Patients Threatening Harm to Others Evaluated in the ED under the Florida Involuntary Hold Act (Baker Act)

Division of Hospital Internal Medicine, the Division of Psychiatry, and the Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, and the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Correspondence to Dr Michael Maniaci, Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224. ude.oyam@leahcim.icainam. To purchase a single copy of this article, visit sma.org/smj-home. To purchase larger reprint quantities, please contact moc.rewulksretlow@snoitulostnirpeR.

Abstract

Objectives:

This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. A The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems.

Methods:

This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected.

Results:

We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED.

Conclusions:

We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.

Homicidal ideation refers to thinking about, conspiring to commit, or planning a homicide. These thoughts may range from globally aggressive thoughts to a specific lethal plan. 1 The literature on patients making homicidal threats is limited in nature, coming from a study nearly 3 decades old that looked at homicidal patients committed for psychiatric treatment. In this study of 110 psychiatric patients, 16% of the commitments were because of homicidal ideation and most of these patients (89%) were psychotic. 2 Most important, this study showed that these patients were inadequately assessed from the medical standpoint. It was believed that healthcare providers were reluctant to provide comprehensive emergency evaluation because of risks associated with their care. In addition, this study did not report on substance misuse in their patient population. Substance misuse and/or alcohol intoxication often play a role as both a primary driver and an exacerbator of preexisting psychiatric illnesses. 3 To our knowledge, no study has examined active medical issues in conjunction with substance misuse in patients making homicidal threats or the importance of addressing medical emergencies in the homicidal patient.

In a study of involuntary patients who were evaluated at an acute care hospital emergency department (ED), homicidal patients were not more violent than other involuntary patients 4 ; however, the impact of this categorization on clinical assessment is unknown. Further characterization of the demographic and clinical variables associated with this patient group may aid in targeted and comprehensive evaluation. The primary objective of this study was to describe the specific threats of harm to others and the psychiatric diagnoses that led to the use of the Baker Act, the Florida involuntary hold act for a subsequent ED evaluation. Our secondary objective was to review homicidal patient demographic and clinical variables and to determine whether these patients represented a unique subset of involuntary patients requiring ED care.

Methods

This study was approved by the Mayo Clinic institutional review board as a retrospective chart review. B The study site was the Mayo Clinic in Jacksonville, Florida, a 22-bed ED located in a 306-bed community academic hospital. Inclusion criteria were age 18 years and older and placed on an involuntary hold in the ED between January 1, 2014 and November 30, 2015.

In Florida, the Baker Act provides for an emergency hold for purpose of involuntary examination when the patient is refusing care and is in danger of harm to self (including neglect) or to others. 5 Under the Baker Act, the patient must meet three criteria to be taken for involuntary examination. First, there must be reason to believe that the patient is mentally ill, with impairment of mental or emotional processes. This definition does not include developmental disability, intoxication or substance misuse impairment, or antisocial behavior. Second, the patient must have refused a voluntary examination or is unable to determine the benefits because of his or her mental illness. Finally, it must be evident that without proper medical care, the patient is likely to suffer from the neglect, resulting in serious bodily harm to him- or herself or others. A Baker Act can be initiated by a circuit court, law enforcement officer, physician, psychologist, psychiatric nurse, or clinical social worker. The law requires that the patient receive a psychiatric examination within 72 hours of initiation, which begins upon arrival at the treatment facility. If a patient is sent to an acute care medical hospital for emergent medical care, then the medical care team may treat the patient in a regular fashion. Within 12 hours of medical clearance by a healthcare professional, the patient must be either transferred to a psychiatric facility for further evaluation and treatment or released by the hospital if the criteria no longer apply. Although many states have enacted statutes that require the notification of an individual who is the target of a threat, 6 in Florida, the law is permissive. If a treating psychiatrist believes that a patient has both the capacity and realistic intent to do harm to a third party, then that psychiatrist may breach confidentiality and notify both the third party and a law enforcement agency. 7 There is no duty to protect the third party, however. Third-party notification was not included in the patients’ medical records and therefore, unknown for this study.

The demographic and clinical data collected included age, sex, race, marital status, patient psychiatric disorder diagnosis, evidence of suicide attempt, record of violence in the ED, drug of misuse information, and ED 30-day readmission rate. Psychiatric diagnoses were obtained from (BLINDED) C or the external clinical care notes of psychiatrists, primary care providers, or subspecialist documentation before the ED evaluation. Information regarding psychiatric illness was obtained from medical record documentation before the ED visit by a psychiatrist, primary care provider, or other care provider at the study institution or from records scanned into the medical record from another facility. Psychiatric diagnoses were then grouped into categories listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition 8 : anxiety disorders, depressive disorders, schizophrenic spectrum and other psychotic disorders, and substance-related and addictive disorder. Patients were deemed to be homicidal if they made a credible statement of intent to harm another individual. Threats of harm were deemed credible if the patient repeated and confirmed the statement to ED staff and the staff believed that the patient had the capability to act on the threat. If a threat meeting the same criteria was made with intention of self-harm, then the patient was deemed suicidal. Suicidal threats were not considered homicidal for the purposes of this study. A patient was considered both suicidal and homicidal only if separate specific threats to self and others were made. Homicidal and suicidal threats were documented by law enforcement or medical personnel on a Baker Act form, which was signed and scanned into the patient’s medical record. These inputted data on the Baker Act form were used to identify homicidal and suicidal patients in this study. Additional information collected on homicidal patients included the context of the homicidal threat, chronic medical disorders, and acute medical issues requiring immediate treatment.

Study data was entered into the REDCap electronic data capture tool 9 hosted at (BLINDED). D Standard descriptive statistics were used for patient demographics and clinical factors. Comparing the homicidal and nonhomicidal patients, categorical variables were evaluated using the χ 2 test and Fisher exact test and continuous variables were evaluated using the Wilcoxon rank-sum test. P ≤ 0.05 was considered statistically significant. All of the statistical analyses were performed using SAS version 9.3 software (SAS Institute, Cary, NC).

Results

Of 251 unique patients with encounters while on involuntary holds during the study period, 13 (5.2%) met the criteria for homicidal ideation ( Table 1 ). Of the 13 patients, 11 (84.6%) were men and 10 (76.9%) were white. Three patients had homicidal thoughts or ideations and 10 patients made specific threats. Five patients acted upon their threats before arrival at the ED.

Table 1.

Clinical characteristics of homicidal patients

Twelve patients (92.3%) had a previously documented psychiatric disorder, including seven patients (53.8%) who had >1 disorder ( Table 1 ). Two patients were uncooperative and one was considered violent because of severe agitation. A chronic medical disorder was identified in 9 patients (69.2%). Eight patients (61.5%) had an active medical issue that required ED intervention. Ten patients (76.9%) were suicidal in addition to being homicidal. Ten patients (76.9%) arrived via medical transport on an involuntary hold for medical clearance before being transported to an inpatient psychiatric facility. Three patients (23.1%) arrived by private vehicle and were placed on involuntary hold while in the ED.

Compared with other involuntary patients, homicidal patients were more likely to be men (11 [84.6%] vs 97 [40.8%], P = 0.003). There were no differences with respect to race (white, 10 [76.9%] vs 192 [80.7%], P =0.722), marital status (married, 3 [23.1%] vs 71 [29.8%], P = 0.761), ED length of stay (6.7 h vs 5.2 h, P = 0.276), psychiatric disorder (11 [84.6%] vs 191 [80.3%], P = 1.00), medical disorder (9 [69.2%] vs 115 [48.3%], P = 0.164), or substance misuse (8 [61.5%] vs 98 [41.2%], P = 0.148; Table 2 ).

Table 2.

Demographic and clinical characteristics of homicidal patients vs all other patients on involuntary status

ED, emergency department.

Discussion

The primary objective of this study was to describe the specific threats of harm that required involuntary hold status in the ED. To our knowledge, this is the first study to examine specific threats of harm made by patients requiring ED evaluation while on involuntary hold. One study previously examined patient threats of harm, but it was limited to threats made to pain practitioners. 10 Our study found that most homicidal statements consisted of specific threats (76.9%) and not simply thoughts/ideations (23.1%). Five patients acted upon their threats before arriving at the ED. These threats included the wielding of a knife against others and driving a car directly into a building before threatening someone with a shotgun. Such grave consequences justified the use of the Baker Act in these instances. It is important for care providers, law enforcement officials, and other individuals to be familiar with statutes that provide for an involuntary hold in emergent and/or threatening situations.

An important finding was that the majority of patients with homicidal ideation also had suicidal ideation. We believe that having both suicidal and homicidal ideations may represent high interpersonal conflicts and verbalization of threats, and true homicidal intent may be the result. When looking at the rates of a homicide followed by a suicide in the United States between 1968 and 1975, there were 0.134 events per 100,000, and this rate increased to 0.22 events per 100,000 in 2007. 11 The near doubling of this rate during the last 35 years is important because it likely contributes significantly to the murder rate for both female and child victims and most often involves one spouse killing the other. 12 This risk also may translate outside the home. A review of active shooter incidents by the New York City Police Department found that of 202 active shooter events, 40% of the incidents resulted in the shooter committing/attempting suicide after harming others. 13 Recognizing the potential link between homicidal and suicidal patients may help avert deadly tragedy.

We found depressive disorder to be the most common psychiatric disorder, whereas Stern et al found that substance-induced psychosis and psychosis related to schizophrenia accounted for 89% of patients with homicidal ideation. 2 The suburban versus urban inner city setting could account for this difference in psychiatric comorbidity. We also found that the majority of patients were calm and cooperative in the ED. It is noteworthy that seemingly calm and cooperative patients had violent homicidal thoughts, threats, and suicidal risk.

The majority (61.5%) of the homicidal patients had medical conditions that required medical intervention. More often, these were exacerbations of chronic medical illnesses and not directly linked to homicidal ideation. There was a wide range of acute medical conditions that varied in severity, from mild (asymptomatic hematuria, abdominal pain), which needed minimal workup and intervention, to more moderate (intoxication, shoulder dislocation, hyperglycemia) and severe (acute heart failure exacerbation, acute seizure), which required more intensive medical care. Stern et al suggested that the inadequate evaluation of acute medical issues in homicidal patients was likely due to the reluctance of healthcare providers to act. 2 Their belief was that homicidal patients posed a greater risk to providers because of the likely obstruction of care. Our study found that comprehensive medical care may be required and is possible because most homicidal patients were cooperative. With involuntary patients, staff may focus only on the mental health issues and overlook neglected medical conditions. Such missteps could result in harm to these patients. ED providers should provide comprehensive evaluations of this patient population.

Our study found that the majority of homicidal patients were men when compared to other involuntary hold patients (84.6% vs 40.8%, P = 0.003). This corresponds with population data looking at gender patterns of homicide offenders in the United States from 1976 to 2015, which found that men committed 90.9% of homicides. 14 We found that most homicidal patients also had a substance use disorder (61.5%). The use of excessive alcohol or other illicit drugs can lead to the loss of inhibition and self-control, bringing out violent tendencies. This effect may be worsened in an individual with an underlying psychiatric diagnosis. 3 Individuals with an underlying diagnosis of depression who also have the comorbid condition of substance abuse are at extreme risk of committing domestic homicide. 15 Considering this, when a male patient with a history of comorbid psychiatric disorder and substance misuse presents in any medical environment, care providers should be aware of the increased risk of homicidal tendencies, both in the acute medical setting and in the home environment. Recognizing this risk and taking proper safety precautions, such as increased security and staff awareness at the medical facility and domestic abuse and safety information regarding the patient’s domestic partners and/or family, may be beneficial.

Our study has limitations. There were a small number of patients with homicidal ideation during the study period, which limits our ability to show an association between homicidal ideation and any variable. This is a retrospective study, which depends on the quality and accuracy of the medical record. What is documented in the medical record and the Baker Act certificate may be just enough information to place an emergency hold and not reflective of all of the factors that went into the decision. Psychiatrists did not see patients in the ED, and information regarding psychiatric illness was obtained from documentation in the patient’s medical record by a psychiatrist, primary care provider, or other provider before the ED evaluation, which may limit our ability to determine the true frequency and specificity of psychiatric disorders. Also, the small number of homicidal patients relative to the overall number of involuntary patients limits any comparison of homicidal and nonhomicidal involuntary patients. Lastly, the study setting received patients from local suburban communities, which may prevent the generalization of the results.

Conclusions

This study makes several important points. First, homicidal patients often had specific plans to act on their threats, which warranted involuntary status. Second, the majority of homicidal patients had a preexisting psychiatric disorder. Most were transferred for inpatient psychiatric treatment. Third, suicidal ideation frequently coexisted with homicidal ideation; therefore, all homicidal patients should be screened for suicidality. ED personnel should be aware of the potential for self-harm. Fourth, homicidal patients often presented with acute medical conditions that required intervention. ED providers must be diligent and comprehensively evaluate these patients who may neglect their health. Finally, care providers should understand state laws to maximize the protection of patients and others. With the rising numbers of involuntary patients seen in acute care hospital EDs, staff should be cognizant of the issues they may face when caring for a patient population in crisis.

Key Points

Homicidal patients were for the most part cooperative and nonviolent in the emergency department setting.

The majority of homicidal patients had a preexisting psychiatric disorder; thus, proper psychiatric evaluation and care are important.

Suicidal ideation frequently coexisted with homicidal ideation; therefore, all homicidal patients should be screened for suicidality.

The majority of patients making threats of harm had a specific plan of action to carry out the threat.

Acknowledgments

The work described herein was funded by the Center for Clinical and Translational Science grant support (UL1 TR000135) in publications relating to this project. This publication was also supported by the National Institutes of Health/National Center for Research Resources Colorado CTSI A grant no. UL1 RR025780. Its contents are the authors’ sole responsibility and do not necessarily represent the official views of the National Institutes of Health.

Footnotes

A Please define CTSI.

The authors did not report any financial relationships or conflicts of interest.

A Baker Act added because Google search did not yield exact results for the phrase “Florida Involuntary Hold Act for Emergency Department Evaluations.”

B Is the Mayo Clinic the appropriate substitution for “(BLINDED)”?

C Please substitute the appropriate institution for “(BLINDED).”

D Please substitute the appropriate institution for “(BLINDED).”

Portions of this manuscript were published in the American Journal of Emergency Medicine (Dawson NL, Lachner C, Vadeboncoeur TF, et al. Violent behavior by emergency department patients with an involuntary hold status. Am J Emerg Med 2018;36:392-395).

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