Physicians’ perspectives on processes for emergency mental health transfers from university health clinics to hospitals in Ontario, Canada: a qualitative analysis

BACKGROUND: In Ontario, Canada, there is variability in how students experiencing a mental health crisis are transferred from university health clinics to hospital for emergent psychiatric assessment, particularly regarding police involvement and physical restraint use. We sought to understand existing processes for these transfers, and barriers to and facilitators of change. METHODS: Between July 2018 and January 2019, we conducted semistructured qualitative interviews by telephone or in person with physicians working at Ontario university health clinics. We developed the interview guide by integrating an extensive literature review, and the expertise of stakeholders and people with lived experience. We analyzed the interview transcripts thematically. Analysis was informed by participant responses to a questionnaire exploring their perspectives about crisis transfer processes. We requested institutional policy and process documents to support analysis and generate a policy summary. RESULTS: Eleven physicians (9 family physicians and 2 psychiatrists) from 9 university health clinics were interviewed. Ten of the 11 completed questionnaires. Policy and process documents were obtained from 5 clinics. There was variation in processes for emergency mental health transfers and in clinicians’ experiences with and beliefs about these processes. Police were commonly involved in transfers from 7 of the 11 clinics, and in nearly all or all transfers from 5 of the 11 clinics. Handcuffs were always or almost always used during transfer at 2 clinics. Three major themes were identified: police involvement and restraint use can cause harm; clinical considerations are used to justify police involvement and restraint use; and pragmatic, nonclinical factors often inform transfer practices. INTERPRETATION: The involvement of police and use of restraints in crisis mental health transfers to hospital were related to pragmatic, extramedical factors in some university health clinics in Ontario. Exploring existing variability and the factors that sustain potentially harmful practices can facilitate standard implementation of less invasive and traumatizing transfer processes.