Q&A: 1013 Patients in Emory Hospitals

Occasionally, Emory Hospitals encounter patients who (1) are at other hospitals and have been placed under a 1013 hold (2) come to an Emory Emergency Department under a 1013 (3) are in our facility when it is determined that it is appropriate for a 1013 hold to be written or (4) want to leave the hospital, despite needing medical treatment, but do not require mental health treatment. Because Emory Hospitals – other than Wesley Woods Geriatric Hospital¹ – are not Emergency Receiving Facilities authorized by the State to examine and treat involuntary patients for their mental illness, it is important that you understand the proper use of 1013 Forms and what to do when you encounter patients under a 1013 hold (“1013 Patients”).

Q: What is a 1013 Form?
A: A Form 1013² allows detention of a mentally ill person against his or her will until (s)he can be transported to the nearest available Emergency Receiving Facility (“ERF”) for a mental health evaluation. The 1013 Forms are intended ONLY to authorize transport to an ERF and authorizes appropriate restraint and care until that transport can be accomplished.

A 1013 Form is NOT used to authorize providing medical care to a patient without capacity to consent or who is otherwise refusing care believed to be necessary. The end goal of the 1013 process is for a patient to get mental health treatment at a state-approved facility. This means that a properly completed form should include the name of an ERF that has agreed to accept the patient. Some private institutions have been approved as ERFs, so you are not limited to transferring patients to state-run facilities.

Q: What should happen when 1013 patients are brought to an EHC Emergency Department?
A: When patients come to the Emergency Department seeking assistance for an emergency medical condition, we are required by federal law to perform a medical screening exam to determine whether the patient in fact has an emergency medical condition and to provide stabilizing treatment if such condition exists. The Centers for Medicare & Medicaid Services (CMS) considers that psychiatric conditions can be emergency medical conditions. Therefore, it is imperative that we provide medical screening exams and any necessary stabilizing treatment to patients who come to our EDs under 1013s. Only after it has been determined that the patient does not have an emergency medical condition that requires stabilization, or we have stabilized patients experiencing a psychiatric emergency, should we transfer the patient to an appropriate emergency receiving facility.

Q: When is it appropriate to place a patient under a 1013 hold?
A: For a 1013 hold to be appropriate, a patient must meet 1013 criteria. That is, the patient must require involuntary evaluation and:

• Must be mentally ill (see the definition below) AND
• Present a substantial risk of imminent harm to self or others as manifested by recent overt acts or expressed threats of violence presenting a probability of physical injury OR
• Be so unable to care for her/his own physical health and safety as to create an imminently life endangering crisis
• And the patient is medically stable for imminent transfer to an ERF

A patient is mentally ill under Georgia law if (s)he has a disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality or ability to cope with the ordinary demands of life. A patient is not mentally ill within the meaning of the Georgia Mental Health Code if (s)he has suffered a Traumatic Brain Injury (a traumatic insult to the brain resulting in organic damage that may cause physical, intellectual, emotional, social or vocational changes in a person).

If the patient requires medical stabilization before (s)he can be transferred to an ERF for a mental health evaluation, DO NOT fill out a 1013 Form. Fill out the Form only when you perceive that the patient is medically stable for transfer and otherwise meets 1013 criteria.

Q: What are appropriate steps when a patient either cannot consent to needed medical care or refuses care we believe is needed but does not need involuntary mental health treatment?
A: A patient without capacity to consent to medical treatment can still be held for necessary treatment without a 1013 Form in place. Efforts should be made to locate legal next of kin for consent, but all necessary/emergent care may be given pursuant to the Emergency Consent Policy notwithstanding lack of express consent. Treatment is necessary or emergent under the law when it will prevent serious physical consequences or death and where delay in obtaining consent would create a grave danger to the physical health of such person, as determined by at least two physicians. This need and the name of the two physicians should be documented in the medical record. Patients without capacity who require emergency care or whose legal next of kin have authorized treatment may be restrained pursuant to the Emory Healthcare Restraint Policy, and no 1013/2013 Form is necessary. In fact, unless the 1013 criteria outlined above are met, a 1013 Form should not be used for this purpose.

It is important to remember that patients with capacity may refuse any and all treatment unless subject to a court order. Thus, it is critical to make an assessment of a patient’s capacity when determining how to proceed.

Q: When will there be a PowerForm to assist in completing the 1013?                                                                                                                                           
A: A PowerForm is being developed and should be ready for implementation by late September 2012. The 1013 PowerForm will have decision support to aid the clinician in completing the 1013.

¹ Because WWGH is a geriatric hospital, WWGH is an ERF only for patients aged 65 and over.
² A Form 2013 serves the same purpose and function as a 1013 Form, except that it specifically addresses drug or alcohol dependent persons and is intended to allow transport for treatment of such dependency.
³ The Emergency Medical Treatment and Active Labor Act, 42 U.S.C.§ 1395dd