Monday, September 01, 2014

Boarding Psych Patients in the ER

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.  


catlover said...

In my state, case managers and other mental health workers that come to the home do nothing but type on their laptops, filling out paperwork that keeps them coming to the clients' home. If they actually help with something, they spend an hour filling out forms and help for 10 minutes. Better not to have their "help." I'm in a state that supposedly has good social services. They used to help more, but I think everything is against the rules now. Not surprisingly, I ditched social services and no longer recommend them to people I meet with serious mental problems.

EastCoaster said...

What are the other 4 states with no provision for mandating outpatient treatment?

Anonymous said...

I have been thru this twice in the last year with a relative who is chronically suicidal, treatment resistant, meds noncompliant, and who never gets good care because our health insurance will not cover the long term psychiatric inpatient treatment they need for their personality disorder (i.e.: somewhere like Austen Riggs, or Silver Hill) Instead, the insurance company will only cover the most appalling care in the community and the private doctors will not take the patient on because of the liability with an acutely suicidal patient.

As a result, we have many crises. And I have sat with them in revoltingly dirty ER HALLWAYS while staff go from filthy homeless with hepatitis C and god knows what else to my relative (without washing hands) and basically tried to keep the person calm when they are phobic, terrified of the violent, psychotic, dangerous people also in the ER. When you have timid people who are also suicidal, a noisy filthy ER is sheer torture.

And when I hear the staff loudly mocking various patients and speculating how long it will be before this one strapped to a gurney will poop in his pants....I used to be a hospital chaplain in my youth, but when I hear such talk, I want to go Rambo....

One worries about what physical diseases the patient will catch, but more importantly the ER is traumatic for the vulnerable mentally ill. A person may be there for nearly a week getting ZERO treatment, and yet the hospital bills one's insurance 2000 dollars a day to cover the care for all the illegals who are getting their care for free. What this does is basically exhaust the unofficial quota of care that the insurance is willing to give for each episode a person has, and so they don't get any actual time in treatment, even if they ever get a bed in a psych unit. The usual thing is the insanity of releasing the patient (still acutely suicidal) back into the community and basically forcing the family to watch them 24/7. This means that family members have to take time off work, if not quit their jobs. They certainly can't say WHY or the person would be stigmatized, and never have a chance of working. If they ever recover...

I live in fear that my relative eventually "succeeds" in committing suicide after another one of such release into the community after an ER ordeal of no treatment. Life in the household gives new meaning to the phrase hyper-vigilance to prevent this...

We are now actively researching states to try and find the one with the best coverage for mental health services for our relative. Will move there with them, as the one we are in now is impossible. We have paid for insurance all our lives, and worked and paid taxes likewise, and the relative in question was a straight A student, and worked part time for years until they became ill, so it's not a family of total moochers....

This is what the abolition of long term mental hospitals actually does: it causes an entire family to have to quit jobs, and move (and don't even get me started on the effects on a marriage, on siblings, on the family system of having to constantly monitor a suicidal person who goes off meds, makes attempts, and is nearly non-functional).

We rightly place a high value on individual liberty and rights but few in the mental health profession ever seem to give a thought to the toll on the family. Who love the patient but are torn apart by their illness.

Anonymous said...

There is no need to worry about catching Hepatitis C in an ER from a nurse caring for a patient with Hep C. I'm a little sensitive about this topic, because I have a younger sibling who got Hep C as a child from a blood transfusion in the 1980's. Her husband of 15 years is negative; both of her children are negative. You don't catch Hep C from other patients in the ER (unless you're sharing needles/blood). It just doesn't work that way. So, no need to worry about other patients with Hepatitis C being around your relative.


Anonymous said...

Guess what. Everyone. Not just psych pts spending weeks in ER. Guess what else. From my experience, the ER, even seclusion room so long as no restraints and there is an actual bed in it is much better than being on some psych wards.

Anonymous said...

Different perspective from a mental health counselor who works part time in a psych hospital

"Even if there were a new pot of money to pay for a gigantic increase in beds, I would argue that this is a very poor way of managing crisis. Right now, hospital units are run primarily by highly paid psychiatrists and nurses. The main overwhelming focus is on medication “stabilization.” This is an extremely costly system. Instead I would support shifting monies to creating crisis care centers that are run almost entirely by peers and therapists with a small group of doctors and nurses as adjuncts. This would not only create a much cheaper model of care, it would also emphasize what is truly needed, humane care directed towards listening, attending to needs, comfort measures, and receiving a space to experience deep distress and extreme states that is safe and caring. Peer respite centers such as Second Story are already on the front lines of providing this type of care."


catlover said...

I usually post about psychiatric troubles since that is my primary problem and that is what this blog is about, but the truth is, the whole system is falling apart, from my point of view. People who are barely medically stable are being sent home with extremely complex medical care regimens that families can't understand or are inadequately trained to handle. Woe to those with multiple problems like heart failure, diabetes etc. who are discharged home to a family without medical training or otherwise very smart, educated and motivated and willing to quit their jobs. And oh, my, they better speak English. If a family doesn't know what a ml is, the poor heart failure patient is screwed and gonna die sooner rather than later, I guess. Idk how the home health workers and people who help on the phone with computerized medical devices can handle the stress either when they can tell the family members can't understand the information. Oh. My. God. I'm sure it's worse than I know, too. Why do we spend so much money to miraculously save a life and then there is not enough help to keep the patient alive after they have been saved?

Anonymous said...


1) Fewer "hospitals" (often causing more trauma) and more peer-run crisis centers:

2) More consumer-driven services: