Understanding the Deeds’ family tragedy

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”