Navigating Medical & Behavioral Health ECOs and TDOs

What's the difference between a medical and behavioral health ECO and TDO? And why should emergency physicians and other medical providers know how to use them to get patients the care they need?

In March 2025, VACEP provided an in-depth presentation and discussion on navigating the legal and clinical complexities of both medical and behavioral health Emergency Custody Orders (ECOs) and Temporary Detention Orders (TDOs). 

The session was led by Dr. Joran Sequeira, VACEP president-elect and medical director with Southside Medical Center, along with Jonathan E. Green, director of the Department of Magistrate Services at the Supreme Court of Virginia. Here, you can watch the full recording

Takeaways:

Mental Health ECO:

Involuntary order placing a patient under law enforcement custody for a Community Services Board (CSB) evaluation. Issued when a person poses a risk of harm to themselves or others due to mental illness. Petitioners can include family members, CSBs, nurses, doctors, EMS personnel.

• Duration: 8 hours under law enforcement custody while awaiting a mental health TDO decision.

Mental Health TDO:

Issued when a patient requires inpatient psychiatric care but is unwilling or lacks capacity to consent. Can be issued without a preceding ECO.

• Duration: 72 hours, followed by a court hearing for further commitment.

• Key Issue: If a bed is not available, patients can be held in the ED for extended periods.

Medical ECO:

Used in cases where a patient lacks capacity and is in a medical crisis requiring emergency treatment. Only licensed physicians can petition for a Med-ECO.

• Duration: 4 hours for assessment and treatment.

• Law Enforcement: May assist EMS in transport but not required to remain in custody.

Medical TDO:

Detains a patient for 24 hours when they lack capacity and refuse treatment necessary to prevent harm. Can be petitioned by a licensed physician via a judge during business hours or a magistrate when a judge is unavailable. Hospital security is responsible for detainment (not law enforcement).