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

Figures & data

Table 1. Stakeholder representatives to the Behavioral Health Initiative Committee.

County Health Agencies Los Angeles County Department of Health Services - Emergency Medical Services Agency Los Angeles County Department of Mental Health Los Angeles County Department of Public Health EMS Providers and Affiliates California State Firefighters’ Association Los Angeles Ambulance Association Los Angeles County Fire Chiefs’ Association Los Angeles County Fire Department Healthcare Providers, Specialty Societies, and Affiliates American College of Emergency Physicians, California Branch Emergency Nurses Association Exodus Recovery Inc. Mental Health Urgent Care Center (AKA “Psychiatric Urgent Care Center”) Hospital Association of Southern California Los Angeles County Mental Health Commission Los Angeles General Medical Center Psychiatric Emergency Services Southern California Psychiatric Society Law Enforcement Agencies Los Angeles County Police Chiefs’ Association Los Angeles County Sheriff’s Department Los Angeles Police Department Peace Officers’ Association of Los Angeles County Public Representatives Los Angeles County Board of Supervisors Health Deputy National Alliance on Mental Illness Insurance Providers LA Care HealthNet

Table 2. Guiding principles for the Los Angeles County EMS Agency Behavioral Health Initiative Committee.

Behavioral health emergencies are medical emergencies and should be treated as such to the maximal extent possible. Behavioral health emergencies are unique in their potential for agitation or violence, which ideally requires an appropriate co-response from EMS and LE. Behavioral health emergencies are best treated in receiving facilities that are appropriately designed and resourced. The system of pre-hospital care for behavioral health emergencies should be based on best practices.

Figure 1. BHE response process map, current state (2016): law enforcement response.

Figure 2. BHE response process map, current state (2016): EMS response.

Figure 3. BHE response process map, proposed future state.

Table 3. Descriptive summary of Behavioral Health Initiative Committee interventions or milestones.

Intervention or Milestone	Date (Duration)	Description
BHIC convenes	1/2016 − 1/2018 (2 years)	Quarterly committee meetings held with stakeholders (Tables 1 and 2), extensive data gathered to describe current state of 9-1-1 response to BHEs, developed process maps (Figures 1 and 2). Committee analyzed and critiqued current state, proposed recommendations for future state (Figure 3).
Tour PSAPs	10/2016 − 12/2016 (2 months)	BHIC members toured PSAPs, held focused discussion with dispatchers regarding their processes and algorithms for triaging 9-1-1 BHE calls and deploying LE vs. EMS.
Survey of PSAP and LE Agencies	1/2018 − 1/2019 (1 year)	LAC-EMSA conducted countywide survey of PSAPs and LE agencies regarding triage practices for 9-1-1 BHE calls, volume and type of BHEs, identified areas of need for greater resources or support. See online supplemental material.
State advocacy for alternate destination	1/2019 − 1/2020 (1 year)	LAC-EMSA engaged with State agencies to advocate for laws and/or policies to authorize EMS transport to alternate destinations (e.g., PUCC and Sobering Centers).^33
Subcommittee to address BHIC recommendations	3/2019 − 3/2021 (2 years)	LAC-EMSA formed subcommittee to advance BHIC recommendations including: evaluation of EMS field protocols for BHEs, pharmacologic treatment options for BHEs, and investigation of (EMS and LE) co-response models.
Pilot of PUCC destination program	6/2019 − 6/2022 (2 years)	LAC-EMSA approved four EMS provider agencies (fire departments) with appropriate education, training, and supervision to pilot test EMS transport to PUCCs.
Pilot of LAPD dispatch of 9-1-1 SI calls to suicide prevention center	6/2020 − 6/2021 (1 year)	LAPD, with support from LAC-EMSA, initiated a pilot of transferring 9-1-1 calls for SI to the regional suicide prevention center; evaluated feasibility, call volume, and outcomes of calls transferred.
Pilot of EMS and LE co-response for BHEs	6/2020 − 1/2022 (18 months)	LAC-EMSA partnered with Long Beach Police and Fire Department to pilot test co-response of LE and EMS for BHE, incorporated into a training model.
LE naloxone administration	6/2020 − 12/2022 (30 months)	LAC-EMSA provided oversight and medical support for LE agencies across LA county to implement naloxone treatment protocols.
Leave behind naloxone program for EMS	6/2020 − 12/2022 (30 months)	LAC-EMSA developed protocols and training for EMS providers to provide naloxone to third parties (family/caregivers) during field encounters.
Subcommittee on pharmacologic treatment of agitation (olanzapine)	1/2021 − 6/2021 (6 months)	Subcommittee of experts from psychiatry, emergency medicine, and EMS evaluated expansion of pharmacologic treatment options to include olanzapine (second generation antipsychotic), developed relevant treatment protocols and drug reference documents. See Table 4.
Subcommittee on EMS field response protocols for BHEs	1/2021 − 6/2022 (18 months)	Subcommittee of experts from psychiatry, emergency medicine, and EMS/paramedic developed new protocols on the care of the patient with agitation and conducted extensive revision of existing protocols. See Table 4.
9-8-8 implementation	1/2022 − 12/2022 (1 year)	9-8-8 system initiated; lessons learned from LAPD pilot (see above) incorporated into countywide implementation.
EMS clinician education on BHE field response protocols	6/2022 − 12/2022 (6 months)	LAC-EMSA developed and implemented “EMS Update” focused on education of new BHE protocols for agitation, olanzapine, and all revised BHE field treatment protocols.

Abbreviations: BHE: Behavioral health emergency; BHIC: Behavioral health initiative committee; ED: emergency department; EMS: Emergency medical services; LAAPCA: Los Angeles Area Police Chiefs’ Association; LAC: Los Angeles County; LAC-EMSA: Los Angeles County Emergency Medical Services Agency; LAPD: Los Angeles Police Department; LE: Law enforcement; PD: Police department; PSAP: Public safety answering point; SI = suicidal ideation.

Table 4. EMS policies related to behavioral health emergencies for adult and pediatric patients.

Policy Title	Reference	Status	Description
Care of the Patient with Agitation	Ref. No. 1307	New (2022)	Definitions of common behavioral health conditions and symptoms, principles and protocols for assessment, and prioritization of verbal de-escalation techniques.
Flow chart for initial approach to scene safety	Ref. No. 1307.1	New (2022)	Diagrammatic representation of approach to scene safety.
Verbal De-Escalation	Ref. No. 1307.2	New (2022)	Verbal de-escalation strategy and mnemonic.
Common Etiologies of Agitation	Ref. No. 1307.3	New (2022)	Description of common etiologies of agitation, field presentation, and likelihood of success by verbal de-escalation.
Olanzapine Drug Reference	Ref. No. 1317.32	New (2022)	Drug reference and protocol for use of olanzapine (atypical antipsychotic).
Patient Destination: Behavioral / Psychiatric Crisis	Ref. No. 526	New (2019)	Guidelines for the transport of patients with BHEs to the most appropriate facility, including triage criteria for psychiatric urgent care centers. Details paramedic training requirements.
Medical Clearance Criteria Screening Tool for PUCC	Ref. No. 526.1	New (2019)	A series of 20 decision support inclusion/exclusion criteria to determine medical clearance and appropriateness for transport to psychiatric urgent care centers.
Intoxicated (Alcohol) Patient Destination	Ref. No. 528	New (2019)	Guidelines for the transport of patients with alcohol intoxication to the most appropriate facility, including triage criteria for sobering centers.
Medical Clearance Criteria Screening Tool for Sobering Center	Ref. No. 528.1	New (2019)	A series of 21 decision support inclusion/exclusion criteria to determine medical clearance and appropriateness for transport to sobering centers.
Behavioral / Psychiatric Crisis	Ref. No. 1209 1209-P (pediatric)	Revised (2022)	Field medical assessment and treatment protocols for behavioral / psychiatric crises. Revised to include verbal de-escalation, indications for Olanzapine, guidance for alternate destination.
Agitated Delirium	Ref. No. 1208 1208-P (pediatric)	Revised (2022)	Field medical assessment and treatment protocols for agitated delirium. Revised to include verbal de-escalation.
Application of Patient Restraints	Ref. No. 838	Revised (2022)	Guidelines for safe application of restraints. Emphasizes respect and dignity for the patient, verbal de-escalation, least restrictive treatments, appropriate medical monitoring, pharmacologic indications, and best practices in coordination with law enforcement.
Suicide Risk Screening	_______	Pending	Provides guidance on use of evidence- based suicide risk screening tool – awaiting further exploration on implementation strategies.

Note. LA County EMS Agency Pre-Hospital Care Manual (available online at: https://dhs.lacounty.gov/emergency-medical-services-agency/prehospital-care-manual/).

PUCC: psychiatric urgent care centers, which have the capability to evaluate and treat behavioral health emergency patients for up to 24 h.