Engaging emergency medical services to improve postacute management of behavioural health emergency calls: a protocol of a scoping literature review

Abstract

Introduction

The public health crisis of escalating mental health, behavioural and substance-related emergencies has revealed the need to approach these complex events from a health perspective, rather than the traditional criminal justice standpoint. Despite law enforcement officers often being the first responders to emergency calls concerning self or bystander harm, they are not optimally equipped to manage these crises holistically or to connect affected individuals to necessary medical treatment and social support. Paramedics and other emergency medical services (EMS) providers are well positioned to deliver comprehensive medicosocial care during and in the immediate aftermath of these emergencies, moving beyond their traditional role in emergency evaluation, stabilisation and transport to a higher level of care. The role of EMS in bridging this gap and helping shift emphasis to mental and physical health needs in crisis situations has not been examined in prior reviews.

Methods and analysis

In this protocol, we delineate our approach to describing existing EMS programmes that focus specifically on supporting individuals and communities experiencing mental, behavioural and substance-related health crises. The databases to be searched are EBSCO CINAHL, Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline, Ovid PsycINFO and Web of Science Core Collection, with search date limits being from database inception to 14 July 2022. A narrative synthesis will be completed to characterise populations and situations targeted by the programmes, describe programme staffing and composition, detail the interventions and identify collected outcomes.

Ethics and dissemination

All data in the review will be publicly accessible and published previously, so approval by a research ethics board is not needed. Our findings will be published in a peer-reviewed journal and shared with the public.

Trial registration number

https://doi.org/10.17605/OSF.IO/UYV4R

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This protocol conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews 2018 guidelines.

• Well-defined eligibility criteria focus on models of care involving mobile emergency medical services (EMS) and other groups that respond to incoming non-emergency calls for service in behavioural, mental health and substance use-related emergencies.

• Anticipated results include detailed and actionable descriptions of EMS-led programmes supporting people with behavioural, mental health and substance use needs and thereby provide a framework for other agencies seeking to improve the care for these high-risk and high-needs populations.

• Our focus will be limited to response models that use EMS and will not include other first responder models without EMS involvement.

• The anticipated heterogeneity between programmes will likely prevent data synthesis.

Introduction

Mental health, behavioural and substance-related calls comprise 5%–15% of 911 (emergency) call volumes in the USA.¹ These calls are received by regionally designated Public Safety Answering Point dispatchers, who are trained to route the call to local emergency medical, fire and/or law enforcement agencies depending on the nature of the call. Emergency medical services (EMS) are therefore responsible for responding to medical 911 calls as well as for the evaluation, stabilisation, temporising management and transport of patients to a higher level of medical care.² However, not all mental health, behavioural and substance-related calls immediately or solely triage to medical response. If high-acuity medical concerns are not present or immediately apparent to the dispatcher, or if there is concern for safety risk to the caller or others, law enforcement may be the sole first responder to the scene, with the patient stabilised and supported on scene, and ultimately potentially taken to a medical emergency department (ED) or jail afterwards.^{3 4} This raises several concerns. First, because EDs and jails frequently serve as receiving centres for those experiencing behavioural emergencies, individuals may be diverted from the psychiatric care they need. Due to a scarcity of psychiatric inpatient beds, patients with mental health needs are increasingly being ‘boarded’ in EDs, where they can wait for days or weeks to receive psychiatric care.⁵ These individuals often find themselves without treatment and in environments that may exacerbate their symptoms.⁶ Although psychiatric EDs that concentrate solely on treating individuals in crisis exist, these programmes are limited in number and are not always present to receive patients from medical EDs and field transport by law enforcement.⁷ Second, interactions with law enforcement can escalate individuals’ mental health crises and may precipitate volatile and potentially dangerous situations.^8–11

As a result, there is increasing interest in integrating mental and behavioural health expertise into emergency response to such calls.^{12 13} This requires interdisciplinary collaboration, as professionals across multiple disciplines work together to evaluate the patient, stabilise the situation and deliver definitive and specialised care.¹⁴ For example, law enforcement agents can evaluate the scene, ensure the safety of the individual(s) who are the focus of the call and of those around them and provide logistical and operational support to other first responders who can then be cleared to enter the scene.¹⁵ In some agencies, mental health professionals have partnered with law enforcement to provide mental health and social services support during and after such calls.¹⁶ In such coresponse models, mental health providers are typically employed by the law enforcement agency and corespond with law enforcement officers to specific calls.^{17 18} However, neither law enforcement nor mental health professionals have the education, training or experience necessary to evaluate, triage and manage the medical aspects of mental health, behavioural or substance use-related calls. This gap calls for strategic integration of EMS providers into these calls beyond their role in emergency stabilisation and transport. Indeed, EMS involvement with mental health, behavioural and substance use-related response efforts has the potential to place greater emphasis on the mental health aspects of these emergencies and help ensure appropriate triage, management and follow-up of underlying medical and psychiatric conditions.¹⁹

Emerging EMS response models to support individuals experiencing mental health crises have expanded options for receiving facilities beyond the ED or jail, and implemented collaborations among paramedics and mental health professionals to better address the crisis and direct the patient to definitive treatment as opposed to the ED. One of the earliest models is the Crisis Assistance Helping Out On The Streets programme in Eugene, Oregon, which paired a medic (either a nurse or an emergency medical technician (EMT)) and a crisis worker with experience in the mental health field to provide assessment, stabilisation, triage and referral, and transportation to a treatment destination.²⁰ Its pioneering success gave rise to other programmes across the USA. For example, in Wake County, North Carolina, the ‘Alternative Destination’ programme allowed EMS providers to transport patients undergoing mental health crises to a psychiatric facility rather than an ED as long as they met prespecified criteria related to vital signs, functional status and mental status.^{21 22} This programme resulted in a 20% decrease in transports to an ED over a 2-year period.²¹ Similarly, the Grady Health System in Georgia paired EMS staff with a crisis team consisting of a paramedic, a licensed counsellor and a clinical social worker.^{21 23} In combination with an expanded dispatching service that allowed 911 calls to be transferred to the state-wide mental health services hotline, the Grady EMS response programme reduced the number of patients being arrested or restrained while improving treatment and conserving resources over its pilot period.^{21 23} Expanded EMS programmes have been implemented internationally as well. The Mental Health Acute Assessment Team in Western Sydney, Australia, comprised a paramedic and mental health nurse, was able to refer patients to mental health facilities or general practitioners instead of EDs.²⁴ Ultimately, almost 70% of patients received treatment in non-ED settings, while two-thirds of patients were transported to mental health facilities.²⁴ Different EMS response models are currently in operation in Sweden, Canada and Australia.19 21 25 26

Funding and staffing are major barriers to the implementation and sustainability of such programmes.¹⁹ Sustainability may be increased through interagency collaboration and use of existing teams and infrastructures, rather than reliance on a dedicated and de novo assembled team. Better understanding of how interagency EMS collaborations have been implemented and funded to respond to mental health, behavioural and substance use-related calls is critical to improving the care for individuals experiencing these emergencies and their communities. We plan to focus specifically on interagency collaborations as these are most likely to be feasible and sustainable in diverse settings which may lack the resources to establish dedicated coresponse units.

To our knowledge, there has been no systematic assessment of how these programmes are organised, what agencies are involved in the collaboration, what conditions and populations are served, in what settings and communities they are located, how they are funded to ensure sustainability and what the outcomes of these programmes are. There is therefore urgent need to understand how EMS can be effectively and efficiently integrated into the acute and postacute care for people experiencing behavioural, mental health and substance-related emergencies. To address this knowledge gap, we propose a scoping literature review of EMS care models for behavioural, mental health and substance-related emergencies.

The described protocol aims to answer the following questions:

1. What professions and types of agencies, if any, collaborate with EMS services in interagency models of response to mental health, behavioural and substance use calls?

2. How are the programmes structured in terms of team roles and response models, modes of activation and required training?

3. What services are delivered as part of the intervention?

4. In what settings have these interagency models been implemented, focusing specifically on understanding their rurality, population size, income distribution, racial/ethnic distribution and geographic region?

5. What are the funding sources and budgets for these programmes?

6. What are the target populations for these programmes (ie, what are the eligibility criteria for receiving care in the programmes)?

7. What are the outcomes of these programmes, if described?

8. What were the implementation challenges of these programmes and what steps were undertaken to improve sustainability?

9. What are the implications of these programmes on issues of health equity, systemic racism and criminal justice reform?

Methods

Patient and public involvement

No patients or members of the public will be involved in this study, as it is a scoping literature review of EMS programmes supporting individuals experiencing behavioural emergencies.

Eligibility criteria

We will include studies meeting the following inclusion criteria:

• Focus on non-emergency response and/or management of patients with mental health, behavioural health or substance (alcohol, drugs) use-related calls by EMS providers.

• Models of care involve an EMS provider, including EMT, paramedic, community EMT or community paramedic. They may also involve other prehospital and first responder providers, such as law enforcement, social services, mental health professionals and others; engagement of these providers is not required for inclusion.

• Models of care responding to incoming calls for service, whether those are 911 calls or an equivalent non-emergency hotline.

• There will be no restriction on the affiliation of the EMS providers included in the study (ie, we will not restrict analyses to studies of EMS providers within ambulance services only and will include studies where EMS providers are part of fire departments, health systems, public agencies, etc).

• All participant demographics (age, gender, ethnicity, etc).

• All countries of publication.

• Published in English.

• All study designs.

The review described by this protocol is intended to describe the utilisation of EMS, particularly when involved with interagency collaborations, in responding to and managing non-emergent aspects of mental health, behavioural and substance use-related emergency calls. Therefore, any services that use non-mobile groups or do not include EMS providers will be excluded from review. Emergency stabilisation with transport to the ED (ie, 911 calls with transport to the ED) and interfacility transport calls will be excluded. Models of care based on appointments instead of calls by individuals, such as clinical patient referrals, will be excluded. We will further exclude studies that describe EMS providers’ attitudes towards mental health, behavioural health or substance use calls, as well as studies that solely focus on curriculum development or education.

Search methods

The literature was searched by a medical librarian for the concepts of EMS and behavioural health calls. Search strategies were created using a combination of keywords and standardised index terms. Searches were run on 14 July 2022 in EBSCO CINAHL with Full Text (1963+), Ovid Cochrane Central Register of Controlled Trials (1991+), Ovid Embase (1974+), Ovid Medline (1946+ including epub ahead of print, in-process and other non-indexed citations), Ovid PsycINFO (1806+) and Web of Science Core Collection (Science Citation Index Expanded 1975+ and Emerging Sources Citation Index 2015+). After limiting results to English language, a total of 3608 citations were retrieved. Deduplication was performed in Covidence, a web-based tool for reference importation and screening and data extraction, leaving 2660 citations.

We will also include grey literature of agency websites, relevant news articles about EMS programmes and service evaluations by additionally searching the names and locations of EMS programmes identified through screening of scientific literature.

Selection

We will use two reviewers to screen citations for inclusion. Screening will be conducted using Covidence software. Each reviewer will perform an initial round of screening based on titles and abstracts. Conflict will be resolved by a third reviewer. After the first screening phase, each reviewer will then perform a second round of screening using full texts to ensure citations fulfil inclusion criteria. Conflicts will be resolved by a third reviewer. The start date for the study was 19 July 2022, and the planned end date is 1 September 2023.

Data extraction

Data will be extracted from papers using an extraction tool developed for this review using the review questions as a guide. The data extracted will include details regarding the EMS team members, other agencies involved in the response, collaboration status (single team or interagency), call intake process, vehicles taken to the scene, typical response sequence taken, typical calls responded to, scope of coverage, funding sources, gaps in the response system, years since programme establishment, status of programme continuation, any barriers and facilitators to implementations discussed in the study, outcomes presented and discussions of health equity, systemic racism and criminal justice reform as related to the programmes.

Data analysis

The data extracted will describe EMS programmes. We expect that the heterogeneity between programmes and the descriptive nature of extracted programme features and outcomes will preclude ability to conduct data synthesis. A narrative synthesis will be conducted to characterise the programmes in terms of populations and situations targeted by the programmes, programme staffing and composition, interventions, implementation features, collected outcomes and implications for health equity, systemic racism and criminal justice reform in the emergencies responded to by the programmes.

Results

The results will include descriptive summary data on the EMS team members, other agencies involved in the response, collaboration status (single team or interagency), call intake process, vehicles taken to the scene, typical response sequence taken, typical calls responded to, scope of coverage, funding sources, gaps in the response system, years since programme establishment, status of programme continuation, any barriers and facilitators to implementations discussed, outcomes presented and discussions of health equity, systemic racism and criminal justice reform as related to responses. No formal statistical modelling will be performed.

Discussion

Behavioural, mental health and substance use-related emergencies are a rising problem with a need for community-based interdisciplinary solutions. Law enforcement has traditionally been one of the first points of contact in mental health crisis responses. However, new response models are necessary to increase access to medical and social support services for at-risk patients and communities. Though their usual role has been in acute stabilisation of patients and transportation of patients, EMS are in a unique position to provide increasingly efficient, directed care for individuals experiencing mental health crises. Interagency collaborations may be uniquely feasible and sustainable in diverse settings and populations. In this review, we will describe the ways in which EMS can augment existing models of response to mental health, behavioural and substance use-related calls to ensure safe, equitable and person-centred care.

We anticipate that the proposed study will be limited by the high level of heterogeneity between EMS programmes, which would preclude formal data synthesis and meta-analysis. However, the primary objective of our review is to characterise the types of programmes that have been implemented, and that includes appreciation for the wide variation that may exist.

Ethics statements

Patient consent for publication

Not applicable.