NUBE 2025

Background: Emergency Department encounters for behavioral health emergencies (BHEs) often originate from 9-1-1 first responders, specifically emergency medical services (EMS) clinicians and law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices or innovative strategies. Over the past 8 years, the Los Angeles County EMS Agency’s Commission has engaged in a comprehensive evaluation of the 9-1-1 response for BHEs and developed a performance improvement plan to advance the quality of care and safety for patients and first responders. This panel will describe the objectives, methods, and interventions of LA County’s Behavioral Health Initiative Committee (BHIC), with potential application to all providers of psychiatric/behavioral emergency services, identifying opportunities to improve the continuum of care and, in particular, 9-1-1 pre-hospital behavioral health services.

Methods: The BHIC was assembled with broad representation from EMS, LE health agencies, and the public. BHIC objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement.

Results: The BHIC generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities’ capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, and develop alternate destination for EMS transport.

This general session will describe a comprehensive performance improvement initiative in LAC-EMS Agency’s 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs. These strategies may be adapted across other EMS systems and requires leadership or support from behavioral emergency specialists.

Learning Objectives:

Understand and apply 4 principles that guide the evaluation and improvement of 9-1-1 services for BHE’s.

Describe key strategies to enhance the EMS quality of care and safety for patients with BHE’s.

Identify opportunities and barriers to shift away from a law enforcement response to a medical response for BHE’s.