Emerging Standard Of Care

Audrey Fraizer

Audrey Fraizer

CDE Medical

*To take the corresponding CDE quiz, visit the College of Emergency Dispatch.*

Behavioral health is everyone’s concern in emergency services, from the caller and patient to the emergency dispatcher and the responders dispatched to intervene in a crisis. Whether police have received training in handling these types of crises or not, they have generally been the default first responders for these types of calls. 

Current thinking and research, however, are changing the way we respond to mental health crises. People experiencing a mental health crisis need to be met with a response that prioritizes community-based mental health care and support.

To meet the challenge and emerging standards of care, the IAED completely revamped MPDS® Protocol 25 and presented it as part of the ProQA® v5.1.1.45 Maintenance Release in November 2022. The protocol now includes the concurrent title Mental Health Conditions and is specifically designed to address acute mental health issues that may be more appropriately addressed by rapidly evolving Crisis/Alternative Response teams.

In addition, an entirely new protocol addresses first-party callers experiencing suicide issues ranging from ideology to imminent suicide potential. This second protocol—stand-alone Protocol 41: Caller in Crisis—is set for release at a later date. 

The revised Protocol 25: Psychiatric/Mental Health Conditions/Suicide Attempt/Abnormal Behavior is used only when a mental health problem is the primary symptom (mental health crisis, abnormal behavior, self-harm). The extensive revision features new and updated Determinant Codes; new Suffixes; new, reordered, and updated Key Questions; new answer choices; new Definitions; a new Special Definition; new and updated PDIs; a new CEI; and new and updated Rules and Axioms. Agencies have been given more control in defining alternate responses and using new Advanced Key Questions.

In addition, the protocol provides lists to help the Emergency Dispatcher identify altered states of consciousness and mental health conditions.

“This will be a very robust system, developed with input from mental health professionals with expertise in this important field of intervention,” said Brett Patterson, IAED Medical Standards Council Chair. “Both protocols will provide EMDs the tools necessary to keep callers, patients, and responders safe.”

It is important to note that police response is not excluded in Protocol 25. According to new Axiom 7: “It is reasonable to utilize a police-only response when a person is INTENDING SUICIDE (no injuries have occurred). This choice must be approved by local policy between the law enforcement and EMS-provider agencies.”

Key Questions
The 13 Key Questions—as opposed to the five Key Questions in the previous MPDS version—are designed to gather as much information as possible while helping Emergency Dispatchers identify situations where another protocol might be more appropriate. The protocol is usually used before an injury has occurred, and with only a few exceptions, specific life-threatening injuries will be treated under another protocol.

One option that represents the new methodology of Protocol 25 is that ProQA now asks the Emergency Dispatcher to either end or continue questioning following Key Question 8, depending on agency policy. The following series of five Advanced Key Questions also depends on local medical control. These Key Questions involve patient history of mental health conditions, previous confrontations with public safety responders, and the existence of a safety plan.

As newly defined in Protocol 25, a safety plan is “A prioritized written list of coping strategies and sources of support that caretakers or patients who have been deemed to be at high risk for suicide can use. These plans can be used before or during a suicidal crisis. The plan is brief, usually in the patient’s own words, and is easy to read.”

Two Advanced Key Questions ask about medication. A change in medication can affect a patient’s condition, as stated in Axiom 6: “A sudden change in patient behavior or personality may signal an underlying medical condition like stroke, OVERDOSE or POISONING, blood sugar abnormality, or head trauma. An ALS response ensures an appropriate, in-person evaluation to rule out these clinically acute medical conditions.”

Determinant Codes, Suffixes, and PDIs
Emergency Dispatchers are instructed to use an ECHO response in Case Entry in cases of patient arrest, or if the patient is unconscious or hanging. 
• DELTA is appropriate if a patient’s life is in danger (e.g., not alert, going into cardiac arrest).
• CHARLIE is for a patient with an altered level of consciousness.
• BRAVO is appropriate if the situation is not immediately life threatening but still requires prompt intervention (e.g., patient is threatening to jump).
• ALPHA is for situations that are not life threatening but, in the name of public safety, still deserve a response (e.g., suicidal ideation).
• OMEGA is for situations that are not prehospital emergencies (e.g., history of mental health conditions).

Suffix codes are added whenever the patient appears to be violent or has weapons and aid in automatically notifying police and/or fire to respond and secure the scene. PDIs are designed to balance caller and patient safety. These include telling the caller to continuously observe the patient and protect the patient from self-harm if it is safe to do so. Dispatch Life Support (DLS) is standard, although the Emergency Dispatcher may need additional training and practice to keep the suicidal patient or self-harm-threatening patient on the line prior to responders arriving on scene.

Studies show
For most of these calls, police presence on scene is not necessary in behavioral health situations. A significant number of calls are related to drug abuse, homelessness, and other quality-of-life issues that may or may not require a time-sensitive response and would be better suited to other opportunities to reduce the volume of calls for service to which police must respond.

A recent analysis examining 911 police calls for service from eight cities found that 23 to 39% of calls were low priority or nonurgent, while only 18 to 34% of calls were life-threatening emergencies.  People with serious mental health disorders are 16 times more likely than the general public to be killed during a police encounter.1

The situation with a potential mental health crisis is handled differently, depending on policing requirements. For example, police in the U.K. do not respond to behavioral health calls like those outlined in MPDS Protocol 25: Psychiatric/Mental Health Conditions/Suicide Attempt/Abnormal Behavior. “It’s not a crime to threaten suicide. Police only respond if the situation presents safety issues to the bystander and responders [EMS crew],” said Beverley Logan, Associate Director, IAED, and National Accreditation Officer, PDC UK Ltd.

A similar philosophy is emerging in the U.S. Communities are developing alternative response models that do not automatically bring police to the scene, such as mobile response teams specializing in behavioral health intervention. 988, the three-digit Suicide and Crisis Lifeline, launched in the U.S. in July 2022 to improve critical support services accessibility and reduce the risk of inappropriate intervention and placement.

Enhance your protocol knowledge
The IAED Learning eXperience Design (LXD) team has focused on training to support the updated version of Protocol 25 (with parts of the lesson incorporated into this CDE article) and the upcoming release of Protocol 41: Caller in Crisis. 

Protocol 41 and associated training optimize an Emergency Dispatcher’s response to callers in mental health crisis and gives the flexibility to lead the caller along the most appropriate assessment and two intervention pathways—SUICIDE IDEATION and THREATENING SUICIDE—depending on their struggle.

Both lessons are part of a new series, the Science of Dispatch, designed to provide important background information about incidents and emergencies that informed the development of the protocols. 

1. Irwin A, Pearl B. “The Community Responder Model: How cities can send the right responder to every 911 call.” The Center for American Progress. 2020; Oct. 28. americanprogress.org/article/community-responder-model (accessed May 10, 2023).