Lessons Learned

Learning from 5150 – Involuntary Psychiatric Hold – Patient Safety Events

According to a Centers for Disease Control and Prevention (CDC) report there were 65.9 million visits to physician offices and five million emergency department visits in 2014 with mental disorders as the primary diagnosis. These data may not come as a surprise since reports from the CDC also indicate an increase in the numbers of adults who report having experienced serious psychological distress. According to a 2017 CDC survey, 2.7 percent of adults aged 18 and over reported having experienced serious psychological distress in the last 30 days, and by 2016 the rate had increased to 3.6 percent. Furthermore, the Agency for Healthcare Research and Quality (AHRQ) reports that between 2007 and 2011, there was a 15 percent increase in the rate of Emergency Department visits related to mental illness and/or substance abuse disorders.

In an effort to gain a better understanding of the challenges faced by those caring for patients with mental and/or substance abuse related diagnoses, we queried the CHPSO database for safety reports containing a common factor in these patient populations, namely involuntary psychiatric holds. As different states have different mental health laws, results were restricted to California. The intent of Section 5150, a California law (other states have similar laws), is to involuntarily hold individuals due to mental illness who may pose a danger to themselves, others, or are gravely disabled and require inpatient psychiatric care. There were over 3800 cases returned from this search. An analysis of a subset (336) of these incidents revealed the following trends and patterns.

Nearly 90 percent of the cases occurred in two location types. More than half (58 percent) were reported from emergency departments (ED) and a third (30 percent) were reported from inpatient general care areas (e.g. medical surgical units). Intensive/Critical Care Units and Other areas each accounted for six percent of the cases.

The incidents were classified based on issues and factors that were repeated across the data, as well as by factors known to be associated with these types of cases (e.g. danger self or others, gravely disabled). The most common theme in the data set was elopement or leaving against medical advice (AMA) (41 percent). Other commonly mentioned themes were staffing, bed availability, and placement or transfer (29 percent). A frequent issue among these cases was the availability of a sitter. In a number of cases involving both staffing and elopement, the sitter was charged with watching two 1:1 patients at the same time and Patient 1 eloped while the sitter was busy attending to the needs of Patient 2.

Issue n (336) Percent
Elopement/ Against Medical Advice (AMA) mentioned 136 40.5 percent
Staff/ Bed Availability/ Placement/ Transfer 98 29.2 percent
Law Enforcement Mentioned 93 27.7 percent
Self-Harm/ Suicide/ Suicidal ideation 93 27.4 percent
Workplace Violence/ Threats/ Aggression 79 23.5 percent
5150 Criteria/ Document or Policy Issue 75 22.3 percent
Psychiatric Evaluation 48 14.3 percent
Alcohol/ Illicit Drugs Mentioned 33 9.8 percent
Medical Evaluation/ Clearance 30 8.9 percent
Gravely Disabled 24 7.1 percent
Family Complaint/ Disruptive Behavior 18 5.4 percent
Contraband 16 4.8 percent
Weapon Mentioned 15 4.5 percent
Danger to Others 13 3.9 percent
Minor Child 10 3.0 percent

Cases involving patients waiting for a psychiatric evaluation were often associated with longer ED stays, particularly when the case was over the weekend. Generally, in California this evaluation is managed by the county’s mental health plan, not the hospital holding the patient. In some cases, patients spent days in the ED waiting for a psychiatric evaluation due to the lack of an available provider. Some patients who were held for the weekend opted to leave AMA. For example, a patient admitted for an intentional overdose on Friday was medically cleared on Saturday; however, the psychiatric evaluation would have to wait until Monday. The patient became upset about staying in the hospital all weekend and decided to leave AMA. Since the patient was still on a 5150 hold, law enforcement had to be notified. The patient was provided with Crisis Hotline information and advised to return for worsening symptoms.

In some cases, the long stays become contributing factors for workplace violence and staff safety, an issue mentioned in nearly one out of four (24 percent) cases reviewed. In one such case, a patient brought to the ED by law enforcement on a 5150 waited over 10 hours for placement. Delays in insurance verification related to out-of-state insurance combined with a backlog of patients waiting for placement at the same facility resulted in the patient being held in the ED until Monday. Staff in the ED expressed concern that the patient’s aggressive, uncooperative behavior made him a poor candidate for an ED holding room. In another case, a patient with bipolar disorder and suicidal ideation was medically cleared for discharge on Saturday morning. The patient required a psychiatric evaluation and it was not completed until Monday at which point the patient was placed on a 5150 hold. On Tuesday, the patient was still in the ED awaiting transfer to an appropriate psychiatric facility. The ED staff reported that by Monday morning the patient had become increasingly agitated and disruptive.

Members of the California Hospital Association (CHA) interested in learning more about the Emergency Medical Treatment and Labor Act (EMTALA) and emergency psychiatric services, including issues related to 5150 holds in emergency departments may want to consider attending the upcoming webinar hosted by CHA, Essentials and Trouble Spots Webinar: EMTALA principles, updates, psychiatric services and compliance tips. This webinar is recommended for emergency department staff, behavioral health managers, business office and admitting managers, risk managers, health care attorneys, social workers, discharge managers, clinic staff and administrators, and compliance officers.

CHA publishes several reference manuals. The EMTALA Manual is a resource used by many Emergency Department directors and nurse managers, offering guidance to hospitals, and provides sample scenarios and answers. CHA’s Consent Manual is a comprehensive resource for consent regarding medical treatment, addressing both state and federal laws. CHA’s Mental Health Law Manual provides a user-friendly guide to state and federal laws governing mental health treatment and privacy. These resources are used by risk managers, privacy officers, chief medical officers, nurse executives, legal counsel, emergency departments, admissions staff and quality managers.

As a follow-up to the January CHPSO safe table meeting on behavioral health, CHPSO will convene another safe table on behavioral health on May 24 at 10am. Sheree Lowe, Vice President of Behavioral Health and BJ Bartleson, Vice President of Nursing and Clinical Services, both of CHA, are guest speakers. Members can register here. As a reminder, CHPSO Safe Table discussions are confidential and open only to CHPSO members. Click here to see if your hospital is a CHPSO member.


The Lanterman-Petris-Short Act: 5150 Involuntary Civil Commitment for Psychiatric Treatment. California Hospital Association. https://www.calhospital.org/lps-act

Richards, JR, Hamidi, S, Grant, CD, Wang, CG, Tabish, N, Turnipseed, SD, & Derlet, RW. (2017). Methamphetamine use and emergency department utilization: 20 years later. Journal of addiction, 2017.

Weiss, AJ, Barrett, M. L., Heslin, KC, & Stocks, C. (2016). Trends in Emergency Department Visit Involving Mental and Substance Use Disorders, 2006-2013. Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project. Statistical Brief, 216.

Wilson, MP, Brennan, JJ, Modesti, L, Deen, J, Anderson, L, Vilke, GM, & Castillo, EM. (2015). Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use. The American journal of emergency medicine, 33(4), 527-530.