Policies and procedures for patient transfers from community clinics to emergency departments under the mental health act: Review and policy scan

Physical restraint within the prehospital Emergency Medical Care Environment: A scoping review

Background

Psychomotor agitation and aggressive behaviour (AAB) have the potential to occur in any healthcare setting, including those in which Emergency Medical Services (EMS) operate. This scoping review aimed to examine the available literature on physical restraint of patients within the prehospital setting and to identify guidelines and their effectiveness, safety to patients and health care practitioners and strategies relating to physical restraint when used by EMS.

Methods

We performed our scoping review using the methodological framework described by Arksey and O'Malley augmented by that of Sucharew and Macaluso. Several steps guided the review process: identification of the research question, eligibility criteria, information sources (CINAHL, Medline, Cochrane and Scopus), search, selection and data collection, ethical approval, collation, summarizing and reporting on the results.

Results

The population of interest, in this scoping review was prehospital physically restrained patients, however, there was a reduced research focus on this population in comparison to the larger emergency department.

Conclusion

The limitation of informed consent from incapacitated patients may relate to the lack of prospective real-world research from previous and future studies. Future research should focus on patient management, adverse events, practitioner risk, policy, and education within the prehospital setting.

Physicians' perspectives on processes for emergency mental health transfers from university health clinics to hospitals in Ontario, Canada: a qualitative analysis

BACKGROUND

In Ontario, Canada, there is variability in how students experiencing a mental health crisis are transferred from university health clinics to hospital for emergent psychiatric assessment, particularly regarding police involvement and physical restraint use. We sought to understand existing processes for these transfers, and barriers to and facilitators of change.

METHODS

Between July 2018 and January 2019, we conducted semistructured qualitative interviews by telephone or in person with physicians working at Ontario university health clinics. We developed the interview guide by integrating an extensive literature review, and the expertise of stakeholders and people with lived experience. We analyzed the interview transcripts thematically. Analysis was informed by participant responses to a questionnaire exploring their perspectives about crisis transfer processes. We requested institutional policy and process documents to support analysis and generate a policy summary.

RESULTS

Eleven physicians (9 family physicians and 2 psychiatrists) from 9 university health clinics were interviewed. Ten of the 11 completed questionnaires. Policy and process documents were obtained from 5 clinics. There was variation in processes for emergency mental health transfers and in clinicians' experiences with and beliefs about these processes. Police were commonly involved in transfers from 7 of the 11 clinics, and in nearly all or all transfers from 5 of the 11 clinics. Handcuffs were always or almost always used during transfer at 2 clinics. Three major themes were identified: police involvement and restraint use can cause harm; clinical considerations are used to justify police involvement and restraint use; and pragmatic, nonclinical factors often inform transfer practices.

INTERPRETATION

The involvement of police and use of restraints in crisis mental health transfers to hospital were related to pragmatic, extramedical factors in some university health clinics in Ontario. Exploring existing variability and the factors that sustain potentially harmful practices can facilitate standard implementation of less invasive and traumatizing transfer processes.