Part 1: Psych patients pack emergency rooms

By Orange County Register

Categories: Neurosciences
Two years ago, Marty Naftel felt one of his bipolar crises coming on and went straight to the hospital. The 53-year old Midway City resident had learned he had bipolar disorder 29 years earlier and had been hospitalized for it many times since. So on that day in June 2012, he knew the warning signs all too well.

“I felt very unstable. Going toward manic,” Naftel recalls. “When I got manic, I would ruin everything. I lost my family. I would spend a lot of money I didn’t have. I would think I had been sent to Earth by Jesus.”

At the emergency room – one of Orange County’s busiest – they put him in a room with someone to watch over him. They kept reassuring him that they were only waiting for a psychiatric bed to open up. But after nine hours, a nurse told Naftel they were sending him home.

“That flipped me out. I just couldn’t believe it,” he says.

Naftel’s story – the long wait, the frustration – is an increasingly common one amongpsychiatric patients who show up at hospital emergency rooms in urgent need of evaluation and treatment. And these days, the ER is typically where they go first.

A severe shortage of psychiatric hospital beds, tight space at longer-term residential facilities and reduced mental health capacity at community clinics has turned emergency rooms in Orange County and throughout California into virtual boarding houses for psych patients. There is not a single bed in the county for psych patients under 12 years old.

Once they get to the ER, patients with mental health disorders are are often held without treatment for many hours, or even days, while they wait for a psych bed to open up – or for an assessment to determine they don’t need one. In an ideal world, those patients would be seen much more quickly, by qualified professionals, in a setting intended specifically for handling urgent psychiatric cases.

“If you had a family member who had a psychiatric emergency, what would you do? The reality is you wouldn’t know what to do,” says Steve Moreau, CEO of St. Joseph Hospital in Orange, which is one of the county’s designated psych facilities.

“There is no psychiatric emergency system in place. The default is for the police or a family member to take them to the nearest emergency room, and I can tell you that none of the ERs, including ours, is built or equipped to deal with psychiatric emergencies.”

The added pressure on ERs – at a time when they are also being stretched thin by an influx of nonpsychiatric patients newly insured under the Affordable Care Act – has deleterious effects on everyone concerned. Most importantly, individuals in acute mental distress are not getting the treatment they desperately need. That has contributed to a rise in verbal and physical assaults on ER nurses, doctors and other hospital staff members.

The presence of psych patients in the ER – sometimes six, eight or even 10 at a time – means less space for patients with broken limbs, burns or chest pain. In many cases, ambulances carrying patients with serious medical crises are diverted to other hospitals. And because mental patients can be a threat to themselves, or others, they frequently need to be guarded.

The amount of time a mental health patient spends in Hoag Hospital’s ER “has been creeping up” and averaged 20 hours last month, notesMichael Brant-Zawadski, executive medical director of Hoag’s Neurosciences Institute.

That is typical. At St. Jude Medical Center in Fullerton, the average ER hold on patients ultimately admitted to psychiatric facilities is about 23 hours. At St. Joseph Hospital, despite the proximity of its psych ward, mental health patients still average about 12 hours in the ER.

And those are only averages. Some mental health patients spend days in the emergency room. And the problem is not limited to Orange County.

“I’m hearing from all over the state about ERs being overrun by psych patients,” says Randall Hagar, director of government relations at the California Psychiatric Association in Sacramento. “I’ve heard stories many times about the difficulty of finding placement for individuals. They can be kept in the ER three, four, five, even up to seven days.”

To be fair, some of the hours psychiatric patients spend in the ER are needed to screen or treat them for medical problems or, as is frequently the case, allow time for recovery from alcohol- or drug-induced intoxication.

But the underlying problem remains: There’s often nowhere to send those patients for psychiatric care, and emergency rooms are simply not set up to address their needs.
From 1995 to 2012, the most recent year for which data exist, Orange County lost 704 psychiatric beds, a drop of 57.8 percent, according to a recent study by the California Hospital Association. In 2012, the county had 16.6 beds for every 100,000 residents – less than one-third the number that mental health experts cite as the minimum needed to meet the needs of psychiatric patients.

One factor has been consolidation in the hospital industry: As hospitals shut their doors, psych beds disappeared with them. Perhaps more importantly, declining reimbursement for mental health care – and the fact that many mental health patients have no insurance at all – have discouraged hospitals from building new psychiatric units or adding beds.

“The more beds you open, the more money you lose,” laments Tom Loats, director of behavioral health at St. Joseph, who oversees that hospital’s psychiatric ward.

St. Joseph has 36 beds in its psych ward, and Loats says that number has not changed in 35 years -- during which the population of Orange County has grown by about 63 percent, to 3.1 million.

Every hospital executive and mental health worker in the county knows there is a gaping need for more inpatient psychiatric beds. But fixing the problem has become a game of chicken because of the financial worries.

“The fear of individual hospitals is that if we build that capability and it becomes known in the community that we have fixed that problem, we are going to get every single psychotic emergency in the county, and the reimbursement system is not sustainable,” says Moreau, the St. Joseph CEO.

The Orange County Healthcare Agency runs a psychiatric crisis stabilization and triage unit in Santa Ana, known as Evaluation and Treatment Services. But it has a woefully inadequate 10 beds – a number that has not risen in decades. ETS is planning a significant expansion as part of a plan in the works to create a couple of dedicated psychiatric emergency centers in the county.

In addition to the scarcity of psychiatric beds, the mental health care services offered at community clinics and other sites have withered in recent years. The great recession, tight budgets and the lingering stigma attached to mental illness all have contributed to a sharp reduction in resources for clinics and crisis services, says Sheree Kruckenberg, head of behavioral health at the California Hospital Association.

“That is what created the influx to the emergency departments, because in many communities the (ER) was the only setting open 24/7 with lights on, where nobody could be turned away,” Kruckenberg says. “So hospitals became the safety net for the safety net, and to this day the numbers are increasing.”

A study that Kruckenberg commissioned for the association shows that from 2006 to 2011, the volume of psychiatric patients in Orange County emergency rooms rose 47 percent. That compared to a 7 percent increase in total ER patient volume.

The problem, as any hospital director, psychiatrist and emergency room director will tell you, is that the ER is the absolute worst – and costliest – place to care for people with mental health disorders.

Psych patients don’t need “the expensive overhead of a medical emergency department,” Loats says. “They’re not coming in for chest pain. It’s kind of like having a Rolls-Royce to pull your trailer.”

One serious challenge is finding psychiatrists who are willing to work in a hospital or be on call for ERs, which are open 24/7. In Orange County, regulations require that psychiatric patients be evaluated by certified psychiatrists.

“There aren’t enough psychiatrists to do that,” Loats says. “They are waiting for psychiatrists who don’t exist.”

For that reason and many others, emergency rooms are simply not good places to treat patients with mental disorders.

“The emergency department is set up to deal with somebody who’s been in an automobile accident or maybe is in cardiac failure,” says Paula Martin, director of the Neuro-Psychiatric Center at UC Irvine Medical Center, which has a 48-bed psychiatric unit and a very crowded ER that often reroutes ambulances to other hospitals.

“It’s very different than what you need to deal with somebody who is in psychiatric distress. In the ER, the lights are bright. There are bells and jingles. It’s very chaotic, and somebody in a psychiatric crisis really needs calmness.”

For mental health patients, timely intervention can make a big difference.

The day after his nine-hour ordeal in the ER, Naftel went to another ER and eventually was admitted to a psychiatric hospital.

“It was very calming,” he says. “I got to see the psychiatrist every day. They changed my medication a little bit. I came out feeling like a new man.”

Naftel is working part time now as a peer mentor at the Wellness Center in Orange, a county-run program that offers discussion groups, classes and outings that focus on employment, educational opportunities and relationship building for people with psychiatric disorders who are in recovery.
View the original Orange County Register articlehere.