When a hospital has no inpatient psychiatric unit, should the patient be discharged and the police called?

When a Hospital Has No Inpatient Psychiatric Unit: Discharge and Police Involvement

Do not discharge a psychiatric patient simply because your hospital lacks a psychiatric unit—instead, arrange urgent transfer to a facility with psychiatric capabilities, and involve police only when necessary for safe transport or when the patient meets involuntary commitment criteria. 1, 2

Critical Decision Framework

Step 1: Assess for Involuntary Hold Criteria

You must initiate an involuntary psychiatric hold if the patient meets state-specific criteria, regardless of whether your facility has a psychiatric unit. 1 Criteria typically include:

• Mental disorder present AND immediate risk of harm to self or others 1
• Persistent wish to die or clearly abnormal mental state (depressed, manic, hypomanic, severely anxious, psychotic, intoxicated, or mixed states) 2, 3
• Specific high-risk features:
  • Still thinking about suicide or made prior attempts 2
  • Substance abuse combined with mood disorder 2, 3
  • Irritability, agitation, threatening violence, delusions, or hallucinations 2, 3
  • Feelings of hopelessness, worthlessness, or excessive guilt 3
  • Inability to form therapeutic alliance or regulate emotions 4

Step 2: Arrange Appropriate Disposition

If involuntary hold criteria are met, you must arrange transfer to a psychiatric facility—discharge is not an option. 5, 3 The process varies by jurisdiction:

• Initiate psychiatric hold (typically 72 hours, ranging 1-30 days depending on state law) 1
• Contact regional psychiatric facilities to arrange transfer 5
• If no psychiatric facility is immediately available, mobilize family, friends, and community resources for close monitoring until transfer can occur 5
• Document the involuntary hold and follow your state's specific procedures 1

Step 3: Role of Police in Transfer

Police involvement should be limited to safe transport when clinically indicated, not as a substitute for psychiatric care. 6, 7, 8

Appropriate police involvement includes:

• Safe transport to psychiatric facility when patient is agitated, violent, or poses flight risk 7, 8
• Enforcement of involuntary hold when legally required by state statute 1, 9
• Emergency situations where patient is actively dangerous to self or others 7

Police should NOT be called simply to:

• Remove a patient from your ED because you lack psychiatric beds
• Discharge a patient who meets hold criteria
• Avoid your responsibility to arrange appropriate psychiatric care

Step 4: If Patient Does NOT Meet Involuntary Criteria

Discharge may be considered only when ALL of the following are verified: 2, 4, 3

• Third-party verification obtained (never rely solely on patient's account) 4
• Adequate supervision confirmed for next several days 2, 4, 3
• Responsible adult agrees to "sanitize" environment:
  • Remove or secure all firearms (temporarily relocate to relative, friend, or law enforcement) 2, 4
  • Lock up or dispose of lethal medications 2, 4
  • Secure knives and other means 1
  • Restrict alcohol access 1, 4
• Follow-up appointment scheduled before discharge 4
• Patient and family counseled about disinhibiting effects of drugs/alcohol 4
• Mental state is stable (GCS 15, no active suicidality) 2

Common Pitfalls to Avoid

Do not rely on "no-suicide contracts"—they have no proven efficacy and should never reduce your vigilance or influence disposition decisions. 4, 3 Patients frequently minimize their symptoms and intent. 3

Do not assume parents will secure firearms without explicit instruction—studies show parents underestimate children's ability to access weapons and will not take precautions unless directly counseled. 1, 4 Simply having a gun in the home doubles youth suicide risk. 1

Do not discharge intoxicated patients—substance intoxication prevents accurate psychiatric evaluation and is associated with higher rates of violence and suicide completion. 2, 10 Police referrals are significantly more likely to be intoxicated (31.3% vs 10.7%). 7

Do not discharge without collateral information—children and adolescents should never be discharged without caretaker verification of the patient's account, regardless of how mild the suicidal behavior appears. 4

Legal and Ethical Considerations

Familiarize yourself with your state's involuntary commitment laws—specific criteria, hold duration, and procedures vary significantly by jurisdiction. 1 Your duty to arrange appropriate psychiatric care supersedes the absence of on-site psychiatric beds. 4, 11

Patients discharged against medical advice (AMA) who remain dangerous expose you to heightened liability risk, particularly when psychiatric illness is present. 11 Between 6-35% of voluntary psychiatric inpatients leave AMA, and these patients have high rehospitalization rates and worse outcomes. 11

The tension between patient rights and physician duties is resolved by prioritizing safety—when in doubt, pursue involuntary hospitalization and transfer rather than discharge. 2, 4, 3 Approximately 24% of suicide attempts occur within 0-5 minutes of plan formulation, emphasizing the impulsive nature and need for protective intervention. 1, 3