It's no secret that over time, the number of available beds in psychiatric hospitals and on psych units of general hospitals have decreased. When the states moved patients from long term beds in state hospitals back into the community (a mostly good thing if you ask me), the promise was for more services in the community, and oops, that never came to be. With time, there are fewer and fewer services available, it's harder to get care with people often waiting weeks to be added to the overburdened caseloads of staff in outpatient mental health centers -- especially those who have no insurance or Medicaid/Medicare -- meaning the people most likely to have the biggest problems seem to have to wait the longest. If you need help now, there's often only one answer: go to the Emergency Room.
This is thing about going to the ER. They often have no miracles. In the hospital where I worked in the clinic, there were a few perks -- the ER had some reserved clinic slots so that they could refer people for outpatient appointments within a few days. Often, however, this isn't the case, and often delaying treatment means that the situation is so bad that the patient needs to be admitted. Because I was at a facility with 84 psych beds, this generally happened fairly quickly, but it many places, this just isn't the case. People can wait for beds for hours (okay, that's life in an ER), days (ugh) or even weeks. Weeks? A psychiatrist in Vermont (where the state hospital had been destroyed in a hurricane) told me they kept patients in the ER for 6 weeks. Six Weeks. I have no idea how they did that and I didn't ask. Did the patient stay in a seclusion room? What if the room was needed for another aggressive patient? Did they get a cubical? A gurney in the hall? A curtained area? Most psychiatric hospitalizations last about 7-12 days. Were they getting medications and therapy in the ER? This is crazy, and I use that term to describe the insanity of our system, not the patients.
This summer, the Department of Health and Mental Hygiene here in Maryland held work groups to discuss the delivery of outpatient care and recommendations for legislation for outpatient civil commitment -- we are one of only 5 states that has no provision for mandating outpatient treatment. The work groups were ordered by the state legislature. I went to some, and at one, an ER physician (not a psychiatrist) made a comment that sometimes patient were held in the ER for days "and they describe those days as the worst days of their lives." This just shouldn't be -- no hospital experience should be horrible because of the setting --granted, it may be horrible if you're in the middle of a panic attack, a heart attack, you've just been shot, or you've lost a limb --but it should be a place to be stabilized, then discharged or admitted, without physical discomfort.
This was my long-winded way of pointing you to an article in Forbes about ER psych boarding. Do read: "Boarding" of Psychiatric Patients Unconstitutional in Washington State by Robert Glatter, M.D. Glatter writes:
In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department. Some of these patients may then be returned to the same ED.
Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.
The ruling leads to some obvious concerns:
“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others. This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.
“The ruling is a call to action, and our main objective must be to get every patient the right level of care. The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.
Glatter goes on to discuss some possible solutions: better outpatient services, case management, crisis beds and mobile crisis units, more beds, and elimination of out-of-network barriers that keep some patients out of some available beds. All good ideas.