Charbot says that anecdotally there has been a marked reduction in wait times for police. She highlights that this collaboration has built important good will between the hospital and police in recognizing their shared responsibility to provide services to those in mental health crisis.
Another collaboration highlighted in the 2013 report is between Hamilton Police Services and St. Joseph’s Healthcare Hamilton. This included developing a protocol and form to assess patients’ level of risk jointly between police and hospital staff. If a patient was assessed at medium or low risk, the officer could leave. Since the collaboration began 18 months ago, it has reduced average police wait times in the St. Joseph’s Healthcare emergency department from 125 minutes to 80 minutes. This information is specific to one hospital’s’ emergency department and one police force.
More information is needed
There are many similar collaborations happening across Canada, and while there are some data for specific organizations, there is a lack of information available on their broader impact.
This is in part due to challenges in identifying the scope of problem in the first place – there is no provincial or national information on the number of apprehensions by police under mental health legislation, or on the percentage of police calls that are related to mental health issues.
When information is collected, it is done so by individual police forces. A Canadian Medical Association Journal article noted that in 2011 Toronto Police apprehended 8500 people under the Ontario Mental Health Act. Jim Chu, Chief Constable of the Vancouver Police Service is quoted as saying that apprehensions under the BC Mental Health Act have quadrupled since 2002, which would mean a quadrupling of police bringing patients to the emergency department for these calls.
And, apprehensions are just one aspect of the role police play in responding to people in mental health crisis.
Terry Coleman, retired Moose Jaw Chief of Police and adjunct professor at the University of Regina, says that while “police services have good measurement systems to facilitate collecting how many times they’ve written a ticket or made an arrest, there is far less information available on police interactions with those who have mental illness.”
Experts and advocates suggest that there is an increase in the number of calls to the police when individuals are experiencing a mental health crisis. Some experts have pointed to de-institutionalization, that is the closure of many inpatient psychiatric facilities and beds, as fueling this increase. However, others, like Coleman, note that there has also been a significant growth in the awareness and education of police officers to help them recognize and deal with individuals in mental health crisis.
Promising collaborations, and future challenges
The sense that more police resources are needed to deal with mental illness has led to other formal partnerships between health care system providers and law enforcement.
For example, Alberta Health Services funds a Police and Crisis Team (PACT) which is a mobile crisis team that brings together mental health professionals and police. The team responds to calls when someone is in mental health crisis and in some cases offers an alternative to the emergency department or criminal justice system, by having mental health providers who can connect individuals in crisis with community-based health care resources.
Laurie Beverley, Provincial Executive Director of Addiction and Mental Health for Alberta Health Services states that while “we cannot cite statistics in terms of the impact of programs such as PACT on emergency departments, it stands to reason that if the services are being provided, and linkages are being made with mental health, addiction, social and support services in the community, then there will be a reduction in the use of emergency departments.”
Beverley’s perspective is echoed by many voices within policing. In August 2013, the Canadian Association of Chiefs of Police issued a press release highlighting a growing burden on police in their first response capacity for those in mental health crisis.
It states “police should not be the front line on mental health issues. Lack of funding in the health care system is putting these people on the streets. We need to shift from a point of crisis to preventing the crisis from occurring in the first place.”
However a research article published last week highlights major gaps in research about the effectiveness of mental health crisis intervention teams in reducing violence during confrontations between people in crisis and the police, and in diversions from emergency departments or the justice system towards mental health treatment.
MacNeil-Charbot points out that police officers are on call 24 hours a day, 7 days a week, while crisis teams and community mental health services tend to not work around the clock. “Mental health apprehension and crises happen at all hours of the day and night” she says “and we will still get calls that end up in emergency departments.”