/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/gen-care/,/policies/clinical/uw-health-clinical/gen-care/behavioral-health/,

/policies/clinical/uw-health-clinical/gen-care/behavioral-health/246.policy

201706152

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Behavioral Health

Protective Custody and Involuntary Commitment for Persons Intoxicated and Incapacitated by Alcohol (2.4.6)

Protective Custody and Involuntary Commitment for Persons Intoxicated and Incapacitated by Alcohol (2.4.6) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Behavioral Health

2.4.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Protective Custody and Involuntary Commitment for Persons Intoxicated
and Incapacitated by Alcohol
Policy Number: 2.4.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: May 26, 2017

I. PURPOSE

To establish policies and procedures for the involuntary treatment of persons intoxicated or incapacitated by
alcohol.

II. DEFINITIONS

A. Intoxicated person: A person whose mental or physical functioning is substantially impaired as a result of
the use of alcohol.
B. Incapacitated by alcohol: A person, as a result of the use or withdrawal from alcohol, is unconscious or
has his or her judgment otherwise so impaired that he or she is incapable of making a rational decision, as
evidenced objectively by such indicators as extreme physical debilitation, physical harm or threats of harm to
self or others, or to property. ..
C. Protective custody: Initiated by a sworn law enforcement officer only. The person’s rights are removed but
the person is not under arrest nor did the person commit a crime.
D. Involuntary Commitment: A legal proceeding which allows for a person with an alcohol use disorder who
meets the criteria in section IV.B. below to be placed into custody in order to obtain care at a treatment
facility.

III. POLICY ELEMENTS

Legal procedures shall be followed in providing involuntary custody or treatment to persons intoxicated or
incapacitated by alcohol. The procedures specified in section IV shall be followed unless other procedures
are mandated or authorized by law. This policy does not apply to persons incapacitated by or dependent on
drugs.

IV. PROCEDURE

A. Intoxicated Persons
i. If a patient is intoxicated by alcohol but does not need to be admitted for medical treatment, law
enforcement may be (but are not required to be) called to assist the intoxicated person travel to the
person's home, an approved treatment facility, or other health facility. The intoxicated person must
consent to the offer of assistance from law enforcement.
ii. If an intoxicated person needs to be admitted to the hospital for medical treatment, a blood alcohol
level (BAL) should be taken and appropriate medical treatment should be furnished.
iii. Minors age 12 and over may request preventive, diagnostic, assessment, evaluation, or treatment
for alcohol detoxification or alcohol abuse without parental consent. However, parental consent is
required when (1) the minor is admitted for detox for more than 72 hours, (2) the minor is admitted
as an inpatient for any reason other than detox, (3) before controlled substances are administered
to the minor (except when related to detox) or (4) when the minor requires a surgical procedure.
B. Incapacitated by Alcohol.
i. A person is deemed to be under protective custody if the person has been placed under protective
custody by a law enforcement officer per WI Statute 51.45(11)(b) or if the person was referred to
UWHC by Tellurian U.C.A.N. per WI Statue 51.45(11)(c). Document in the medical record law
enforcement initiation of protective custody.
ii. Law enforcement are required to take a person (minors and adults) who is incapacitated by alcohol
into protective custody and to bring the person to an approved facility or to the emergency
department for medical treatment.
iii. If any person incapacitated by alcohol does not require hospital admission and is medically cleared
for discharge from the emergency department:
a. A Blood Alcohol Level (BAL) should be taken.
b. Contact an approved alcohol detoxification facility, (currently in Dane County, Tellurian
UCAN (223-3311) is the approved public treatment facility for persons incapacitated by



UW HEALTH CLINICAL POLICY 2
Policy Title: Protective Custody and Involuntary Commitment for Persons Intoxicated and Incapacitated by Alcohol
Policy Number: 2.4.6

alcohol). The referring RN or attending physician must contact the approved facility to
verify whether they can admit the person.
c. If the person will be transferred to an alcohol treatment facility, the referring RN and/or
attending physician should complete the appropriate transfer forms. Currently this is the
“Referral from Hospital to Detox form.” A copy of this form should be sent to Health
Information Management (HIM) for scanning into the medical record.
d. Upon acceptance to the appropriate county treatment facility, contact University Police for
transport.
C. Protective Custody. If a person under protective custody for alcohol requires admission for medical
treatment:
i. A BAL level should be taken immediately.
ii. When the person is admitted, the person is deemed to be under protective custody and in the care
of UW Health. Document in the medical record law enforcement initiation of protective custody.
iii. The patient may be detained in protective custody at UW Health not for longer than 72 hours after
admission, exclusive of Saturdays, Sundays, and legal holidays. A person may voluntarily consent
to remain at UW Health for a longer period of time, as medically appropriate.
iv. Once a person under protective custody is medically cleared for discharge, the referring RN or
attending physician should contact the appropriate alcohol detoxification facility to verify whether
they can admit the person.
v. The referring RN and/or physician should complete the Referral from Hospital to Detox form.
(Currently in Dane County the facility is Tellurian UCAN) A copy of this form should be sent to HIM
for scanning into the medical record.
vi. Upon acceptance from the approved treatment facility, contact University Police for transport.
D. Involuntary Commitment (3-Party Petition): If a person habitually lacks self -control such that the patient
presents a danger to self or others, it may be possible to initiate involuntary commitment.
i. Involuntary commitment is appropriate for persons who meet all of the following criteria:
a. The person habitually lacks self-control as to the use of alcohol beverages and uses such
beverages to the extent that health is substantially impaired or endangered and social or
economic functioning is substantially disrupted;
b. The person's condition is evidenced by a pattern of conduct which is dangerous to the
person or to others;
c. A relationship between the person's alcoholic condition and the pattern of conduct (during
the immediately preceding 12-months) which is dangerous to person or others can be
established to a reasonable degree of medical certainty;
d. There is an extreme likelihood that the pattern of conduct will continue or repeat itself
without the intervention of involuntary treatment or institutionalization;
e. There is no suitable alternative available to commitment in which the subject will
voluntarily participate; and
f. The county department is able to provide the most effective and appropriate treatment.
ii. To initiate a 3-Party Petition, contact the AODA Consultation Service through Health Link or paging
and by calling 263-7919 during regular business hours. If determined to be appropriate, the AODA
counselor will discuss the next steps for initiating the process.

V. SPECIAL CONSIDERATIONS

A. An intoxicated individual reporting suicidal ideation should not be transferred to an alcohol treatment facility.
The person should be evaluated for admission to the hospital. After the person is no longer considered to be
intoxicated, incapacitated, or under protective custody, contact Psychiatry to evaluate for suicidal ideation
prior to patient discharge.

VI. FORMS

A. Protective Custody:
Tellurian UCAN Detoxification referral from University Hospital (for those intoxicated persons who do not
need to be admitted) - available in Emergency Room.
B. Involuntary Commitment:
Affidavit in Support of Petition for Involuntary Commitment.

VII. COORDINATION



UW HEALTH CLINICAL POLICY 3
Policy Title: Protective Custody and Involuntary Commitment for Persons Intoxicated and Incapacitated by Alcohol
Policy Number: 2.4.6


Author: Nurse Manager, Emergency Services
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Administrative Program Manager; AODA Consult Services; Office of General Counsel
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: May 15, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VIII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

IX. REFERENCES

A. Wisconsin Statutes Chapter 51, Prevention and Control of Alcoholism
i. Protective Custody: WI Statute 51.45(11)
ii. Emergency Commitment: WI Statute 51.45(12)

X. REVIEW DETAILS

PVersion: Revision
Last Full Review: May 26, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #8.09