EMPS

Emergency Certificate

TrainingDepartment of Children and

Families

EMPS Emergency CertificateLegislation

House Bill No. 5244

Be it enacted by the Senate and House of Representatives in General Assembly convened:

1 Section. Section 17a-78 of the general statutes is amended by adding subsection (f) as follows (Effective October 1, 2010):

(f) Any clinical social worker licensed under chapter 383b, advanced practice registered nurse licensed under chapter 378 or professional counselor licensed under chapter 383c who has (1) received a minimum of eight hours of specialized training in the conduct of direct evaluations as a member of any emergency mobile psychiatric services team under contract with the Department of Children and Families, and (2) reasonable cause to believe, based on a direct evaluation of a child, that such child (A) has psychiatric disabilities, (B) is dangerous to himself or others or gravely disabled, and (C) is in need of immediate care and treatment may issue an emergency certificate that requires the hospitalization of such child for a psychiatric and medical evaluation. Such child shall be evaluated not later than twenty-four hours after the issuance of the emergency certificate and shall not be held for more than seventy-two hours pursuant to such certificate unless committed pursuant to section 17a-77. The Commissioner of Children and Families shall collect and maintain statistical and demographic information pertaining to emergency certificates issued under this subsection.

(See Handout)

Purpose of EMPS

Emergency Certificate

Clinical tool for emergency situations

• When current intervention is inadequate for managing the risk/ substantial possible risk of a child with a “psychiatric disability.”

• Allows trained EMPS LPC’s, APRN’s and LCSW’s to order a child to an emergency department for further evaluation

• May be used when caretakers unable or unwilling to safely transport a youth with a psychiatric disability and substantial risk to self or others or who is gravely disabled to an emergency department for further evaluation.

Anticipated to be used rarely and only as a last resort ……

PER*Police

request evaluation

PEER Psychologist

requests evaluation

EC

ACT, Crisis, Jail

Diversion

LCSW;s and APRN’s

(DMHAS)

EMPS ECEMPS LCSW’s, APRN’s, LPC’s)

(DCF)

Transport to ED

Evaluation within 24 hours

3 days maximum hold

“Reasonable cause to believe”

Person has psychiatric disability

Danger to self or other, or

Grave disability, and

In need of immediate care and treatment

* Protective Custody for transport only; not an arrest, results confidential

Transport to ED

Evaluation within 24 hours

3 days maximum hold

“Reasonable cause to believe”

Person has psychiatric disability

Danger to self or other, or

Grave disability, and

In need of immediate care and treatment

* Has received a minimum of 8 hrsof specialized training in the conduct of direct evaluations

Physician’s Emergency Certificate

PEC (CGS §17a-502)

Issued by Licensed Physician

Exam required by Physician in past 3 days

15 day commitment to psychiatric facility

Conclusion (clear and convincing vs. “reasonable cause to believe”)

Danger to self or other, Grave disability, and

In need of immediate hospitalization

EMPS EC

Standard and

Definitions

Activity

Statute Standard

2) reasonable cause to believe, based on a

direct evaluation of a child, that such

child (A) has psychiatric disabilities, (B)

is dangerous to himself or others or

gravely disabled, and (C) is in need of

immediate care and treatment … that

requires the hospitalization of such child

for a psychiatric and medical evaluation

Reasonable Cause to Believe

Reasonable Cause To Believe

v.

Beyond a Reasonable Doubt

based on a direct evaluation

of a child…

LCSW, APRN or LPC must DIRECTLY EVALUATE the child through a face-to face assessment AT THE TIME they issue the Emergency Certificate

Psychiatric Disability

“A "person with psychiatric disabilities" is anyone who has a mental or emotional condition that substantially and adversely affects his ability to function and who requires care and treatment. “ http://www.cga.ct.gov/2002/olrdata/jud/rpt/2002-R-0848.htm

“Persons with psychiatric

disabilities”

3) “Persons with psychiatric disabilities” means those children and adults who are suffering from one or more mental disorders, as defined in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”;

Conn. Gen. Stat. § 17a-540 (2007) (Formerly Sec. 17-206a)Definitions: As used in sections 17a-540 to 17a-550, inclusive, unless otherwise expressly stated or

unless the context otherwise requires

“ …is a danger to himself or

others…”

“there is a substantial risk the individual will inflict physical harm upon his own person or upon another person. “

http://www.cga.ct.gov/2002/olrdata/jud/rpt/2002-R-0848.htm

Gravely Disabled

A person, as a result of mental or emotional impairment, is in danger of serious harm as a result of an inability or failure to provide for his or her own basic needs such as essential food, clothing, shelter or safety and that hospital treatment is necessary and available and that such person is mentally incapable of determining whether or not to accept such treatment because his/her judgment is impaired by mental illness/psychiatric disability.

CT Office of Protection and Advocacy P&A Publications "Your Rights in a Psychiatric Facility" a P&A Self-Help Publication. Last updated 04/2011

Gravely Disabled Minor (CA)

>"a minor who, as a result of a mental disorder, is unable to use the elements of life which are essential to health, safety, and development, including food, clothing, and shelter, even though provided to the minor by others.“

Cal. Welf. & Inst. Code § 5585.25

Emergency Certificate

Review

Emergency Certificate Form

Confidentiality-Routine

Non disclosure Rule

As a professional mental health representative you may not release of information, oral or written, without the consent of the client or his authorized representative.

Federal substance abuse confidentiality regulations

42 CFR Part 2 Non disclosure Rule

An Alcohol and Drug Program may not disclose any information about any patient, this includes if a patient is receiving, has received, or has applied for alcohol and/or

drug services. This governs all federally assisted programs

C.FR Chapter 1Subpart D 251 Medical Emergencies

“Patient identifying information can be disclosed to medical personnel who have a need for such information about a patient for the purpose of treating a condition which imposes an immediate threat to any individual and which requires immediate medical intervention.”

Confidentiality

Exceptions

Collaboration with Police

Under most situations sharing mental or behavioral health information with police is not permissible. The exception is available when a person is a danger to self, others or gravely disabled.

In this situation, communication and collaboration with police is for individual crisis management.

Mental Status

“Based on Direct Evaluation

of a Child”

Warm-Up

Activity

Apply MSE and Results of

Overall Evaluation to

Risk to Self Standard

Risk to Others Standard

Gravely Disabled Standard

Need for Immediate Care and Treatment

Activity:

Scenarios

Accurate, Thorough

Completion of EMPS EC

Helps to assure that youth’s needs, psychiatric disabilities, medical issues and risk factors are attended to after he/she leaves your care

Accurate, Thorough

Completion of EMPS ECCommunicates to Emergency Department

> Why youth has a substantial risk of harm to self or others or is gravely disabled,

> Medical issues they may need to attend or be aware of when treating the youth (illnesses, head injuries, recent ingestions, recent medication changes or non-compliance, recent substance abuse, allergies)

> Pertinent psychiatric history that may help to demonstrate why youth is at risk and what further treatment may be necessary

> Other issues such as whether “Duty to Warn obligations under Tarrasoff/ Frazier have been met

Accurate, Thorough

Completion of EMPS EC

Demonstrates how standards set forth in statute are met

“(2) reasonable cause to believe, based on a direct evaluation of a child, that such child (A) has psychiatric disabilities, (B) is dangerous to himself or others or gravely disabled, and (C) is in need of immediate care and treatment”

Questions that may strengthen

documentation

How are you justifying psychiatric disability?

Is psychiatric disability linked to risk and need for immediate care and treatment?

How did you reach the belief that there a substantial risk that youth may harm him/herself or others or is gravely disabled?

What risk factors exist and how did you weigh these factors to come to your conclusion?

Why is a lower level of care not adequate and/or why is immediate care and treatment necessary?

Documentation:

Danger to him/herself Words or actions showing intent to

commit suicide or bodily harm.

Words or actions indicating gross disregard for personal safety.

Words or actions indicating a specific plan to suicide.

Means available to carry out suicide plan (i.e. pills, firearms present

Documentation

Danger to others

Threats against particular individuals.

Attempts to harm certain individuals.

Means available to carry out threats or to repeat attempts (i.e. firearms, or other weapons).

Expressed intention or attempts to engage in dangerous activity.

Documentation

Gravely Disabled Examples: (cite specifics) Signs of malnourishment or dehydration.

Inability to articulate a plan for obtaining food.

No food available in the house or at hand if not in a house.

Irrational beliefs about food that is available (i.e. it’s poisoned, inedible, etc.)

Destruction or giving away of clothing to the point where the person cannot clothe themselves.

Inability to formulate a reasonable plan to obtain shelter.

Activity:

Problematic EC

Reporting

Complete the paper EMPS Emergency Certificate

1. Original given to EMT or Police Officer. It MUST be delivered to receiving ED by transporting party

2. Copy for agency/clinician records

3. Will need to make an additional copy at your agency and submit it to DCF Contract Manager within 3 days of issuance of Emergency Certificate

EMPS-EC Procedures

1. If the responding EMPS clinician is not qualified to issue an emergency certificate, they will immediately call their supervisor to arrange for a qualified EMPS clinician to respond to the location and conduct the emergency certificate assessment.

2. The qualified EMPS clinician will conduct the evaluation and complete the Emergency Certificate Form.

(As a matter of practice/procedure an EMPS provider should sending having a second EMPS clinician to support the EMPS clinician completing the Emergency Certificate Form.)

EMPS-EC Procedures

3. If the result of the assessment is that an emergency certificate requiring hospitalization (for a psychiatric and medical evaluation) will be issued, the EMPS clinician will immediately contact 911 or an ambulance for transportation. Under no circumstances should an EMPS clinician transport the child to the ED.

4. If the EMPS clinician determines that there are significant safety concerns that cannot be addressed by the ambulance EMTs, then the EMPS clinician will call 911 for police support and/or transportation.

EMPS-EC Procedures

5. When the ambulance (or police) arrives, the EMPS clinician will supply the EMT (or police officer) with a signed copy of the Emergency Certificate Form. They will also have a copy of their DCF certification with them so that they can show proper authorization to the EMT or officer upon request.

6. EMPS supervisor will submit copies of EMPS EC to DCF Contract Manager.

Making the EC Process Go as Best

as Possible for youth and family Be aware of own behavior and reactions and

encourage all participants (family members, youth) to stay as calm as possible.

Take steps to protect youth’ and family’s privacy. PLAN who will say what, what actions should be

taken to keep things as safe, how/when and what youth should be told about process…Anticipate trouble spots ….

When you have the time, use the time to de-escalate youth, educate family about process and what will happen at the emergency department,

Encourage family members to do things like get medications together, pack a small bag, call other family members to notify them of the emergency, etc.

Making the EC Process Go as Best

as Possible for youth and family Encourage family to attend to the needs of other

children before 911 arrives. Be aware of interested on-lookers. Try to conduct

as much “business” as possible away from prying eyes and ears.

Take time to notify 911/ police of all risks (weapons, active substance abuse, specific nature of threats, presence of small children or pets, predicted volatility, etc.) so they can be prepared to manage the situation safely

Be as discreet as possible when going in and out of home

Making the EC Process Go as Best

as Possible for youth and family

Provide as much information to youth as possible and safe to do so.

Encourage police and EMT’s to refrain from use of sirens and lights unless absolutely necessary.

Ask police if they have the ability to come in an unmarked vehicle.

Ask EMTS and/or police how you can be helpful to them while also asking them to let you take the lead if they see it as appropriate to do so.

Call ED ahead to time to let them know pertinent risks and concerns.