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

Andrea Chittle; Shane Neilson; Gina Nicoll; Juveria Zaheer

doi:10.9778/cmajo.20210135

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Table 1:

Demographic characteristics of participants^*

Characteristic	No. (%) of participants n = 11
Gender
Female	7 (64)
Male	4 (36)
Specialty
Family practice	9 (91)
Psychiatry	2 (9)
Years in practice
≤ 5	1 (9)
6–10	3 (27)
≥11	7 (64)
Years working in student health
≤ 5	3 (27)
6–10	2 (18)
≥ 11	6 (54)

↵* Data were extracted from questionnaire responses for 10 participants and from the interview transcript for 1 participant, who did not complete a questionnaire.

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Table 2:

Participants’ beliefs about mental health transfers (from questionnaire) (n = 10)

Item	Range^*	Mode^*^†
Police or security are required for safe transfer	1–3	2 (n = 4), 3 (n = 4)
Handcuffs are required for safe transfer	0–1	1 (n = 6)
Using police or security officers for mental health transfers is stigmatizing	1–4	3 (n = 5)
Using restraints routinely for mental health transfers is stigmatizing	2–4	4 (n = 7)
Clinicians and individuals transporting students to hospital have a good working relationship	1–3	3 (n = 4)
Where police/security officers are involved in student transfers, a risk assessment by the clinician issuing a Form 1 is considered in determining whether restraints are used	0–4	3 (n = 6)
Where police/security officers are involved in student transfers, officers appear skilled and confident in assessing risk in order to determine whether restraints are used	0–4	2 (n = 5)

↵* Response options ranged from 0 (“Disagree strongly”) to 4 (“Agree strongly”).
↵† Most frequently occurring value.

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Table 3:

Description of transfer process and policies at the clinics when Form 1 is issued, and representative quotes (n = 11)

Type of process; institution no.	Transfer process	Police or campus police involved	Handcuffs used	Representative quote
Fixed
Emergency response is activated, with police transporting student to hospital in most cases
1^*	Campus police (special constables of municipal police) are contacted to transport student. In rare cases, 9-1-1^¶ is called, and municipal police convey student.	Always	Formerly always; now discretionary use	We will contact our campus police service; they will come, and again, there will be … a joint assessment of the situation, and typically students are not needing to be handcuffed anymore. (Participant E1) They [police] don’t use any restraint procedures unless the situation indicates that, and it is done in as low-key and as kind of student-friendly and gentle a way as possible. (Participant E2)
2^*	Campus police (special constables of municipal police) are called to transport student.	Always	Almost always	They [police] mostly … 9 times out of 10, will apply handcuffs to a patient, which can be a very traumatic experience. (Participant D)
3^*^†	Campus police (special constables of municipal police) are called to transport student.	Always	Always	Every time that I’ve called, they [police] have handcuffed the patient. And zero times did I think it was necessary. … I remember having a conversation … with the police officers to maybe consider not handcuffing, because the patient was totally willing to go, but … they said “no” in each circumstance. (Participant K)
4^*^†	9-1-1 is called, and police or paramedics, or both, convey student.	Almost always	Never	The nurse arranges [for] the police to come. (Participant B) That horrified me. … Handcuffs? … I hadn’t even thought of handcuffs. (Participant B)
5^*^†	9-1-1 is called, and a mobile crisis team (police and mental health worker) or paramedics, or both, convey student.	Majority of cases	Rarely	The time there was [handcuffs] … I think it was out of necessity. … The person was verbally resistant before … police arrived, but then, when police arrived, they were a little more physically resistant, so it was out of necessity they used restraints. … But otherwise it’s never been discussed because I think it was just clear it wasn’t needed. (Participant I)
6^*	9-1-1 is called, and police or paramedics convey student.	Almost always	Rarely	We started specifically requesting for police instead of paramedics … and then our experience has been if that’s available, they do send a mental health officer, or an officer with some mental health training. And we have usually had pretty good success. (Participant A) I can’t ever remember handcuffs being used. (Participant A)
Emergency response is activated, with ambulance conveying student to hospital in most cases
7^*	9-1-1 is called, and student is most often transported by paramedics. In rare instances, where safety concerns are identified, police become involved in transfers.	Rarely	Rarely	[We] would call an ambulance, and usually they will come to the university and then they will take [the student] from there. If we have any concerns about [the student] wanting to leave, or [if we] feel unsafe, we call security, which is on campus. That has happened quite a few times where we have just had security waiting until the ambulance comes and takes the person to the hospital. (Participant H) Definitely no, nothing really that we have seen in terms of restraints or anything like that. (Participant H)
8^†^‡	Campus police (special constables of municipal police) are called. Campus police call 9-1-1 and wait in clinic until paramedics arrive. Paramedics convey student to hospital.	Not specified in protocol	Not specified in protocol	–
Flexible: students are often accompanied by clinic staff, with discretionary involvement of police or paramedics
9^*	Student is accompanied to hospital by clinic staff in the majority of cases. Occasionally, student is accompanied to hospital by friends or family. In rare cases, on the basis of safety concerns, 9-1-1 is called, and police or paramedics, or both, convey student.	Rarely	Rarely	Usually what will happen if someone is really, really distressed, whether they’re certified or not, [clinic staff] will escort them over to the emergency department. (Participant C1) The options can be the patient going with one of our nursing staff, [taking] them over; the patient being escorted by the police; and the patient being escorted by a family member or friend. Those would be really the 3. Or when I say one of our nurses, also some other nonnursing staff, like a clinic manager will sometimes take students to the hospital on a Form 1. (Participant C2)
10^*^†	Student is accompanied to hospital by clinic staff in the majority of cases. Occasionally, student is accompanied to hospital by friends or family. In some cases, on the basis of safety concerns, 9-1-1 is called, and police or paramedics, or both, convey student.	About 50% of the time	Rarely	For those patients who are seeking help and recognize that they need help and who accept our assessment that they should be [on a] Form 1, because they are a risk to themself or to others, we offer them … transportation that we arrange, and an accompaniment with one of our staff people. We’ll actually send a nurse with a patient to the [emergency department], and hand over the patient at the [emergency department] to a nurse and triage at the [emergency department]. (Participant J)
Form 1 not used
11^‡^§	NA	NA	NA	–

Note: NA = not applicable.
↵* Information was drawn from interview transcripts.
↵† Information was obtained from policy and process documents.
↵‡ No physician respondent.
↵§ Clinic director reported Form 1 use to be rare.
↵¶ Emergency telephone contact number in Ontario.

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Table 4:

Quotes supporting themes

Theme; subtheme	Representative quote^*
Police and restraints cause harm to students experiencing a mental health crisis
Police involvement is problematic generally	A lot of people have had some very negative interactions with the mental health care system and the justice system, that’s for sure. (Participant C1) People already have enough trouble being in hospital, but to have to be taken in handcuffs … out of the building and loaded up in a police cruiser and taken half a block, it seems brutal and traumatic for the patient, and sends all the wrong messages about a caring, supportive environment. (Participant C1)
Police involvement may interfere with future treatment	They [patients] are very suspicious and hard to engage. (Participant C1) The idea that you’re breaking trust with a vulnerable person can have huge impacts on care down the road. (Participant D) We have run into people who have either come back for another reason and are clearly unwell, or who have come back with significant reluctance, saying … “I am only here for X, Y, Z; I am not going to tell you all this because of what happened last time.” … Having been placed on the Form 1 and transferred sometimes will, I think, prevent people from coming back. (Participant D)
Police involvement and restraint use are justified on the basis of patient considerations
	[We are] balancing the safety of the student with what’s going to be most comfortable for them and finding the right balance there. And I know it is potentially not a great experience to be escorted by police, but definitely when it’s really necessary for their safety, then it really does make sense. (Participant C2) If we have any indication that someone may be violent toward other people or is actively psychotic … we engage the police at all times. (Participant J) Paramedics aren’t really trained to go after a patient and chase them down. Not that that is something that happens frequently, but it’s still something … you have to be concerned about, in potential worst-case scenarios, and how that could turn out. (Participant B)
Transfer processes are often informed by extramedical factors
Rationale for police involvement	I think there may have been some concern based on … union responsibilities and roles for the staff that were involved, that it was outside of their roles. (Participant E1) I think the main risk is if the student decides to flee the situation and our staff wouldn’t really be able to make them go to [the emergency department]. And then … if something went wrong and the student ended up hurting themselves, how would that affect the staff that was unable to really do that job properly? (Participant C2) In the past, we used to send a counsellor or a nurse with them [the student] in a taxi, and we found that to be too time-consuming because they might end up in the emergency department for 5 hours waiting to be seen. So, they [clinic administration] changed that policy to us calling 9-1-1. (Participant H) We’re quite busy in our clinic … so … one part of it is, do we have staff that can leave, and usually they [staff] will wait with the students until the students get seen. (Participant C2) My feeling is that police probably are the right group to do the transfer. … The reason I think police [is] just because I think it’s faster, and sometimes that’s important because it’s not a pleasant experience often for patients to be sent to hospital on a Form 1. (Participant I)
Extramedical rationale for restraint use	It was really just concerns from the police standpoint of their liability, and that was the main issue. (Participant J) They [police] mostly … 9 times out of 10, will apply handcuffs to a patient, which can be a very traumatic experience. And so discussions that we have had with the constables about whether or not that should be done are typically met with, “You know what, we have to cater to the highest potential risk.” (Participant D) The campus police say that they are following the guidelines of [municipality name] Police Service, which say, “Use restraints every time.” And my impression — this has not been said to me, but my impression is — that they are always supposed to use restraints, but there are a few officers who go against … the commanding officer’s request. They make a decision in the moment, and … I am not sure that that would be supported by their organization. (Participant D)